Y.Y.

SABRI
RADIOLOGY NOTES 3rd YEAR-RADIOLOGY M.SHAHIN

DEPARTMENT –KASR AL AINY

‫بسم هللا الرحمن الرحيم‬

KASR AL AINY
Diagnostic and Interventional Radiology Department
MEDICAL IMAGING 3rd YEAR INVESTIGATION MODULE

NOTES
Based On Radiology 3rd Year Lectures
Prepared By
Prof. Youssriah Yahia Sabri
Revised by
Prof. Mohamed A. Shahin

2022-2023

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RADIOLOGY NOTES 3rd YEAR-RADIOLOGY M.SHAHIN

DEPARTMENT –KASR AL AINY

Why to request a radiological exam for a patient

o To reach or make sure of a clinical diagnosis
o To know underlying cause of illness Congenital /
inflammatory/ neoplastic etc. .…
o To differentiate medical from surgical management
o To assess anatomical details of an already known diagnosis
and rule out associated condition.


INTRODUCTION
 List of Diagnostic imaging studies
1) Modalities using X-rays
a. Plain x-rays
b. Special techniques using contrast
materials (Angiography, GIT
Barium studies, Urinary tract
studies ,etc. see later)
c. Fluoroscopy
d. DEXA
e. Mammography
f. CT scan
2) MRI
3) Ultrasound/Doppler/Duplex
4) Nuclear imaging/PET/SPECT

 An x-ray is a bundle of electromagnetic energy called photons.

 X-rays are produced by establishing a very high voltage between two
electrodes, called the anode and cathode located inside a vacuum tube.

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DEPARTMENT –KASR AL AINY

 A Tungsten anode is used in an X-ray tube, because it has a high melting

point.
 In an X-ray tube, when electrons hit the Tungsten anode only a small
fraction of the energy is in the form of X-rays, most of their kinetic energy
is lost as heat.
 The anode is specially designed to withstand the heat and the „tube‟ also has
a cooling mechanism.
 X-rays can either pass all the way through the tissues, or be deflected and
scattered or absorbed.
 The scattered radiation is the cause of biological hazards of X-rays.
Fetuses are the most exposed to the biological effect.
 X-ray passing through the tissues depends on the energy of x-ray and the
atomic number of tissues. Higher energy is more likely to pass through, while
structures with higher anatomic number are more likely to absorb the x-ray.
 Lead has a high atomic number so it is used as a shielding material for X-
ray.
 How do x-rays passing through the body create an image?
1) X-rays that pass through the body to the film render the film dark
(black)
2) X-rays that are totally blocked do not reach the film and render the film
light (white)
3) Air = low atomic no. = x-rays get through = so air will be black
4) Metal or bones = high atomic no. = x-rays blocked =so metal will be
white

 Images formed can be received on conventional radiographic films or

more recently are produced digitally where they can be processed,
transmitted, viewed, printed and archived digitally.
 When the patient is close to the film, magnification of the x-ray image is
less.
 Most useful application of plain x-rays is in chest and skeletal systems.

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RADIOLOGY NOTES 3rd YEAR-RADIOLOGY M.SHAHIN

DEPARTMENT –KASR AL AINY

 Fluoroscopy: Is real time imaging using x-rays .Contrast agent may be

used.

 Main uses of fluoroscopy is in :

1) Gastrointestinal imaging.
2) Genitourinary imaging.
3) Angiography.
4) Others: e.g. foreign body removal, intraoperative, musculoskeletal.

 Mammogram: Special X-ray machine is used to study breasts to assess

masses calcifications and used in survey.
 DEXA (Dual Energy X-ray Absorptiometry) is a special x-ray machine
used to diagnose osteoporosis and measure bone mineral density
(osteomalacia).

 Computed Tomography (CT): CT

scanning is a medical imaging procedure that
uses x-rays to show cross-sectional images of
the body (slices like a loaf of bread).
 Helical CT scan uses rotating x-ray source
and detectors.

 Hounsfield units are units used in CT to differentiate between

different tissues, it represent tissue density:
1) Bone = +1000
2) Muscle= +50
3) Water= zero
4) Lung= - 200
5) Fat =- 100
6) Air = - 1000

 Advantages of CT scanning :
1) It is more sensitive than plain X-ray to detect lesions.
2) Has better tissue characterization (bone,
muscle, fluid, fat ...) than plain X-ray.

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RADIOLOGY NOTES 3rd YEAR-RADIOLOGY M.SHAHIN

DEPARTMENT –KASR AL AINY

3) It can show axial, sagittal and coronal images.

4) Slice thickness can be changed.
5) Multislice CT allowed new techniques e.g. CT angiography, CT
enterography

 Contrast materials in CT
1) Intravenous :ionic and non-ionic e.g. Urografin , omnipaque
2) Oral : gastrografin
3) Intrathecal: omnipaque

 Magnetic Resonance Imaging (MRI):

1) MRI works on hydrogen atoms.
2) 75-80% of the body is water.
3) The protons are stimulated by a radiofrequency RF coil and are left to relax
in a magnetic field creating energy which is used to create the image.
4) More expensive than CT but
5) Better soft tissue details than CT but bones and calcium not visualized.
6) Images produced may be
a) T1 images are better to show anatomy(fig.)
b) T2 images are better to show pathology
c) Axial, Sagittal and Coronal Planes (MRI can
be made in any plane)
d) Contrast used in MRI is Gadolinium.
7) Contraindications to MRI:
a. Absolute contraindications: pace –makers
b. Relative contraindications: metallic foreign body or implant
c. Open MRI can be used for patients with claustrophobia.

 Ultrasound (US) Imaging

1) Advantages of US
a) Cheap
b) No Ionizing Radiation
c) No Magnetic Hazards
d) Quick
e) Available (Can Be A Bed Side Imaging Technique)

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DEPARTMENT –KASR AL AINY

f) Can Be Applied To Any Part Of The Body

g) Including Soft Tissues
2) Disadvantages of the US
a) US is operator dependent.
b) US cannot penetrate bones.
c) Gas can obstruct the view of some organs (US has
relatively poor quality in gaseous abdomen).
3) Doppler / Duplex ultrasound
US used to estimate the blood flow through the blood vessels.
 Nuclear Imaging
• Scintigraphy (=gamma scan):
a) Patient given radioactive drug that travels to a
certain organ and emits gamma rays
b) Detected by a gamma camera.
c) e.g. bone scan used for early detection of
bone metastases.
• PET (Positron Emission Tomography) :
a) Use a radioactive tracer (18 FDG{
fluorodeoxyglucose})
b) FDG emits positrons
c) PET used in detecting
malignancies, staging tumors,
assess their response to therapy
and detect recurrence
d) PET/CT now all PET machines are combined with CT
machines
• SPECT (Single Photon Emission Computerized Tomography)
a) SPECT integrates two technologies; CT & radio-active drug.
b) SPECT scans measure gamma rays.
 Patient Preparations for Radiographic Techniques:
a. Generally, little patient preparation (convenient in trauma cases).
b. Kidney function tests prior to IV contrast.
c. Ideally, a patient should fast for 6 hours before an US, CT, PET and
angiography examination.

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RADIOLOGY NOTES 3rd YEAR-RADIOLOGY M.SHAHIN

DEPARTMENT –KASR AL AINY

MUSCULOSKELETAL IMAGING
 Imaging Techniques used
• Conventional Radiography
• Fluoroscopy
• Computed Tomography
• Magnetic Resonance Imaging
• Ultrasound
• Scintigraphy
• Arthrography
• Angiography.

1) Conventional Radiograph is a gateway to (MSK) imaging –

a. Assessment to bone prior to any further study choice.

(Fractures, bone tumors, joints, etc.) .
b. The standard two views in musculoskeletal X-ray
examination are AP and lateral

2) CT:
i. CT is indispensable in the evaluation of many traumatic conditions
(e.g. detect intra articular fragments) and in various bone and soft
tissue tumors because of its cross sectional imaging capabilities.
ii. Bones, blood and metals are white (hyperdense) in CT

3) MRI
The musculoskeletal system is ideally suited for evaluation
by MRI since different tissue displayed different signal
intensities on T1 & T2 weighted images.

4) US
Uses:
1- Evaluation of the rotator cuff,
2- Injuries to various tendons, e.g. The Achilles tendons
3- Occasionally soft tissue tumors such as hemangioma.
4- The most effective application however is in evaluation of the
infant hip for which ultrasound has become the imaging modality
of choice .
5) Radionuclide bone scan (scintigraphy)
a. Image the entire skeleton at once.
b. It provides a metabolic picture.
c. Helpful in conditions as metastatic cancer.
6) Arthrography (= contrast administration in a joint)

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RADIOLOGY NOTES 3rd YEAR-RADIOLOGY M.SHAHIN

DEPARTMENT –KASR AL AINY

 Contrast: Either
a. Positive contrast (iodine containing agent)
b. Negative contrast ( air )
c. Both positive and negative
 Joints: shoulder, elbow ,knee, ankle

7) Angiography (= contrast in arteries)

a. Demonstrate the vascular supply of a tumor
b. Locate vessels suitable for pre-operative intra-arterial chemotherapy.

GASTROENTESTINAL AND ABDOMINAL

IMAGING
 Imaging Techniques used
 Plain x-ray :
 Luminal Contrast studies.
 Ultrasound.
 Computed tomography (CT).
 Magnetic resonance imaging (MRI).

1) Plain X-ray

May be of use in emergencies e.g.

i. Acute abdomen with suspected intestinal obstruction (> 3 fluid

levels in AP abdomen erect )
ii. Viscus perforation. (air under right cupola in chest x-ray)
iii. Radiopaque (dense =white) stones of gall bladder.

2) Luminal Contrast Studies

A) Contrast media in the gastrointestinal tract.

a. Barium (Ba) sulfate suspensions are the preferred material for most
examinations.
b. Water-soluble contrast agents in
• Perforation of a hollow viscus or
• To detect leakage in surgical anastomosis
B) The Radiographic Examination
Can effectively detect many lesions as:
 malignancies,

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RADIOLOGY NOTES 3rd YEAR-RADIOLOGY M.SHAHIN

DEPARTMENT –KASR AL AINY

 strictures,
 ulcers
 diverticula
 polyps
C) The Examination Of The:
1) Esophagus = Ba swallow
2) Stomach= Ba meal
3) Small bowel :-
a. Oral administration of Ba=per-oral small-bowel series(Ba meal
follow through)
b. Administration of contrast by a tube in the jejunum=enteroclysis is hardly done in
modern radiology
4) Large Bowel= Ba enema
5) Bile Ducts and Pancreatic duct: Endoscopic retrograde
cholangiopancreatography (ERCP).
6) Bile ducts: percutaneous transhepatic cholangiography
(PTC)
3) US
 Abdominal US: To examine the solid organs of the abdomen and
the gallbladder.
 Endoluminal ultrasound: US probe attached to an endoscope to
detect and stage malignancy.
 US can be used while performing fine-needle aspiration (FNA) and
biopsy.
 In cases of abdominal trauma: US may be useful if CT is not available or
to quickly identify intraperitoneal hemorrhage.
4) CT
 Usually done after oral and I.V. contrast administration.
 CT is the only commonly accepted means for analyzing
abdominal trauma, particularly of the liver.
 CT abdomen and pelvis can detect
a. Masses
b. Thickening of the walls of the hollow organs and extrinsic
processes can be easily detected.
c. A major role of CT is staging malignancy (for initial
staging /distant metastases, and for evaluation of recurrence
following surgery).
d. CT enterography

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DEPARTMENT –KASR AL AINY

e. CT colonography (CTC) is another application for colon cancer

screening and detection of polyps and malignancies of the large
bowel.
4) MRI
1) Nearly all organ systems can be evaluated.
2) Small-bowel obstruction and Crohn disease in particular have become
common indications for use of MR imaging =MR enterography.
3) MRCP in the assessment of the biliary tree.
4) MRI has no application in studying acute trauma.
NEURORADIOLOGY
⚫ Imaging Techniques used
⚫ Plain Radiographs
⚫ Computed Tomography
⚫ Magnetic Resonance Imaging
⚫ Ultrasonography
⚫ Cerebral arteriography
⚫ Functional imaging:
⚫ SPECT and PET imaging,
⚫ CT perfusion
⚫ MR diffusion WI
⚫ MR Perfusion WI
⚫ MR Spectroscopy
1. Plain x-ray
a) Used for spine.
b) Standard views are AP and Lateral; oblique views may be needed.
c) An initial examination for the evaluation of spine trauma.
2. CT
a) CT is the preferred modality for studying practically all acute head
injuries
⚫ Examination times are short,
⚫ intracranial hemorrhage is well demonstrated, and
⚫ Skull fractures are readily apparent.

b) Assessment of cerebral stroke

a. Acute intracranial hemorrhage is typically very bright
(white) (iron in hemoglobin ),

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RADIOLOGY NOTES 3rd YEAR-RADIOLOGY M.SHAHIN

DEPARTMENT –KASR AL AINY

b. Whereas an acute cerebral infarction demonstrates low attenuation

(darker than brain).
c) Spine trauma: CT spine follows plain x-rays.
d) Intravenous administration of an iodinated contrast agent “light up”or
enhance pathologic conditions such as neoplasm, infections.
e) Special CT techniques:
i. CTA (CT angiography): detect stenosis, injury and
aneurysms of cerebral arteries.
ii. CT venography: demonstrate dural venous sinuses.
iii. CT perfusion: can differentiate ischemic tissue from
definite infarction.
iv. CT myelography: Intrathecal CT administration (fig.).
Not frequently used.
3. MRI
a) It is the modality of choice in identification of cerebral parenchymal
detailed anatomical structures and pathologies.
b) Allows visualization of intra-spinal anatomy with much higher contrast
resolution than does any other modality.
c) In patients with a suspected herniated disk, MR imaging is the most
sensitive examination
d) MR imaging is very sensitive in its ability to detect abnormalities in bone
marrow of the spine.
e) Spine trauma: MRI is only indicated if:
 Spinal cord injury suspected
 Intraspinal hemorrhage.
 Ligament injury
 Post traumatic sequel
f) Contrast enhanced MRI by I.V. gadolinium (Gd-DTPA) may light up
intracranial pathologic conditions.
g) Special MR Techniques:
i. MRA and MRV: useful for studying brain vasculature
ii.MR perfusion: Perfusion MR imaging measures cerebral blood flow
at the capillary level of an organ or tissue region.
iii. MRS (MR Spectroscopy): provides information about brain
metabolism and tissue composition.
iv. MR diffusion: a functional MRI technique that can be used to
discriminate benign from malignant masses.

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RADIOLOGY NOTES 3rd YEAR-RADIOLOGY M.SHAHIN

DEPARTMENT –KASR AL AINY

HEAD AND NECK IMAGING

⚫ Imaging Techniques used
A) CT and MRI are the main modalities used
B) Other modalities
 US : thyroid gland and salivary glands
 Sialography : Contrast administration in salivary glands

CHEST IMAGING
⚫ CHEST X-RAY
1) PA VIEW (CXR) (fig.): In Erect Position is the Standard
View
 Indications
1. CHEST DISEASE
2. CHECKUP
3. STAGING CANCER
4. PRE-OPERATIVE
5. PRE-EMPLOYMENT
2) OTHERS VIEWS:
Lateral View: in chest disease with the PA film
AP supine: patient cannot stand.

⚫ CT CHEST
1) CT CHEST without IV contrast: Assess any chest
abnormality.
2) CT CHEST with IV contrast: to see mediastinal vessels
in mediastinal lesions.
3) HRCT (High Resolution CT): to assess interstitial lungs
disease or airways disease.
4) CT PULMONARY ANGIOGRAPHY: To assess
pulmonary arteries (fig.) for thromboembolism.
5) VIRTUAL BRONCHOSCOPY (colored fig.): To assess the bronchial
tree if endoscopy fails or is contraindicated
⚫ MRI CHEST
Indications :
1. Thoracic inlet lesions

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DEPARTMENT –KASR AL AINY

2. Mediastinal mass (e.g. cystic or solid)

3. Chest wall masses
4. Diaphragm
5. Functional imaging (Diffusion WI)
⚫ US CHEST
Indications: Bed side assessment of pleural lesions and peripheral lung
lesions.
⚫ PET /CT
Indications :
1) Staging of malignancies
2) Evaluate response to therapy
3) Detection of recurrence.

CARDIOVASCULAR IMAGING
⚫ CHEST X-RAY
First modality of cardiac imaging and can direct further investigation.
⚫ ECHOCARDIOGRAPHY ( =Cardiac Ultrasonography)
 Primary investigation in cardiac conditions.
 Widely available
 Accurate
 Operator dependent.
⚫ DOPPLER /DUPLEX (=US of Vessels)
 Primary in peripheral vascular diseases (arterial, venous).
 Rapid decision in acute and critical cases.
 Accurate, real time.
 Widely available.
 Relatively cheap.
 Operator dependent.
CARDIAC MRI (CMR)
⚫ Gold standard modality in cardiac volumes and
functions.
⚫ Multiplanar imaging (images in any plane).
⚫ Excellent soft tissue characterization (thrombi, masses).
⚫ Assess blood flow
⚫ No ionizing radiation

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DEPARTMENT –KASR AL AINY

BUT
⚫ Needs expert operator
⚫ Needs special post processing workstation.
⚫ Costly and time consuming.
⚫ Not wide availability.
UROGENITAL IMAGING
 Imaging Techniques used
• Plain X-ray (PUT) =KUB (kidney ureter bladder)
• Intravenous Pyelography (IVP)
• Retrograde Pyelography
• Ultrasound
• Computed Tomography
• Magnetic Resonance Imaging
• Radionuclide scanning.
 PUT (KUB)
Indications:
1) To assess radio-opaque urinary calculi (fig.).
2) To detect calcifications.
3) Preliminary to IVP.

 IVP (IV contrast injected and excreted by kidneys)

Currently, it is being replaced by other techniques such as uro-
CT or uro‐MRI.

 RETROGRADE PYELOGRAPHY (ascending cysto

urethrography) ACU :
Contrast given by catheter in urinary bladder or urethra
Assess urinary bladder, urethra, ureteric reflux and
micturition.

 CTU (CT UROGRAPHY)

1) Non- contrast (CTUT) to detect urinary radio-dense

stones.
2) Post contrast CT to assess urinary tract anatomy, pathology
and give an idea about renal function.

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RADIOLOGY NOTES 3rd YEAR-RADIOLOGY M.SHAHIN

DEPARTMENT –KASR AL AINY

 MRU (MR UROGRAPHY)

No ionizing radiation so particularly beneficial in pediatrics and
pregnant females.

 US

BREAST IMAGING
 DIGITAL MAMMOGRAPHY
Types
a) Screening mammogram: in asymptomatic women
b) Diagnostic mammogram : in symptomatic women or if
abnormality found during screening.
Role
1) It shows masses and calcifications.
2) Determine exact size and location of breast abnormalities
3) Image the surrounding tissue and lymph nodes.
Advances
1) Computer-aided detection and diagnosis.
2) Tomosynthesis: slices taken at different angles to see the lesion
clearly.
3) Contrast-enhanced digital mammography
 US
1) Characterize mammographic or palpable masses as cystic or
solid.
2) Evaluate masses in dense breasts patients: (young females,
pregnant, lactating females).
3) Identify an abscess in a patient with mastitis
4) Evaluate non-palpable abnormalities for which the
mammographic diagnosis is uncertain
5) Guide interventional procedures (e.g. biopsy)
BUT
1) No substitute for screening mammogram.
2) Inaccurate for sizing large tumors
3) Cannot assess chest wall invasion

 MRI
1) Screening of high risk individuals
2) Diagnosis of problematic cases

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DEPARTMENT –KASR AL AINY

3) Implants
4) Post therapy assessment

FEMALE PELVIC IMAGING

 Imaging Techniques used

A) HYSTEROSALPINGOGRAPHY

1) Contrast (water soluble) administration in

uterus and fallopian tubes.
2) To investigate infertility :

a) Morphology of the uterine cavity.

b) Tubal patency.
c) Peritoneal cavity adhesions.

3) The examination had to be scheduled before the ovulation phase of the

menstrual cycle (7th -10th day) to minimize the possibility that the patient may be
pregnant.

B) PELVIC ULTRASOUND

1) Trans abdominal or trans vaginal

2) Indications : pregnancy, infertility, vaginal bleeding, pain ,masses,
assessing IUCD (Intrauterine contraceptive device)
C) CT

1) May be done after US for further or better evaluation of pelvic

pathology.
2) Done after oral and IV contrast.

D) MRI

1) It is the modality of choice for assessment of

congenital uterine anomalies.
2) Fetal MRI: IS DONE IF

a) US was difficult to perform (e.g. Obese pregnant patient)

b) US detected fetal anomalies,
c) Placental abnormalities.

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DEPARTMENT –KASR AL AINY

PEDIATRIC IMAGING
 X-ray: Used in:

a) Factures
b) Chest
c) Skeletal survey ( x-rays to spine and appendicular skeleton to assess
diffuse or multiple skeletal changes)
d) X-ray + Contrast administration ( Ba swallow…etc.)

 US: Used in:

1) Abdomen and pelvis

2) Special US in Children

a) Hip ultrasound for CHD

b) Pyloric ultrasound for CHPS
c) Cranial ultrasound

 CT
 MRI

 CT VERSUS MRI IN PEDIATRIC AGE

a. MRI is superior to CT in neurological disorders

b. MRI is superior however in assessment of vascular as well as
intraspinal extensions.
c. MRI and CT are equally accurate in assessment of abdominal
masses, lymph nodal metastases as well as direct tumor spread.
d. CT will likely remain the preferred technique for assessment of
pediatric abdomen (after US screening) because it is readily available.

 PET/CT

For staging of cancer and follow up of therapy and detecting recurrence.

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DEPARTMENT –KASR AL AINY

INTERVENTIONAL RADIOLOGY
 Procedures providing noninvasive or minimally invasive treatment for many of
the most common vascular and non-vascular disorders .
 Less morbidity and mortality than surgery.
 Less hospital stay, cost and postoperative burden.
 Some cases need combined interventional and surgical management: e.g.
preoperative embolization of vascular tumors,
 Approaches of interventional Radiological techniques:

1) Percutaneous
2) Endovascular

1) Percutaneous :

i. Biopsy

 Soft tissue or bone biopsy

 US or CT guided

i. Drainage

 Abscess or cyst
 US or CT guided

ii. Ablation

Of some tumors as osteoid osteomas

2) Endovascular:

1) Balloon dilatation and stenting of narrow arteries.

2) Embolization of vascular lesions (AVM, aneurysm, AV fistula...

3) Intra-arterial chemotherapy injection in a tumor.

BEST OF LUCK

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