Introduction to Radiology

Radiology is that branch of medical science which utilizes different physical methods to produce
images of the human body. Analysis of the images for changes in the outline of the displayed
tissue/organs and for optical density differences between normal and diseased tissues to arrive at
a radiological diagnosis helps the physician so that he/she can start appropriate management.

Available Imaging Modalities

1.Plain radiography.
2.Contrast radiography.
3.Computerized tomography.
4.Sonography.(ultrasound U/S )
5.Radionuclide studies.
6.Magnetic Resonance Imaging (MRI).

BASIC PRINCIPLES

1.Plain radiography

X-rays = high energy EM waves , penetrates matter depending on thickness and atomic no.
causes darkening of a photographic emulsion(silver halide)

produced in x-ray tube by accelerating beam of electrons to strike a metal target:

factors adjusted by technologist.-

KVp = energy of x-ray beam,

MAs =no. of x-rays produced.

Radiographs obtained by positioning patient between x-ray tube and x-ray film.
Areas of the body that allow more rays to pass through cause more darkening of the film-
Radiolucent eg air in the lungs,fatty areas.

Areas that absorb(attenuate) the rays appear white - Radiopaque eg bone, calculi,metals,
positive radiographic contrast agents.
CONTRAST STUDIES

Positive contrast agents are substances with high atomic numbers that are introduced into various
body systems to increase the optical contrast between that organ and the adjacent tissues

eg Iodinated water soluble organic compounds for intravascular

use- angiograms, intravenous pyelograms (IVP) ,myelograms

Barium sulphate suspensions for gastrointestinal studies

HARMFUL EFFECTS OF IONIZING RADIATION

Unit of measurement= 100 rads = 1 Gray

(rem) (sievert)

Chest ...avg dose = 5 mSv.

CARCINOGENIC

MUTAGENIC

In Diagnostic Imaging using X-rays the risk is low and not proportional to the dose received but
expressed as a random chance.eg. Approximate estimates for the risk of fatal cancer arising
within the lifetime of patients exposed to the typical dose for chest radiography is between 0.7
and 2 per million.
COMPUTERIZED TOMOGRAPHY

Uses a very narrow X-ray beam which passes through the patient to very sensitive electronic
detectors which record changes of the beam as it passes through different tissues as electronic
signals.

These signals are processed by the computer using different reconstruction algorithms to produce
a 2 dimensional grey scale image. Because the sensitivity of the detectors is so high all the
available information is not displayed at the same time .

The window width(W) and center or level can be adjusted so that the display is optimized for the
tissues of choice.

eg as bone absorbs most of the X-rays it appears white on the display(hyperdense or of high
attenuation) and is viewed at a high width(4000) and level(400) so that the cortical bone can be
differentiated from the cancellous bone.

At low widths and levels all hyperdense areas (bone,metals,calcifications,clotted blood,Barium

or Iodine contrast agents) all show the same degree of whiteness on the display.

Because of its high gaseous content most of the X-ray beam passes through the lung parenchyma
with little change (low attenuation) and the lungs are viewed at negative levels (-600)

The degree of change of the X-ray beam as it passes through the body(attenuation) can be given
a numerical value (HOUNSFIELD UNIT HU) which is set so that water is at 0 HU.

bone = 400-1000 HU

calcification = 100-300 HU

clotted blood = 60-80 HU

soft tissues = 30-80 HU

water = 0 HU

fat = -60 to-100 HU

lung = -600 HU

These are average values and show slight variation with different machines.
ULTRASOUND

Uses high frequency sound waves(3.5-10 Mhz; audible sound = 20-20,000 hz) which passes
through human tissues with varying degrees of penetrance and reflection depending on tissue
type.

The U/S probe (transducer) transmits the sound waves and then acts as a receiver for the
reflected beam (echo) which by electronic manipulation is converted to a 2D grey scale image
depending on the strength of the echo and its spatial location.

Fluids eg bile blood urine do not produce any echoes (sonolucent) and appear black on the grey
scale image.

Bone and calcium reflect all of the transmitted sound and appear white (strongly echogenic,
hyperechoic) on the display.
They also cause an acoustic shadow due to interruption of transmission of the sound beam.

Fatty tissue and gas (bowel or lung) are moderately echogenic and scatter the sound beam
obscuring penetration and visualization of deeper structures.(disadv)

The images viewed on the U/S monitor are in real time (very fast data acquisition) however this
is usually frozen to obtain hard copy images of a small sector or linear window of that part of the
body under which the probe is positioned.

Duplex scanning is a combination of 2D imaging and Doppler sampling of the vessels displayed
to quantify blood flow. In colour flow imaging the Doppler signal is colour coded for easier
identification of the vessels.

NUCLEAR MEDICINE (radioisotope imaging)

Isotopes are unstable elements that decay to stable elements by radioactive decay releasing
gamma ray or alpha or beta particles.

In medical imaging gamma ray releasing elements (technectiun 99m, galluim -67 and various
isotopes of iodine) are labelled to compounds that are preferentially take up by the organs or
tissues of choice and then simulate metabolic or physical pathways intrinsic to those tissues.

The emitted gamma rays are collected by a gamma camera which can produce analogue images
or quantify the radioactive activity at various anatomic sites to give an estimate of normal or
abnormal function.

This is the main advantage of Radioisotope imaging as the analogue images show poor spatial
resolution compared to other imaging modalities.( disadv)
MAGNETIC RESONANCE IMAGING (MRI)

The body contains naturally occurring paramagnetic substances eg hydrogen nuclei.

In MRI these are orientated in one plane by a strong external magnetic field and out of that
plane by radiofrequency pulses. As the hydrogen nuclei return to their original orientation they
emit energy in the radiofrquency range which is detected by a receiver coil and then
electronically converted to grey scale images.

Images in different planes (sagittal. coronal or axial) can be produced without changing the
patient’s position.

Many different pulsing sequences are now available so that images can now be acquired that
document blood flow (MR angiography)

On the grey scale image bright areas corresponds to areas of high emitted signal. The same tissue
however may emit different signal intensity on different imaging sequences. eg CSF appears
dark on a T1 weighted (T1W) sequences and bright on a T2 weighted (T2W) imaging
sequence. The T1 or T2 refers to different times for stimulating the protons and receiving the
emitted signal.

Disadv --- cost.

CONCLUSION

Because of the cost and inherent risks associated with some of the available methods, effective
use can only be achieved if proper emphasis is placed upon the history and physical examination
and then using the Radiology referral to ask certain questions. The answers provided by
interpretation of the images will point to the most likely diagnosis.

Points to keep in mind when deciding on the best imaging test :

1.Cost
2.Risks/Side effects/Complications.
3.Sensitivity.
4.Specificity.
Available Imaging Modalities

1.Plain radiography.
2.Contrast radiography.
3.Computerized tomography.
4.Sonography.(ultrasound U/S )
5.Radionuclide studies.
6.Magnetic Resonance Imaging (MRI).

Optimal use of the above can only be achieved by understanding the advantages and limitations
of each technique with respect to each disease process.

Two important terms;

SENSITIVITY: ability to detect disease.

probability of having an abnormal test given the presence of disease.

SPECIFICITY: ability to identify absence of disease.

probability of having a negative test given no disease.

A non-specific test when positive gives a long list of differential diagnoses that may cause the
abnormality.

The specificity is increased by correlating the clinical and biochemical data with the imaging
abnormality.

Sometimes a disease process can be diagnosed without the need for radiological studies.