DIAGNOSTIC IMAGING AND BASIC PRINCIPLES OF IMAGING METHODS

LEARNING OBJECTIVES

 To appreciate the role and importance of imaging in

medicine

 To understand the different imaging modalities and

their uses in medicine

 To understand the indications, contraindications and

limitations of different imaging modalities and when to
apply them to improve patient care.
 OUTLINE
 Introduction
 Historical perspective
 Classification
 Imaging techniques
 Uses of imaging in medicine
 Application by specialties
 Appropriate use of radiation
 Complications
 Loco regional challenges
 Future trends
 Conclusion
 References
 INTRODUCTION
 Imaging is a veritable tool in the evaluation of surgical
patients. Many surgical diagnoses can be made with clinical
assessment. However, radiological investigations remains
vital to the diagnosis, preparation and follow up of patients.

 A myriad of imaging options are available to the surgeon and

the onus lies on him to understand the basic principles of
each technique.

 The trend of surgical advancement is towards the use of non

invasive techniques which has less morbidity and mortality
compared to the more invasive methods, with overall
improved outcome in surgical management.

 Imaging can never replace clinical competence

 HISTORICAL PERSPECTIVE

 Wilhelm Conrad Rontgen: discovered x-

rays in 1895. Nobel prize in 1901. Father
of radiology.
 1920: use of contrast for xray studies
 1950s: nuclear medicine was born
 1970s: ultrasounds came into use
 Sir Godfrey Hounsfield invented CT in
1975
 CLASSIFICATION

 Imaging in surgery can be classified into:

 i) ionizing or non-ionizing radiation.

 ii) contrast enhanced or non-contrast

 iii) single or combined modality

 IMAGING TECHNIQUES
 X-rays(conventional radiography)

 Fluoroscopy

 Ultrasound

 Computed tomography

 Magnetic resonant imaging

 Nuclear medicine
 RADIOGRAPHY

 Oldest and commonest imaging technique.

 Uses ionizing radiation (xrays).

 Parts: Xray tube, collimator, table, film

 PRINCIPLE:

 Xrays emitted from an xray source are absorbed to

varying degree by different materials and tissues and
therefore cause different degree of darkening of
radiographic film, resulting in an image.
Advantages Disadvantages

 Cheap * ionizing
radiation
 Short developing * poor soft tissue
contrast
 Good for assessing
bone
 FLUOROSCOPY

 Uses xrays like in conventional

radiograph. However, a fluorescent
screen, image intensifier and a video
converter is used.
 Allows for real-time imaging.
 Higher dose of radiation
 Found extensive use in functional studies,
Interventional radiology and image
guidance
 ULTRASOUND

 Second most common method of imaging.

 Relies on high frequency sound waves generated
by a transducer containing piezoelectric material.

 Parts: monitor, probe, keyboard

 Principle:
Generated sound waves are reflected by tissue
interfaces and, by ascertaining the direction and the
time taken for a pulse to return, it is possible to form
an image.
 Focused Assessment with Sonography in
Trauma(FAST)

• Used in emergency abdominal trauma to

access intraperitoneal fluid collections
suggestive of intraabdominal injury.
• View included
- hepatorenal recess (morison pouch)
- perisplenic view
- subxiphoid pericardial window (douglas
pouch)
- Suprapubic window
• Extended-FAST
 Ultrasound
Advantages
 No radiation
 Inexpensive
 Allows interaction with patients
 Superb soft-tissue resolution in the near field
 Dynamic studies can be performed
 First-line investigation for hepatic, biliary and prostate disorders
 Endocavitary ultrasound for gynaecological and prostate disorders
 Excellent resolution for breast, thyroid and testis imaging
 Good for soft tissue, including tendons and ligaments
 Excellent for cysts and foreign bodies
 Doppler studies allow assessment of blood flow
 Good real-time imaging to guide interventional biopsies and drainages
Disadvantages
 Interpretation only possible during the
examination
 Long learning curve for some areas of
expertise
 Resolution dependent on the machine
available
 Image cannot be reliably reviewed away from
the patient
 CT SCAN

 Some of the major advances in radiology in recent

years are in cross sectional imaging esp. CT SCAN.

 CT uses a computer to create an image from an

integration of multiple xrays exposures taken in a
circle round the patients.

 HEAVY IONISING RADIATION DOSE.

 PARTS: Gantry, xray source, detectors, table

Computed tomography

Advantages
 High spatial and contrast resolution
 Contrast resolution enhanced by imaging
in arterial and/or venous phases
 Rapid acquisition of images in one breath-
hold
 Imaging of choice for the detection of
pulmonary masses
 Allows global assessment of the abdomen and
pelvis
 Excellent for liver, pancreatic, renal and bowel
pathology
 Three-dimensional reconstruction allows complex
fracture imaging
 Multiplanar reconstruction and three dimensional
imaging, e.g CT angiography and colonoscopy
Disadvantages

 High radiation dose

 Poor soft-tissue resolution of the peripheries
and superficial structures
 Patient needs to be able to lie flat and still
 claustrophobia
* Cranium(white)-calcium

* Pineal body (white)- calcified

* Air (Very dark) – Sinus

* CSF (Dark) – Ventricles

* CSF (Dark) – Sulci

* White Matter (Gray)

* Gray Matter (Light Gray)

 Magnetic Resonance Imaging

 Newest of the imaging techniques.

 Does not use ionizing radiation.
 Parts: magnet, radiofrequency coil, table
 PRINCIPLE: body tissues consist of
protons/electrons. In a strong uniform field
such as a MRI scanner, these nuclei align
themselves with the main magnetic field.
 A brief radiofrequency pulse is applied to
alter the motion of the nuclei. When
removed, the nuclei realign with the main
magnetic field, emitting energy (RF
Signal)
 T1 relaxation is the time taken for the magnetic vector to return to its resting
state.

 T2 relaxation is the time needed for the aisle spin to return to its resting state

 T1 weighted image is produced by using short Time to Echo (TE) and Repetitive
time (TR)

 T2 weighted image is produced using longer TE and TR time

 T1 weighted image is good for demonstrating Anatomy while T2 weighted

image is good for demonstrating pathology.

 In T1 weighted image, tissue of high fat content appear bright white (hyper
intensity) while compartment filled with fluid appear dark (hypo intense)

 In T2 weighted image, tissue of high fat appear dark (hypo intense) while
compartment filled with fluid appear white (hyper intense)
 MAGNETIC RESONANCE IMAGING

Advantages
 No ionizing radiation
 Excellent soft-tissue contrast
 Best imaging technique for
 Intracranial lesions
 Spine
 Bone marrow and joint lesions
 Limitations
Absolute contraindications
 Metallic Prosthesis and implants in orthopaedics
Ocular metallic foreign bodies
Pacemakers
Cochlear implants
Cranial aneurysm clips
 Relative contraindications
 First trimester of pregnancy
 Claustrophobia
 Long scan times so patients may not be able to keep still,
especially if in pain
 Limited availability
 Expensive
 RADIONUCLIDE SCAN

 A radioactive element (radionuclide) is

administered as a radiopharmaceutical agent,
and a detector (gamma camera) is used to record
and localize the emission (gamma ray) and thus
form an image.
 Agents: technetium, gallium, thallium, iodine
 These are usually labeled for organ specificity.
 PET SCAN

 An extension of radionuclide studies

 Same principle but uses substances that
emit positron and not gamma rays.
 Agent: 18F – 2-Fluoro-2-deoxy-D-
glucose(FDG)
 Radionuclide imaging

Advantages
 Allows functional imaging
 Allows imaging of the whole body
 Bone scan has a high sensitivity for
metastatic bone disease, fractures and
infection
 PET scanning is valuable in the detection
of metastatic cancer.
Disadvantages

 Specific agents are required for specific

indications
 Often non-specific and an abnormal
result may require further imaging
 Generally poor spatial resolution
 OTHERS
Contrast studies
 Enhanced, Non-enhanced and Combined
 Radiocontrast: iodinated (iohexol, ioversol
Barium
Diatrizate
 MRI contrast: Gadolinium.
 USS contrast: microbubbles

 SPECT …..SINGLE-PHOTON EMISSION COMPUTERIZED

TOMOGRAPHY SCAN( A TYPE OF NUCLEAR IMAGING)

 MYELOGRAPHY, ARTHROGRAPHY, ARTERIOGRAPHY, SINOGRAPHY

are other forms of REAL-TIME imaging modalities that assess both
anatomy and functions of organ system
CLINICAL
PHOTOGRAPH A
CLINICAL
PHOTOGRAPH B
CLINICAL
PHOTOGRAPH C
 Above are clinical pictures illustrating
the importance of imaging in surgery

 Photos A and B are pre and post op

pictures of patients with post burn neck
contractures

 Photo C shows pre and post Blounts

disease correction
 RELATIVE RADIATION DOSE

Radiography Equivalent number of

chest X-rays (approx.)

Chest PA 1
Abdomen AP 50
Pelvis AP 35
Lumbar spine AP and Lat 65
Barium meal 150
Barium enema 250
IVU 125
CT head 115
CT chest or abdomen 400
 USES OF RADIOLOGICAL TECHNIQUES
IN SURGERY

 To AID diagnosis of a surgical

disorder(DIAGNOSTIC)

 To guide a surgical procedure(THERAPEUTIC)

 Monitoring

 Interventional radiological techniques

 APPLICATION BY SPECIALTIES

ORTHOPEDICS

 1. Trauma: xrays, CT
 2. Bone infection: xray, CT, MRI, Bone
scan
 3. joint infection: USS, CT, MRI
 4. Degenerative dx: xrays, CT, MRI
 5. Guidance fluoroscopy, CT
 The use of C-ARM intraoperatively in fracture
reduction, fixation and percutaneous pinning
in SUFE cannot be over emphasized.

 Post Op check X rays

 Doppler ultrasound use in both Plastic and

orthopaedic surgeries in determining vascular
patency is rewarding
 GENERAL SURGERY

a) Acute abdomen: Bowel obstruction,

perforation, ischemia, GIT
Hemorrhage, inflammatory lesions

Modalities: chest xray, abdominal

xray, USS, CT SCAN, MRI
b) Trauma: USS, CT, MRI
c) Masses: USS, Contrast studies, CT
MRI
 FAST USS
2) UROLOGY
a) Bladder outlet obstruction: USS,
RUG/MCUG,
b) Urolithiasis: USS, IVU, CT SCAN
c) Trauma: USS, XRAY, RUG, MCUG,
CT,
d) Masses: USS, CT, MRI
 NEUROSURGERY/CTU

 1. Transfontanelle USS

 2. Trauma: CT, xrays

 3. Mass lesions: CT, MRI

 4. Guidance: fluoroscopy, CT
 ONCOLOGY

 1. Diagnosis
 2. Staging –
* T: crossectional imaging e.g USS, CT,
MRI
* N: USS, MRI, CT, Radionuclide studies
3. Follow up
 Proper Use of Imaging

 It is not a substitute for good clinical skill.

 Always prefer simple (hence cheaper) investigation to the
complex one if the simple one has a good chance at
making the diagnosis.
 If possible, avoid those with significant complication rate
and inherent danger.
 It should not delay treatment of life threatening
conditions
 Its better to having good communication links with the
radiologists.
 All request forms must be properly filled.
COMPLICATIONS

• Contrast induced adverse effect,

anaphylactic reaction and renal
injury

• Radiation induced carcinogenesis

(stochastic and deterministic effect)

• Injury to nearby structures/ during

invasive or interventional radiology
 Future Trends

 Advanced image guided surgery e.g.

stereotactic CT guided neurosurgery, MR
guided tumour resection

 Contrast enhanced USS(CEUS).

 Local Challenges

 Unavailability

 Cost/out of pocket spending

 Dearth of specialist radiologist.

 CONCLUSION

 Imaging is a veritable tool in the management of

surgical patients.

 New imaging techniques are constantly being

introduced and the surgeon must make frantic efforts to
keep up to date with them.

 Close communication between the surgeon and the

radiologist is indispensable in achieving this goal.

 It is not a substitute for clinical proficiency. Therefore, it

 TAKE HOME MESSAGES

 That the place of imaging in surgery cannot be

overemphasized in surgical management of patient

 That proper knowledge of different modalities, their

indications and limitations are indispensable in
making diagnosis, treatment and monitoring

 Adequate understanding and knowledge of various

complications of these imaging techniques would help
to prevent them while deploying them.
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