MINISTERUL SĂNĂTĂŢII AL REPUBLICII MOLDOVA

UNIVERSITATEA DE STAT DE MEDICINĂ ŞI FARMACIE

„NICOLAE TESTEMIŢANU"

O. MALÎGA, N.ROTARU, A. OBADĂ

MEDICAL IMAGING IN TABLES AND

ALGORITHMS
Guidelines

CHIŞINĂU

2015
CZU: 616-073.75(076) M 18
Approved by Central Methodological Council of “Nicolae
Testemiţanu” USMF (Report No. 3 CMC of
07.02.2013)

Authors:
Oxana Malîga – lecturer of the Chair of Radiology and Medical Imaging of
„Nicolae Testemiţanu” USMF, DM
Natalia Rotaru – head of the Chair of Radiology and Medical Imaging of „Nicolae
Testemiţanu” USMF, DM, PhD
Anatol Obadă – lecturer of the Chair of Radiology and Medical Imaging of
„Nicolae Testemiţanu” USMF

The Guidelines touch upon a very important problem of healthcare of

patients in absolutely all areas of medicine, because not a single area of modern
medicine can be imagined to be successful without the use of data obtained through
medical imaging methods.
Methodical materials contain tables, figures and algorithms that highlight
key moments in medical imaging and facilitate their understanding.
The new Guidelines are recommended for the 3rd-year students of Faculty of
Medicine, which only start studying clinical disciplines, but it will be also useful
for the 6th-year students, who resume studying the subject "medical imaging" on the
basis of clinical knowledge to master the art of using imaging methods in order to
obtain maximal information in each case.

Reviewers:
- Nicolae Nalivaico– DM, associate professor of the Chair of Radiology and Medical
Imaging of „Nicolae Testemiţanu” USMF
- Valeriu Pripa – dr. med., associate professor of the Chair of Radiology and
Medical Imaging of „Nicolae Testemiţanu” USMF, Head of the Department of
Radiology of PMSI Republican Clinical Hospital

DESCRIEREA CIP A CAMEREI NAŢIONALE A CĂRŢII

Imagistica medicală în tabele şi algoritme: Recomandări metodice/

O.Malîga, N.Rotaru, A.Obadă.. – Chişinău
(Tipogr. Ch.: CEP "MEDICINA" 2015)
62 p. ex.
ISBN 978-9975-4437-8-4.
616-073(076.5)
M 18

2
 CONTENTS

Introduction 4

I. MEDICAL IMAGING. COMPONENT PARTS. METHODS OF 5

EXAMINATION

II. CHEST IMAGING 18

III. CARDIOVASCULAR IMAGING 32

IV. IMAGING OF DIGESTIVE TUBE AND HEPATOBILIARY SYSTEM 40

V. IMAGING OF OSTEO-ARTICULAR SYSTEM 49

VI. IMAGING OF KIDNEYS AND URINARY SISTEM 53

Bibliography 62

3
INTRODUCTION

Medical imaging is the branch of medicine that deals with exploration

of the organs and the systems of the human body for diagnostic purposes,
evaluation the treatment effectiveness and prevention of pathologic processes
using electromagnetic waves and ultrasound.
On the other hand and on the basis of the name, medical imaging can
be defined as diagnostic imaging, visualization of normal and pathological
structures of the human body.
For years, doctors could only dream of being able to view pathological
changes in the patient's body. The first opportunity to realize this dream
occurred in 1895, with the discovery of X-rays by W.C.Roentgen. Radiology
had remain the only method of viewing up to the 50s, when the clinical use of
methods of ultrasound and nuclear medicine started. The term "medical
imaging" itself arose when digital image processing became possible.
At present it is impossible to imagine everyday medical practice
without the use of imaging methods in order to make a diagnosis and to check
the effectiveness of treatment. Knowledge of these methods is essential for a
successive and effective activity of each physician, aside from his specialty.
This guideline does not pretend to replace manuals and intends to
facilitate the introduction in the subject and further mastering medical
imaging by students.

4
I. MEDICAL IMAGING. COMPONENT PARTS. METHODS
OF EXAMINATION
Table 1.1
KEY DATES IN RADIOLOGY HISTORY
Year Event
1895 Discovery of X-rays (W.C.Roentgen)
1896 Discovery of radioactivity (H.Becquerel)
1901 Rontgen receives the Nobel Prize in Physics for the discovery of x-rays
1905 The first book on Chest Radiography is published
1918 G. Eastman introduces radiographic film
1920 The Society of Radiographers is founded
1934 Joliot and Curie discover artificial radionuclides
1937 The first clinical use of artificial radioactivity is done at the University
of California- Berkeley
1946 Nuclear medicine is founded
1950 The first clinical use of ultrasonography (W.D. Keidel)
1950ʹ Development of the image intensifier and X-ray television
Wide-spread clinical use of nuclear medicine starts
1962 Introduction of SPECT and PET methods
1967 The first clinical use of MRI takes place in England
1972 CT is invented by British engineer Godfrey Hounsfield
1977 The first human MRI images are produced
1979 Comack and Hounsfield receive the Nobel Prize in Medicine for
computed axial tomography
1975- Advancement of clinical use of two-dimensional ultrasonography
1985
1985 Clinical use of Color Doppler begins

5
 Table 1.2.
COMPONENT PARTS OF MEDICAL IMAGING
Method Radiology Ultrasonography Magnetic resonance Nuclear medicine Thermography
imaging
Characteristics
Energy X-rays Acoustic waves Magnetic field and radio Gamma rays Infrared rays
waves
Source of energy X-ray tube Piezoelectric Permanent magnet, Radionuclide Human body
crystal antennas

Morphological +++ +++ +++ + - ++ ++

investigation
Dynamic investigation + ++ + +++ -
Terminology Opacity Hyperechoic Hyper-intensive, Hot area
Lucency Hypoechoic Hypo-intensive Cold area
(hyperdensity, hypodensity (node, spot)
in computed tomography)
Ionizing action + - - + -

Contraindications Pregnancy - Implanted metallic Pregnancy -

dispositives
Contrast media Substances with higher or Substances with Paramagnetic substances
lower density micro bubbles

6
 Table 1.3.

X-RAY PROPERTIES

Common for all Travel straight ahead, along the straight line
kinds of
electromagnetic Travel with the velocity of light (300 000
waves
km/sec)

Travel in all directions

Passing through Penetration

the human body
Absorption, Density

which depends Thickness

on:
Frequency (wavelength)

Dispersion

Chemical photographic action

Effect of fluorescence

Ionizing effects In the air

In the human body Somatic

Genetic

Cannot be detected by sense organs

7
 Figure 1.1.
X-ray tube

Glass bulb, vacuum

Electron stream
Cathode
e Anode

X rays

Table 1.4.
NATURAL CONTRAST LEVELS
(from minimal to maximal density)
Level Substance with appropriate density
1 Air
2 Fat tissue
3 Liquids / soft tissues / parenchymatous organs
4 Bones
5 Metal

8
 Table 1.5.

UNITS OF MEASURE FOR IONIZING RADIATION

Characteristics. Old unit SI unit Correlation
Level of detection old unit/ SI unit
of radioactivity.
Radioactivity of Curie (Cu) Becquerel (Bq) 1Bq=0,027mCu
the source of
ionizing radiation

Air Roentgen (R) Coulomb/kilogram 500R=129mC/kg

(C/kg)
Absorbed dose Rad (Radiation Grey (Gy)
(for X-rays) Absorbed Dose)

Equivalent dose Rem (Rad Sievert (Sv) 1Sv=100rem

(independent of Equivalent Man)
the nature of
ionizing radiation)

Table 1.6.

CHARACTERISTICS OF RADIOGRAPHIC IMAGE

Characteristics Meaning

Contrast Correlation between white and black.

Variation of shading set between the most dark and the
most white point of the image
Definition Clearness of the contour lines of the image.
The contour lines should be: well-defined
clear
precise,
an unclear contour may mean a sign of pathology

Resolution Minimal distance between 2 well distinguishable objects

(when these may be appreciated like 2 different objects)

9
 Table 1.7.

LAWS OF FORMING OF RADIOGRAPHIC IMAGE

Law Cause Conclusions

Conic X-ray beam has a conical Radiographic image is always

projection shape with its top at the X- larger than the object
ray tube and its base on Closer the object is to the screen
the radiographic plate (x-ray film), the image is less
increased
Summation A radiographic image is a 2 items, located in the same plane
of plans two-dimensional image of (in the way of x-ray) but at
a three-dimensional object different distances from the X-ray
tube and film overlap and project
simultaneously
When tilting the X-ray tube, the
image of the object located closer
to the tube, will be shifted more
towards the periphery of the
screen (parallax effect) and so
two objects will be projected
separately
Tangential X-rays travel straight The image of a plane object
projections ahead, along the straight located parallel to the screen is
line always increased but not
deformed

X-rays are neither The image of a plane object

reflected nor refracted by located oblique to the screen is
structures that meet increased and deformed

The image of a plane object

located perpendicularly to the
screen is linear

10
 Table 1.8.

RULES OF IMAGE POSITIONING (ORIENTATION)

Method Conceivable position of the patient, for the radiographic

image orientation

Radiography Vertical (cranial upward, caudal downward), face to face (left

of the patient is on right of the examiner, right of the patient is
on left of the examiner) or profile for lateral projection

CT, MRI The patient is positioned in dorsal decubitus, the examiner

looks at the patient being at his feet (for axial images anterior-
upward, posterior-downward, left-on right, right-on left)

Table 1.9.

CLASSIFICATION OF RADIOLOGICAL CONTRAST MEDIA

Radionegative (lucent, nonopaque), low density: gases

Radiopositive Insoluble (barium sulfate)

(opaque): high
density Liposoluble (iodinated CM)

Water- The elimination mainly through biliary

soluble ways
(iodinated The elimination Ionic
CM) mainly through Non-ionic
urinary ways
Double contrastation (using both radiopositive and radionegative media)

11
 Figure 1.2
Plane (conventional, linear) tomography.

· The patient is immovable.

· X-ray tube and screen are moving synchronously in opposite directions,
pivoting around an axis fixed to the depth chosen for investigation.

Figure 1.3.

Computed tomography

X-ray tube

· The patient is immovable.

· X-ray tube and detectors move around the patient
· X-ray beam is fan-shaped collimated

12
 Table 1.10.

COMPARATIVE ANALYSIS OF PLANE TOMOGRAPHY AND

COMPUTED TOMOGRAPNY

Characteristics Plane tomography Computed tomography

The presence of the Indistinct, but present Not present

image of the structures
located above and below
the plane of section
Grades (levels) of 5 (those of natural ≥2000 (Hounsfield scale)
contrast contrast)

Real plan of section Frontal, most often Axial

Possibility of 3D - +
reconstruction

Cost of investigation Relatively low High

Figure 1.4.
Piezoelectric crystal and piezoelectric effect

At rest Mechanical stress Mechanical

Accumulation of deformation under
electric charge the action of
electricTabelul
current 1.11.

13
 Table 1.11.

PROPERTIES OF ULTRASOUND

Propagation Rectilinear

The velocity of propagation of ultrasound in a

homogeneous medium at a given temperature is constant

The mean velocity of propagation of ultrasound in

biological media is 1540 m/s

When going Reflection It occurs when the object size exceeds

through the ultrasonic wavelength
human body

Occurs at a The greater the

transition zone difference in acoustic
between two media impedance between
with different two media, the more
acoustic impedance ultrasound is
reflected
In regions where
acoustic waves meet
air or bone (large
difference in acoustic
impedance)
investigation
becomes practically
impossible
Absorption

Refraction

Dispersion

14
 Table 1.12.
Methods of ultrasonography
Echography (based on the Doppler-echography (based on the
reflection of ultrasound from reflection of ultrasound from
immoveable structures): mode moving structures): Doppler
methods

· A (amplitude) · Pulsative
· M (motion) · Continual
· B (brightness, two- · Color Doppler
dimensional echography) · Tissular Doppler (tissue in
· 3D motion)
· 4D · Power Doppler (analyzes very
low flows)

Table 1.13.

CHARACTERISTICS OF IONIZING RADIATION

Characteristics Nature Electric Mass Penetration in
charge substances
Ionizing
radiation
α particles Identical with +2 4 atomic Very low –
nucleus of mass 0,5 mm
helium
β particles Electron or -1 or +1 of electron More than α –
positron 0,5 cm
γ-rays Electromagnetic - 0 High
waves
X-rays Electromagnetic - 0 High
waves

15
 Table 1.14

MAIN ADVANTAGES AND DISADVANTAGES OF DIFFERENT

IMAGING METHODS

Method Advantages Disadvantages

Radiography · easily accessible · does not allow

· visualizes fine details functional
· can serve as forensic investigation
document, allows · does not allow
creating archive guiding invasive
· lower radiation dose manipulations

Fluoroscopy · Allows functional · High radiation dose

investigation · Visualizes less
· Allows guiding invasive details
manipulations · Relatively subjective
· Cannot serve as
forensic document

Computed · The possibility of · Ionizing effect

tomography studying small · High cost
anatomical structures · Only transversal
including several mm in (axial) sections are
diameter primary images
· Elimination of
summation
· Possibility of
reconstruction in
different sections and 3D
· Objective densitometric
analysis of structures
· Differentiating density
variation of 0.4-0.5%
· Allows guiding invasive
manipulations

16
USG · Non-invazive · Operator-depending
· Does not use ionizing · Impossibility to
radiation investigate the
· Painless, harmless to the structures covered by
patient air, bone, fat
· Easily accessible
· Relatively low cost
· Portable, can be
performed under any
circumstances (to
bedside, in the operating
room, etc.).
· Can be performed in any
patient and probe
position
· Can be repeated as often
as necessary

MRI · Does not use ionizing · Very high cost

radiation · Relatively less
· Allows different plans of accessible
scanning · Duration of scanning
· Excellent soft tissue is very long
visualization · Impossibility of
· Excellent view of the investigation of the
brain and spinal cord patients having
· Does not require contrast metallic implants
agents to visualize blood · Insufficient view of
vessels, biliary ducts, calcified structures
heart

17
 II. CHEST IMAGING

Scheme 2.1.

EXAMINATION OF A CHEST RADIOGRAPH

1. Identification Name of the patient

Date of examination

2. Estimation of the quality of Position of the patient

the film Exposition

3. Examination of bony
structures and soft tissues

4. Examination of the Cardiac silhouette;

Pulmonary hilum
mediastinum Identification of the trachea and
the main bronchi

5. Examination of pleura Parietal,

Diaphragmal,
Visceral pleura.
Fissures

6. Examination of lung fields From cranial to caudal

Comparison right-left
Pulmonary vasculature.

7. Semiological analysis.
Additional structures

18
 Table 2.1.

SIMPLE CHEST X-RAY. PULMONAY FIELDS AND ZONES

Pulmonary fields Pulmonary zones

Pulmonary Limits Pulmonary Limits

field zone
Superior Inferior Medial Lateral

Apical The upper Clavicle Perihilar Mediastinal The line drawn

thoracic (intern, shadow board through the
contour medial) middle of the
clavicle shadow
that projects over
the lung field

Superior Clavicle The Central The line Medioclavicular

anterior (medial) drawn line (drawn from
arch of the through the the intersection of
2nd rib middle of the the shadow of the
clavicle clavicle with the
shadow that chest wall to the
projects over diaphragm)
the lung field
Medial The The Peripheral Medioclavicul Lateral chest wall
anterior anterior (lateral) ar line (drawn
arch of the arch of the from the
2nd rib 4th rib intersection of
the shadow of
Inferior The Diaphragm the clavicle
anterior with the chest
arch of the wall to the
4th rib diaphragm)

19
 Table 2.2.

SIMPLE CHEST X-RAY.

BASIC ANATOMICAL LANDMARKS

Anatomical structure Landmark on standard chest

radiograph

Frontal The most left point of the cardiac About ≈ 1 -1.5 cm medial from
view shadow the left medioclavicular line
The most right point of the About ≈ 1 – 1.5 cm lateral from
cardiac shadow the right lateral contour of spinal
cord

The upper point of the right Anterior arch of the 5th – 6th rib,
hemidiaphragm inspiration
Left hemidiaphragm 1-2 cm lower than the right one

Bifurcation of trachea T5
Angle 45-70°
Right bronchus is more vertical
than the left one
Aortic arch (upper level of the T3
cardiac shadow)
Right pulmonary hilum Medial zone
Between the anterior arches of the
2nd and the 4th rib
left pulmonary hilum About ≈ 2 cm (or width of a rib)
upper than the right one

Lateral Oblique fissure (right lung) From T4 via right pulmonary

view hilum to the upper point of the
right hemidiaphragm

Horizontal fissure (right lung) Level of the anterior arch of the

4th rib

Oblique fissure (left lung) From the intervertebral disk T3-

T4 via the left pulmonary hilum to
the upper point of the left
hemidiaphragm

20
 Scheme 2.2.
PULMONARY SEGMENTS

Right lung Left lung

Upper
1. Apical
2. Posterior
lobe 1. Apical
3. Anterior 2. Posterior
3. Anterior
4. Superior lingual
5. Inferior lingual
Middle
lobe Note The segments 1 and 2
4. Lateral may form a common segment
5. Medial

Lower
lobe
6. Superior (apical) 6. Superior (apical)
7. Medial bazal
8. Anterior bazal 8. Anterior bazal
9. Lateral bazal 9. Lateral bazal
10. Posterior bazal 10. Posterior bazal

21
 Scheme 2.3.

EXAMINATION OF PULMONARY OPACITY

1. Localization segment,
lobe,
lung

2. Number single,
multiple
disseminated

3. Form Corresponding to anatomical structures

(lob, segment);
Rounded
Ring-shaped
Linear
Triangle
Irregular

4. Dimensions Extensive: total (al the hemithorax)

subtotal: 2/3 of hemithorax
Limited: up to 1/3 of hemithorax
Nodular: less then 2.5 cm

5. Borders ill-defined
well-defined
regular,
irregular

6. Structure homogeneous,
heterogeneous

7. Mediastinum Without displacement

Displaced towards the opacity
Displaced from the opacity

8. Mobility (for fluoroscopy) Immobile

Mobile by itself
Mobile secondary to the movements of
other structures

22
 Algorithm 2.1.

Total or subtotal opacity

Extensive opacity

Position of the mediastinum

Displaced from the Without displacement Displaced towards

opacity the opacity

Structure
Pneumonia
Structure

Homogeneous Heterogeneous Heterogeneous Homogeneous

Pleural Diaphragmal Pulmonary Atelectasis

effusion hernia cirrhosis
(with Pneumonectomia
intestinal
loops)

23
 Algorithm 2.2.

Limited opacity

Limited opacity

Shape

Corresponding to an Does not correspond to

anatomical structure anatomical structures

Situated in costo-
Dimensions diaphragmatic angle,
oblique upper border Pleural
effusion

Lens-shaped opacity Interlobar

Corresponding Smaller
in the region of pleural
to a lobe or
interlobar fissure effusion
segment
Encapsulated
Structure pleural
Parietal
localization effusion
Inflammation
Connected to the Sinostosis
ribs of the ribs
Homogeneous Heterogeneous

Atelectasis Pulmonary
cirrhosis

24
 Algorithm 2.3.

Rounded opacity

Rounded opacity

Number

Single Multiple

Localization
Metastasis

Extrapulmonary Intrapulmonary
Echinococosis
Incapsulated
pleural Contour
effusion
Eosinophilic
infiltration
Diaphragmal
hernia Unclear Clear

Mediastinal Echinococosis
Inflammation
mass

Tuberculom
Liver mass
Peripheral
pulmonary
cancer

25
 Algorithm 2.4.

Ring-shaped opacity

Ring-shaped opacity

Localization

Intrapulmonary Close by thoracic wall

Walls Relaxation of
diaphragm

Thin Thick
Encapsulated
pneumotorax
Aeric cyst
Uniform Patchy
Anomaly of
Liquid ribs
Sanitized (with hydro- Cancer with
cavern aeric level) destruction

Bronchectasis
Present Absent

Absess Tbc cavern

Polichistosis

26
 Algorithm 2.5.

Nodular opacity

Nodular pulmonary opacity

Dimensions

Miliary (1-2 мм)

Mean (5-8 мм) Large
or small (3-4 мм)
(more than de 9 мм)

Contours Contours
Disseminated
hematogenous
tuberculosis
Clear Not clear Clear Not clear
Pneumoconiosis

Pneumonia

Metastasis Pneumonia
Tuberculosis
Pneumonia
Metastasis
Pulmonary edema
Tuberculosis

27
 Algorithm 2.6.

Pulmonary hyperlucency

Pulmonary hyperlucency

Unilateral Bilateral

Pulmonary pattern in the

Chronic pulmonary
hyperlucent region emphysema
Congenital heart
disease with
Absent Present pulmonary
hypovasculature

Compensatory
Pneumothorax
hyperpneumatosis
Valve bronchial
obstruction

28
 Algorithm 2.7.

Examination of changers in pulmonary hilum

Changers in pulmonary hilum

Unilateral Bilateral

Concomitant changes of the lung Changes neighboring organs

Absent
Present Heart Lungs Mediastinal lymph
nodes
Age of the
patient Cardiovascular
Changers in pulmonary · Viral
disease with
hilum secondary to lymphadenopathy,
heart dilatation
pulmonary disease · Lymphadenopathy in
systemic diseases
· Metastases

Young, Adult,
child elderly
Working in dusty
conditions in antecedents

Hilum
Tuberculous contour
bronchadenitis Yes No

Clear, Unclear
polycyclic Pneumoconiosis

Disseminated
Mediastinal lymph Central pulmonary
tuberculosis
node metastases cancer

29
 Table 2.3.

Disturbance of bronchial patency

The degree of Changes in ventilation Radiological
bronchial obstruction symptom
Partial obstruction The amount of the air Diminution of lung
inhaled through the affected transparence
bronchus and exhaled is the
same, but less than normal,
reducing the volume of the
lung

Valve obstruction The air is inhaled through Hyperlucency

the affected bronchus, but
cannot be exhaled being
accumulated in the lung

Complete obstruction Bronchus is closed, no air is Opacity

inhaled through it

Figure 2.1.

The degree of bronchial obstruction

a) b) c)

a) Partial obstruction
b) Valve obstruction
c) Complete obstruction

30
 Table 2.4.

RADIOLOGICAL SEMIOLOGY OF PULMONARY PATHOLOGY

SYNDROMES

Radiological Opacity Total/subtotal

changers: Limited
Rounded
Ring-shaped
Nodular

Hyperlucency

Changers of
pulmonary hilum

Changers of Decreasing
pulmonary pattern
Accentuation

Deformation

Localization of Parietal syndrome Soft tissue pathology

pathological Bone pathology
changers:
Pleural syndrome Pleural effusion
Pneumothorax
Hydropneumothorax
Pleural calcification

Mediastinal Presence of air in

syndrome mediastinum
Presence of liquid in
mediastinum
Presence of anomalous tissue
in mediastinum

Pulmonary syndrome Alveolar

Interstitial
Bronchial
Vascular
Parenchymatous: Nodular
Cavitary

31
 III. CARDIOVASCULAR IMAGING

Figure 3.1.
Evaluation of cardio-thoracic ratio (CTR)

· Cardio-thoracic ratio (CTR) is the ratio between the maximal transverse

diameters of cardiac shadow and of the chest, measured on a chest X-
ray in posterior-anterior projection.

Table 3.1.
Normal CTR

Age Normal CTR

New-born up to 0,58
Adolescents and adults 0,44-0,48
Elderly 0,50-0,55

32
 Table 3.2.

Normal pulmonary circulation

Pulmonary circulation Normal pulmonary pattern (pulmonary

particularities vasculature)

· Low blood pressure in · Consists of pulmonary arteries and

pulmonary vessels veins (in young and adult persons; in
(25/10 mm Hg) elderly persons (after 50-55 years
· Low vascular resistance, old) it includes interstitial connecting
Blood depositing tissue as well
function · Dichotomic division of vessels (each
· Blood vessels of both divides in 2)
systemic and pulmonary · Diameter of each following vessel is
circulation are present 2 times less than this of the previous
· Arterio-venous and · In orthostatic radiograph pulmonary
veno-arterial pattern is more apparent in inferior
anastomoses are present regions
(normally, blood · 1,5-2 cm to the thoracic wall,
circulation via pulmonary vasculature is no more
anastomoses is ≤ 1% of seen (capillary segment)
minute-volume of · Radial direction of the pulmonary
pulmonary circulation) arteries in basal regions
· Dependent on respiratory · Horizontal direction of the pulmonary
motions veins in basal regions, more apparent
in middle and inferior regions
· Normal pulmonary hilum in adult
person: width of right hilum is ≤ 14 -
15 mm and is the same or 1-2 mm
less than the width of the space
between the right hilum and the
cardiac shadow

33
 Table 3.3

Pulmonary pattern disturbances in cardiovascular pathology

Syndrome Cause Pulmonary pattern In which pathology

disturbances it may occur

Hypovolemia Decrease of · Pulmonary Congenital heart

the amount hyperlucency diseases with
of blood that · Narrowing of pulmonary
comes in peripheral pulmonary hypovasculature
pulmonary arteries
circuit in · Narrowing of
systole pulmonary hilum, its
structure is
unchanged
(sometimes it is
difficult to visualize)
· Pulmonary artery
convexity may be
extruded, concave or
normal

Hypervolemia Increase of · Dilation of Congenital heart

the amount pulmonary vessels diseases with
of blood that · Transparent lung pulmonary
comes in fields hypervasculature
pulmonary · Dilation of
circuit in pulmonary hilum, its
systole structure is unchanged
· Nodular opacities
in the region close to
hilum (transversal
section of dilated
vessels)
· The waist of the
heart is diminished,
pulmonary artery
convexity is extruded

34
Venous Disturbances · Homogenization · Congenital or
congestion of of pulmonary hilum acquired
pulmonary · Diminution of mitral stenosis
venous transparence of lung · Mitral
return fields insufficiency
· Unclear contour · Left ventricle
of blood vessels and insufficiency
bronchi · Total cardiac
· Kerley lines failure

Pulmonary Increase of · Dilation of Diseases which lead

hypertension pulmonary pulmonary hilum, to hypervolemia and
vascular its structure is venous congestion in
resistance unchanged the absence of the
· Nodular opacities opportune treatment
in the region close
to hilum
(transversal section
of dilated vessels)
· Decrease of
pulmonary
vasculature in
peripheral regions
· Pulmonary artery
convexity is
extruded
· Narrowing of
pulmonary veins

35
 Figure 3.2.

Cardiac convexities. Simple chest X-ray

Aortic knob
Ascending aorta,
superior vena cava Pulmonary artery

Left atrial auricula

Right atrium
Left ventricle

36
 Table 3.4.

Pathological cardiac configurations

Cardiac Mitral Aortic Tricuspid

configuration (triangular,
trapezoid,
Structures cardiomyopathic)
involved
Right atrio-vasal Displaced Displaced Displaced cranially
angle cranially caudally

Waist of the heart Smoothed, Extruded Smoothing of all

Pulmonary artery cardiac convexities
convexity is
extruded

Aortic knob Diminished or not Extruded

seen

Dilation of the May be LV LV dilation The heart shadow

heart shadow dilation. May be dilation is dilated
May be dilation of the ascending bilaterally, „lies”
of RA convexity aorta on the diaphragm
and double
contour because
of LA dilation

Pathologies · Mitral · Aortic · Important

valvulopathy valvulopathy pericardial
· Atrial septal · Coarctation of effusion
defect aorta · Polyvalvulopathy
· Persistent ductus · Arterial including that of
arteriosus hypertension the tricuspid valve
· Tetralogy of · Dilative
Fallot cardiomyopathy

37
 Table 3.5.

Possibilities and value of imaging modalities

in assessing cardiac pathology

Imaging modality

Signs Radiological Priority method

Nuclear
contrast CT ECHO MRI
medicine
methods
Morphological
changes ++ +++ +++ +++ + ECHOCG

Functional
++ ++ +++ +++ ++ ECHOCG
status
Function of
the valves + + +++ +++ - ECHOCG

Coronary
Coronary
arteries +++ ++ - ++ -
angiography
Myocardial
perfusion and Nuclear
- + - +++ +++
metabolism medicine

Thoracic
++ +++ ++ +++ + CT, MRI
aorta

38
 Scheme 3.1.

Sequence of primary investigation of a patient with cardiovascular

pathology

1. · Anamnesis
· Clinical examination

2. Electrocardiogram

3. Simple chest X-ray

4. Echocardiography

5. Diagnostic conclusion.

6. If diagnosis is not clear, functional investigation and/or additional

imaging methods using:

· Angiography
· CT
· MRI
· Myocardial scintingraphy

39
 IV. IMAGING OF DIGESTIVE TUBE AND HEPATOBILIARY
SYSTEM

Table 4.1.

BASIC METHODS OF THE DIGESTIVE TUBE CONTRASTATON

(BARIUM MEAL TECHNIQUES)

Method Contrast agents Object to be visualized

In thin layer (small Radiopositive Relief of mucosa, folds.

amount of contrast (barium sulphate)
media)
Double contrast Radiopositive Thin relief of mucosa (area
(barium sulphate) + gastrica). Visualization of
radionegative vegetations.
(air)

In tight filling Radiopositive Shape, position, dimensions,

(barium sulphate) peristalsis of the digestive
tube segment.

Figure 4.1.
Topography of digestive tube organs

Stomach
Duodenum
Spleen flexure
Hepatic flexure
Transversal colon
Ascending colon
Jejunum
Cecum Descending colon

Appendix
Ileum
Rectum
Sigmoid

40
 Figure 4.2.

Projection of the abdominal parenchymatous organs

Simple abdominal X-ray

Table 4.2.

Simple abdominal X-ray in acute abdominal syndrome

(Orthostatic position)

Cause of acute abdominal

syndrome Radiological findings

Pneumoperitoneum (subdiaphragmal
Perforation of a cavity organ
free air in peritoneal cavity)

Intestinal occlusion Hydro-aeric levels

41
 Table 4.3.
RADIOLOGICAL ANATOMY OF DIGESTIVE TUBE ORGANS
Organ Localization Folds Dimensions Particularities
Oesophagus The posterior Longitudinal Maximal Basic physiological
mediastinum width up to narrowings:
2-3 cm · Pharyngoesophageal
(level of the VI-th
Length cervical vertebra)
usually · At the level of the
about 25cm aortic arch
· At the level of the
tracheal bifurcation
· Diaphragmal
Stomach The left upper Longitudinal in
part of the the region of
abdominal lesser curvature,
cavity in the region of
greater curvature
the folds are
oblique and may
form an
irregular contour
Duodenum Behind the Longitudinal in Length - 24 A fixed segment
stomach, duodenal bulb, cm (excepting the bulb).
caudally from transversal in Forms Treitz angle
the pyloric the rest of the with jejunum
region segments
Jejunum Predominantly Transversal Total length
in the left part („like bird’s is 2-3 m in a
of the feather”), living
abdominal evident person;
cavity about 6 m in
Ileum Predominantly Transversal dead body
in the small („like bird’s
pelvis feather”), less
evident, not
clearly viewed
in the distal
regions
Colon Peripheral It is possible to see
regions of the haustra coli,
abdominal sometimes - taenia coli
cavity

42
 Table 4.4.

PASSAGE OF CONTRAST MEDIA VIA DIGESTIVE TUBE

Segment of Beginning of appearance Complete evacuation of

digestive tube of contrast media in the contrast media
organ after oral use

Oesophagus Immediately 5-7 seconds

Stomach Several seconds From 1.5-2 to 4 hours; most

often about 1.5 hours

Duodenum 30 seconds

Jejunum 40 seconds 3-5 hours

Ileum About 1.5 hours 8-9 hours

Colon 3-4 hours (ileocecal Complete contrast

passage and cecum) enhancement of all parts of the
colon within 18-24 ore

43
 Scheme 4.1.

PATHOLOGICAL CHANGES OF DIGESTIVE TUBE

FUNCTIONAL MORPHOLOGIC
Changes Hypertonia Changes Ptosis
of tonus Hypotonia of position Ascension (hernias including)
Atonia Displacement
Spasm Torsion
Traction
Changes Hyperkinesia
of Hypokinesia Changes of Pathological mobility of
peristalsis Akinesia mobility normally fixed segments
Decreased mobility of normally
mobile organs

Changes Hypersecretion Changes Length Dolichosegments

of of Brachisegments
secretion dimension
Changes Acceleration Width Megasegments
of transit Slowing Stenosis

Changes Minus- Recess

of contour filling Incisure
Amputation
Impression
Rigidity
Plus- Niche
filling Diverticulum
Spicules

Changes of shape
Changes Fold Hypertrophy
of relief dimensions Atrophy

Anomalous Deviation
fold Convergence
orientation Interruption
Disorganization

44
 Table 4.5.

DIFFERENCIAL DIAGNOSIS OF DIGESTIVE TUBE

STENOSES

Characteristics Benign stenosis Malignant stenosis

Length Long Short

Number Single or multiple Single

Transverse Axial Asymmetric

Change of size Progressive Sharp

increase:

Folds Not interrupted Interrupted, disorganized

Other possible signs Rigidity

45
 Table 4.6.

Radiological investigation of the biliary tract

The way of introduction Visualized

Contrast method
of contrast agent structures
Without contrast (simple abdominal X-ray) Radiopositive
concrements in
gallbladder and bile
ducts

Peroral cholecystography Per os Gallbladder

Intravenous Intravenous Gallbladder and bile

cholecystocholangiography ducts

Endoscopic retrograde By catheter introduced in Biliary tree,

cholagniopancreatography the ductus choledochus pancreatic duct
through Oddi sphincter,
introduced in the
duodenum
endoscopically
Percutaneous transhepatic In bile ducts by Bile ducts,
cholangiography percutaneous puncture of sometimes
the liver gallbladder
Perioperative and By the catheter (tub t Bile ducts
postoperative Kehr) placed in ductus
cholangiography cysticus, perioperatively
(usually during
cholecystectomy). The
investigation is
performed during surgery
or in the postoperative
period

46
 Scheme 4.2.

IMAGING SIGNS OF LIVER PATHOLOGY

Normal liver Homogenous

(Ultrasonography) Micronodular
structure

Tubular formations Portal vein

with narrow walls in Artery
the region of the Hepatic duct
hilum

Diffuse liver Liver dimensions Enlarged

diseases Diminished

Structure Heterogeneous

Echogenity Hyperechoic
(if USG performed) Hypoechoic
Calcification

Vascularization Unchanged
Portal hypertension

Focal liver Dimensions

diseases
Localization Lobe
Segment

Number Single
Multiple

Structure Homogenous
Heterogeneous

Density Solid
Fluid

Contour Well-defined (regular or

iregular)
Ill-defined

47
Indirect signs Deformation of contours

Impression/amputation of
vascular and/or biliary
structures

Associated changes Cirrhosis

Steatosis
Portal hypertension

48
 V. IMAGING OF OSTEO-ARTICULAR SYSTEM

Scheme 5.1.
Types of fracture

Mechanism of Mechanical power

fracture
Stress ("tired")
By firearm
Pathologic fractures

Relation between the Direct

place of application of
Indirect
force and the place of
fracture

Number Single
Multiple
Comminuted
Simultaneous
Line of fracture Complete Direction of line Transversal
of fracture
Oblique
Spiral
Longitudinal
In shape of T, V, Y
Incomplete „Green steak”
Subperiosteal
Depressed
Fissure

49
 Table 5.1.

Radiological changes of bones and joints

Bone Changes of Hyperostosis

changes shape
Exostosis
Oedostosis („bone swelling”)
Scoliostosis
Changes of Atrophy
dimension
Hypoplasia
Hyperplasia
Dysplasia

Changes of Destructive Osteoporosis

structure
Osteolysis
Osteodestruction
Osteonecrosis

Constructive Osteosclerosis

Changes of Linear
periosteum:
Lamellar
Periostitis
/periostosis Dentate
Spicular
Spur periosteum ("cap")
Heterogeneous ossification

Changes of Traumatic Fracture

axis and
Luxation
position
Scoliostosis

50
Articular Changes of Thickness Widening
changes intraarticular
Narrowing
space
Disappearance
Shape
Transparence
Changes of articular surfaces

Changes of Volume Thickening

soft tissues
Reduction in size
Dislocation
Structure Induration
Calcification
Aetiology Primitive (of Inflammation
tissue itself)
Trauma
Tumour
Secondary to bone pathology

51
 Table 5.2.
The most frequent bone tumours

Benign tumours Malignant tumours

Name Tissue Name Tissue

Osteoblastoclastoma Bone Osteosarcoma Bone
Osteoid osteoma
Osteoma

Chondroma Cartilage Chondrosarcoma Cartilage

Chondroblastoma
Chondromyxoid
fibroma

Osteochondroma Bone and Sarcoma Ewing Reticuloendothelial

cartilages

Myxoma Connective Reticular Reticuloendothelial

Lipoma tissue sarcoma
Fibroma

Angioma Vascular Angiosarcoma Vascular structures

structures
Eosinophilic Reticuloidal, Periosteal Periosteum
granuloma eosinophils fibrosarcoma

52
 VI. IMAGING OF KIDNEYS AND URINARY SISTEM

Figure 6.1.

Simple abdominal X-ray. Variants of concrements (stones) localization

1. Renal stone in the superior calyx

2. Renal stone in the middle calyx
3. Renal stone in the inferior calyx
4. Concrement in the renal pelvis
5. Concrements in the ureter
6. Triangular concrement in the ureter
7. Calculus in the bladder-urethral orifice

53
8. Multiple small stones in the inferior part of ureter
9. Calculi in the urinary bladder
10. Calculi in the prostate
11. Phleboliths
12. Transverse apophysis ossification of the 3rd lumbar vertebra
13. Calcification in the right adrenal gland
14. Pancreatic calcifications
15. Splenic calcification
16. Calcified costal cartilage
17. Biliary concrements
18. Appendicular concrement
19. Calcified retroperitoneal lymph node
20. Calcified lymph nodes
21. Calcified fibroma
22. Calcified renal vessel
23. Calcified mesenteric lymph node
24. Calcified splenic artery
25. Calcified wall of a cyst (in the left kidney)
26. Calcified hydatic cyst (in the liver)

54
 Figure 6.2. (a, b)

Renal topography

a)

40-50°

b)

55
 Figure 6.3.
Renal structure

Papilla
Sinus fat

Medullar substance

Pelvis cap
Pyramid
Bertin
column

Cortical substance

Capsule
Rod

Fornix

Pelvis

56
 Table 6.1.
POSITION OF KIDNEYS
Orientation of renal
Age Position of kidney pelvis

During intrauterine In the pelvis Lateral

period

< 4 years Gradually rising to lumbo- Undergoes rotation

diaphragmatic bed around the
longitudinal axis
> 4 years Situated in lumbo-diaphragmatic Medial
bed on the sides of the spine,
retroperitoneal,
between the XI-th thoracic
vertebra and the II-nd-III-rd
lumbar vertebrae

Scheme 6.1.
Developmental abnormalities of urinary system
Anomalous Renal agenesis · Absence of kidney (more often, on the
number left)
· Absence of renal artery
· Compensatory hypertrophy of
contralateral kidney

Renal aplasia ·Embryonal bud is present

·The kidney is rudimentary, frequently
with cystic degeneration and
calcifications
·Hypoplasia of the renal artery
·Absence of pelvis and ureter - blind
ureter

Supernumerary · an independent kidney with its separate

kidney excretory system and vascularization
· ectopic kidney, most often inferior
lumbar
· ectopic inflow of ureter

57
 Duplication of · common parenchymal mass, with two
kidney unequal systems of calyx-pelvis
· complete reno-ureteral duplicity
· incomplete reno-ureteral duplicity

Anomalous Renal hypoplasia · partial

dimension · total
· uni- or bilateral

Renal · usually bilateral enlarged kidneys

hypertrophia · thickened renal parenchyma
· increased diameter of excretory
cavities
· increased diameter of vessels
· Harmonious renal proportions
· Not often unilateral - compensatory
hypertrophia (in case of agenesia,
hypoplasia)

Anomalous Persistent fetal · normal – disappears at the age over 4

shape lobulation years
· irregular kidney contour, normal
vasculature, normal excretory cavities

Renal fusion § bilateral · Horseshoe kidney

symmetric · S-shaped
(„sigmoid”) kidney
§ bilateral · L-shaped kidney
asymmetric · Boulder-shaped
kidney
§ unilateral
asymmetric

Anomalous Ectopia · cranial ectopia – intrathoracic kidney

position · caudal ectopia – inferior lumbar,
pelvic, presacral kidney
· cross ectopia

Malrotaţion · anterior, posterior, external orientation

of the hilum
· multiple renal arteries, atypical
emergence

58
Anomalous Cystic dysplastic · multicystic kidney
structure of kidney diseases · segmental cystic dysplasia
parenchyma · renal hypoplasia with polycystic
dysplasia
· multiple cysts associated with urinary
way obstruction

Hereditary cystic · hepatorenal polycystic disease

kidney disease · cystic disease of the medulla
· microcystic renal disease with
congenital nephrotic syndrome

Renal cysts in · tuberous sclerosis or Bourneville’s

hereditary disease
malformation · Lindaun disease
syndromes · hepatocerebrorenal syndrome

Anomalous · Multiple renal arteries - (accessory arteries) polar

renal vessels (aberrant) 43,5% (Hellstrőm)
· Absence of renal arteries, hypoplasia of renal arteries

Excretory tract · Duplicity of calyx, pelvis

malformations · Microcalyx
· Megacalyx (hypoplasia of pyramids with intact cortical
substance) – wide pelvic rods
· Blind ureter
· Diverticulum of calyx
· Ureterocele - sacciform dilatation of the terminal ureter
0.5-4cm (snakehead)
· Ectopia of ureteral ostia
· Retrocaval ureter
· Congenital hydronephrosis - parietal neuromuscular
dysplasia
· Congenital ureteral stricture at the pyelocaliceal junction,
ureterovesical junction
· Other malformations - stenosis, endoluminal membranes,
torsions

59
 Figure 6.4.

Nuclear medicine. Renography.

Segments of renal curve.

I. Vascular segment
II. Accumulation segment (filtration/secretion)
III. Segment of elimination (excretion)

Figure 6.5.

Pathological changes of renal curve

a) Obstructive changes at the level of the

right kidney

60
b) Reduced renal function of the left
kidney

c) Bilateral chronic renal failure

61
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