Mr Wandah

Medical imaging 101 lecture notes

RHIBMS, Buea

Medical imaging
Medical imaging is the technique and process of imaging the interior of a body for clinical
analysis and medical intervention, as well as visual representation of the function of some
organs or tissues (physiology). Medical imaging seeks to reveal internal structures hidden by
the skin and bones, as well as to diagnose and treat disease. it also establishes a database of
normal anatomy and physiology to make it possible to identify abnormalities. In radiography,
sound waves or radiations are used to generate images.
Radiation is defined as a moving form of energy. It can be classified into two categories, i.e.,
ionizing and non-ionizing type. Ionizing radiations can be further classified into
electromagnetic radiation (matter less) and particulate radiation. Electromagnetic radiations are
energy packets (photons) traveling in the form of a wave. Basic examples of electromagnetic
radiation are x-rays and gamma rays. Particulate radiation consists of a beam of particles that
can be either charged or neutral. Electromagnetic radiations have high energy and can easily
penetrate body tissues. Ionizing radiation is mainly used for diagnostic purposes.
Medical imaging techniques
With the ever-evolving advances of modern technology, doctors now have more options than
ever when it comes to diagnosing a patient’s condition. There are both invasive and non-
invasive methods.
A. Diagnostic radiology
it is a group of diagnostic methods that use non-invasive techniques to locate and identify
certain conditions and diseases. The types of tests and equipment used in diagnostic radiology
generally use a low dose of radiation to generate a detailed image of a specific area. Radiology
is essential for diagnosing many diseases and conditions, particularly cancer. These procedures
can be anything from MRI and CT scans to X-rays and ultrasounds. Diagnostic tests can consist
of physical examinations and biopsies to pregnancy tests and cancer screenings. Diagnostic
testing is defined as any approach used to collect information in order to make an informed
clinical decision about a patient. While the types of diagnostic tests can vary, they all are used
for the goal of estimating the probability of a certain disease or condition in a person.
Some of these diagnostic methods require a compound to be consumed or a chemical to be
injected to increase vein visibility. There are a number of different diagnostic radiology
methods available in the current age of medicine.

• Ultrasound • Nuclear Medicine Scans

• Computed Tomography (CT) Scans • Radiography (X-Rays)

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 • Magnetic Resonance Imaging • Fluoroscopy
(MRI) Scans • Mammography
• Coronary Calcium Scoring • Arthrogram
• Virtual Colonoscopy
1. Ultrasound
Principle
Medical ultrasound is based on the use of high-frequency sound to aid in the diagnosis and
treatment of patients.
Procedure
In an ultrasound exam, a transducer both sends the sound waves and records the echoing
(returning) waves. When the transducer is pressed against the skin, it sends small pulses of
inaudible, high-frequency sound waves into the body. As the sound waves bounce off internal
organs, fluids and tissues, the sensitive receiver in the transducer records tiny changes in the
sound's pitch and direction. A computer instantly measures these signature waves and displays
them as real-time pictures on a monitor. The technologist typically captures one or more
frames of the moving pictures as still images. They may also save short video loops of the
images.

In most ultrasound exams, the patient will lie face-up on an exam table that can be tilted or
moved. Patients may turn to either side to improve the quality of the images. The radiologist
will apply a water-based gel to the area of the body under examination. The gel will help the
transducer make secure contact with the body. It also eliminates air pockets between the
transducer and the skin that can block the sound waves from passing into the body. The
sonographer places the transducer on the body and moves it back and forth over the area of
interest until it captures the desired images.

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Result interpretation and abnormalities
Case 1: pregnancy ultrasound
1. Subchorionic haemorrhage
This condition occurs when the membranes or the sac that holds the fetus in the uterus, partially
separate from the uterine wall. Blood leaks into the area between the uterine wall and the
pregnancy which may be visible on ultrasound.

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 2. Abnormal yolk sac

The yolk sac is the earliest fetal structure that forms in the gestational sac within the uterus
during pregnancy. Having a yolk sac that is too large or too small has been associated with
pregnancy loss

3. Low fetal heart rate

They are required in case of;

• Brain: Imaging the neonatal brain.

• Thorax: Confirms pleural effusions and pleural masses.
• Abdomen: Visualizes liver, gallbladder, pancreas, kidneys, etc.
• Pelvis: Useful for monitoring pregnancy, uterus and ovaries.
• Peripheral: Assesses thyroid, testes and soft - tissue lesions.
Benefits

• Most ultrasound scanning is non-invasive (no needles or injections).

• Occasionally, an ultrasound exam may be temporarily uncomfortable, but it should not
be painful.

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 • Ultrasound is widely available, easy to use, and less expensive than most other imaging
methods.
• Ultrasound imaging is extremely safe and does not use radiation.
• Ultrasound scanning gives a clear picture of soft tissues that do not show up well on x-
ray images.
• Ultrasound is the preferred imaging modality for the diagnosis and monitoring of
pregnant women and their unborn babies.
• Ultrasound provides real-time imaging. This makes it a good tool for guiding minimally
invasive procedures such as needle biopsies and fluid aspiration.
Risks

• Standard diagnostic ultrasound has no known harmful effects on humans.

Limitations of General Ultrasound Imaging

• Ultrasound waves are disrupted by air or gas. Therefore, ultrasound is not an ideal
imaging technique for the air-filled bowel or organs obscured by the bowel. Ultrasound
is not as useful for imaging air-filled lungs, but it may be used to detect fluid around or
within the lungs.
• Similarly, ultrasound cannot penetrate bone, but may be used for imaging bone fractures
or for infection surrounding a bone.
• Large patients are more difficult to image by ultrasound because greater amounts of
tissue weaken the sound waves as they pass deeper into the body and need to return to
the transducer for analysis. Ultrasound has difficulty penetrating bone and, therefore,
can only see the outer surface of bony structures and not what lies within (except in
infants who have more cartilage in their skeletons than older children or adults).
Radiographers typically use other imaging modalities such as MRI to visualize the
internal structure of bones or certain joints.
Subtypes of ultrasound

• Prostate or Transrectal Ultrasound

• Transvaginal Ultrasound
• Ultrasound-Guided Biopsies
• Liver biopsy
• Prostate biopsy
• Thyroid biopsy
CT scan
Computed tomography (CT) scan, also known as computerized axial tomography (CAT), or
CT scanning computerized tomography is a painless, non-invasive diagnostic imaging
procedure that produces cross-sectional images of several types of tissue not clearly seen on
a traditional X-ray. CT scans may be performed with or without contrast medium. A contrast
may either be an iodine-based or barium-sulfate compound that is taken orally, rectally, or

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intravenously which can enhance the visibility of specific tissues, organs, or blood vessels. The
duration of the procedure will depend on the area being scanned.
Patient Preparation
The roles and responsibilities of a nurse extend throughout the whole duration of the CT scan
procedure — from taking patient’s history, obtaining informed consent, preparing the patient,
and providing education.
Procedure
The protocol and procedures for computed tomography (CT) scan varies per area but generally,
the following steps are followed:

• The patient is positioned on an adjustable table inside an encircling body scanner

(gantry); straps and pillows may be used to help in maintaining the correct position.
• The patient may be instructed to hold his breath during the scanning.
• A series of transverse radiographs are taken and recorded
• The information is reconstructed by a computer and selected images are photographed.
• Once the images are reviewed, an I.V. contrast enhancement may be ordered and
additional images are obtained. The patient is assessed carefully for adverse effects to
the contrast medium.

The CT scan uses X-rays (A form of high energy electromagnetic radiation that can pass
through most objects, including the body. X-rays travel through the body and strike an x-ray
detector (such as radiographic film, or a digital x-ray detector) on the other side of the patient,
forming an image that represents the “shadows” of objects inside the body)).

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As with all x-rays, dense structures within the body—such as bone—are easily imaged, whereas
soft tissues vary in their ability to stop x-rays and therefore may be faint or difficult to see. For
this reason, contrast agents have been developed that are highly visible in an x-ray or CT scan
and are safe to use in patients. Contrast agents contain substances that can stop x-rays and are
therefore more visible on an x-ray image. For example, to examine the circulatory system, an
intravenous (IV) contrast agent based on iodine is injected into the bloodstream to help
illuminate blood vessels. This type of test is used to look for possible obstructions in blood
vessels, including those in the heart. Oral contrast agents, such as barium-based compounds,
are used for imaging the digestive system, including the esophagus, stomach, and
gastrointestinal (GI) tract.
Types

The following are the different types of computed tomography (CT) scans:

Abdominal and pelvic

CT scan of the abdomen and pelvis combines radiologic and computer technology to determine
the cause of unexplainable abdominal or pelvic pain and diseases of the bladder, uterus,
liver, colon, small bowel, and other internal organs.

Indication Abnormal Results

• Detects inflammatory process

• Abscesses
• Inspect soft tissue and organs of the abdomen, pelvis
• Cysts
and retroperitoneal space
• Obstructive disease from
• Evaluates trauma
a tumor or calculi
• Helps in the staging of neoplasms
• Primary and metastatic
• Detects edema, hemorrhage, cysts, and tumors
neoplasms
• Measures effectiveness to chemotherapy
Bone and skeletal

Computed tomography (CT) scan of the bone is indicated to provide information and assess the
severity of different bone diseases and conditions such as fractures, cancer, and infection.

Indication Abnormal Results

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 • Identify any joint abnormalities
• Determine abnormalities in the upper and lower
• Bone fractures
spine
• Joint abnormalities
• Detect unsual active bone formation
• Primary bone tumors
• Establish the presence and extent of fractures,
• Soft-tissue tumors
ligament, or tendon injuries, primary bone
• Skeletal metastasis
tumors, skeletal metastases, and soft tissue
tumors
Brain

Also known as “cranial CT scan” or “Head CT”. It is indicated to provide detailed information
on head injuries, stroke, brain tumors and other diseases affecting the brain.

Indication Abnormal Results

• Identify intracranial abnormalities and

lesions
• Arteriovenous malformation
• Determine focal neurological
• Cerebral atrophy
abnormalities
• Cerebral edema
• Guides brain surgery or biopsy of
• Congenital anomalies
brain tissue
• Edema
• Evaluate suspected head injury such as
• Hydrocephalus
subdural hematoma
• Intracranial tumors
• Monitor the effectiveness of
• Intracranial hematoma
chemotherapy, radiotherapy, or
• Infarction
surgery, as part of the management of
intracranial tumors
Ear

In CT scan of the ear, the radiologist is able to diagnose conditions such as chronic otitis media,
ear infections, cholesteatoma, conductive hearing loss, mastoiditis, and cochlear implants.

Indication Abnormal Results

• Diagnose cochlear abnormalities

• Investigate ossification of the cochlea coils
• Cochlear abnormalities
prior to cochlear implantation
• Osseous changes of the external
• Depict osseous changes in the petrous
auditory canal and middle and inner
and temporal bone
ear structures
• Determine the appropriate surgical and
• Tympanosclerosis
therapeutic method for patients with inner
and middle ear disorders

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• Evaluate postsurgical therapy of patients
with middle and inner ear disorders
• Differentiate cholesteatoma from chronic
inflammation
• Evaluate the cause of bilateral hearing loss

Renal (Urography)

A renal scan examines the structural and functional abnormalities of the kidney. It is indicated
to detect tumors, obstructions, and lesions.

Indication Abnormal Results

• Abscesses
• Calculi
• Congenital anomalies
• Identify and diagnose renal abnormalities, such as • Hematomas
calculi, obstruction, tumor, polycystic disease, • Kidney infection or damage
congenital anomalies, and abnormal fluid • Lymphoceles
accumulation • Obstructions
• Evaluate retroperitoneal pathologies • Polycystic kidney disease
• Renal cell carcinoma
• Renal cysts or masses
• Vascular or adrenal tumors
Thoracic

CT scan of the chest aids in determining the cause of an unexplained cough, fever, difficulty of
breath, chest pain, and other respiratory symptoms. It is recommended for screening of possible
lung cancer in its early, curable stage.

Indication Abnormal Results

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• Diagnose a dissection or leak of an aortic aneurysm or aortic arch
aneurysm
• Diagnose the invasion of a neck mass in the thorax
• Differentiate emphysema or bronchopleural fistula from a lung
• Accumulation of
abscess
fluid, blood, or fat
• Distinguish tumors adjacent to the aorta from aortic aneurysms
• Aortic aneurysms
• Differentiate tumors from calcified lesions (signifies tuberculosis)
• Cysts
• Detect the mediastinal lymph nodes
• Enlarged lymph
• Assess primary malignancy that may metastasize to the lungs,
nodes
especially in the patient with a primary bone tumor, soft-tissue
• Nodules
sarcoma, or melanoma
• Pleural effusion
• Identify the extent of lung diseases such as bronchiectasis,
• Tumors
emphysema, and diffuse interstitial lung disease
• Locate observed neoplasms (e.g., Hodgkin’s disease), especially with
the mediastinal involvement
• Plan radiation therapy

Computed tomography (CT) is contraindicated in:

• Pregnant women/patient (absolute contraindication)

• Patients with a known allergy to contrast agent
• Patients with claustrophobia
• Patients with renal impairment unless the benefits outweigh the risks
• Patients with hyperthyroidism or toxic goiter (induce thyrotoxic crisis)
• Patients with complications after a previous administration of a contrast
• Patients with severe obesity (usually more than 300 pounds)
Nursing Responsibilities during CT Scan

The following are the nursing interventions and nursing care considerations for a patient
undergoing computed tomography:

Before the procedure

The following are the nursing interventions before computed tomography:

• Informed Consent. Obtain an informed consent properly signed.

• Look for allergies. Assess for any history of allergies to iodinated dye
• Instruct the patient not to eat or drink for a period of time especially if a contrast
material will be used.

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 • Provide information about the contrast medium. Tell the patient that a mild
transient pain from the needle puncture and a flushed sensation from an I.V.
contrast medium will be experienced.
• Inform about the duration of the procedure. Inform the patient that the
procedure takes from five (5) minutes to one (1) hour depending on the type of
CT scan and his ability to relax and remain still.
After the procedure

The nurse should be aware of these post-procedure nursing interventions after computed
tomography (CT) scan:

•Diet as usual. Instruct the patient to resume the usual diet and activities unless
otherwise ordered.
• Encourage the patient to increase fluid intake (if a contrast is given). This is
so to promote excretion of the dye.
Normal Results

The following are the expected normal results of computed tomography (CT) scan

•
Specific type of CT scan reveals normal findings
• Normal findings on a CT scan shows bone (which has the densest tissue) appears
as white areas. Tissues densities will show as shades of gray, and fat tissue
appear as black or dark gray. Cerebrospinal fluid (has no tissue) will appear as
black. Air will also look black and darker than fat.
Abnormal Results

The abnormal results of a computed tomography (CT) scan vary per area.

• The specific type of CT dependent on the area of study (see abnormal results
above).
Benefits of CT

• The procedure is swift

The whole procedure is fast, safe and pain free for patients. Patients are scanned efficiently and
the referring doctor is able to access results almost immediately.
• Highly detailed images
Our CT scans produce high-resolution and highly detailed images, detecting abnormalities
which may not appear in other scans. This is crucial when determining whether a patient
requires surgery, and reduces the need for exploratory surgery, not to mention playing an
essential role in the diagnosis and treatment of certain cancers.
• Precise results
The highly-detailed images mean precise and accurate results, ensuring you receive the best
possible treatment plan for your diagnosis, particularly in the treatment of tumours and cancers.

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MRI

An MRI (magnetic resonance imaging) scan is a painless test that produces very clear images
of the organs and structures inside the body. MRI uses a large magnet, radio waves and a
computer to produce these detailed images.

Because MRI doesn’t use X-rays or other radiation, it’s the imaging test of choice when people
will need frequent imaging for diagnosis or treatment monitoring, especially of their brain.

Uses of MRI

MRI is preferred to CT when soft-tissue contrast resolution must be highly detailed (eg, to
evaluate intracranial or spinal cord abnormalities, inflammation, trauma, suspected
musculoskeletal tumors, or internal joint derangement). MRI is also useful for the following:

• Vascular imaging: Magnetic resonance angiography (MRA) is used to image arteries

with good diagnostic accuracy and is less invasive than conventional angiography. A
gadolinium contrast agent is sometimes used. MRA can be used to image the thoracic
and abdominal aorta and arteries of the brain, neck, abdominal organs, kidneys, and lower
extremities. Venous imaging (magnetic resonance venography, or MRV) provides the
best images of venous abnormalities, including thrombosis and anomalies.

• Hepatic and biliary tract abnormalities: Magnetic resonance

cholangiopancreatography (MRCP) is particularly valuable as a noninvasive, highly
accurate method of imaging the biliary and pancreatic duct systems.

• Masses in the female reproductive organs: MRI supplements ultrasonography to

further characterize adnexal masses and to stage uterine tumors.

• Certain fractures: For example, MRI can provide accurate images of hip fractures in
patients with osteopenia.

• Bone marrow infiltration and bone metastases

MRI can also be substituted for CT with contrast in patients with a high risk of reactions to
iodinated contrast agents. With MRI, contrast agents are often used to highlight vascular
structures and to help characterize inflammation and tumors. The most commonly used agents
are gadolinium derivatives, which have magnetic properties. MRI of intra-articular structures
may include injection of a diluted gadolinium derivative into a joint.

Contraindication of MRI

• Patients with claustrophobia

• Patients who are confused or agitated
• Patients who are unstable and require continuous life-support equipment, because most
monitoring equipment cannot be used inside the scanner room. Magnet adaptive
equipment is becoming available for use in the MRI scanner room.

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 • Patients with implantable metal objects such as pacemakers, infusion pumps, aneurysm
clips, inner ear implants, and metal fragments in one or both eyes, because the magnet
may move the object within the body and injure the patient.

B. Interventional radiology

Interventional radiologists are doctors that use imaging such as CT, ultrasound, MRI,
and fluoroscopy to help guide procedures. The imaging is helpful to the doctor when
inserting catheters, wires, and other small instruments and tools into the body. This
typically allows for smaller incisions (cuts). Interventional radiologists often are
involved in treating cancers or tumors, blockages in the arteries and veins, fibroids in
the uterus, back pain, liver problems, and kidney problems.

Examples of interventional radiology procedures include:

• Angiography or angioplasty and stent placement

• Embolization to control bleeding

• Cancer treatments including tumor embolization using chemoembolization or

Y-90 radioembolization

• Tumor ablation with radiofrequency ablation, cryoablation, or microwave

ablation

• Needle biopsies of different organs, such as the lungs and thyroid gland

• Breast biopsy, guided either by stereotactic or ultrasound techniques

• Uterine artery embolization

• Feeding tube placement

Read on

• Coloscopy
• Bronchoscopy
• Mammography (Mammogram)

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 • Angiography
C. Radiotherapy
Radiation therapy or radiotherapy is a treatment using ionizing radiation, generally provided
as part of cancer therapy to either kill or control the growth of malignant cells. It is normally
delivered by a linear particle accelerator. Radiation therapy may be curative in a number of
types of cancer if they are localized to one area of the body, and have not spread to other
parts. It may also be used as part of adjuvant therapy, to prevent tumor recurrence after
surgery to remove a primary malignant tumor (for example, early stages of breast cancer).
Radiation therapy is synergistic with chemotherapy, and has been used before, during, and
after chemotherapy in susceptible cancers

Risk of radiation

Ionizing radiation includes

• High-energy electromagnetic waves (x-rays, gamma rays)

• Particles (alpha particles, beta particles, neutrons)

Ionizing radiation is emitted by radioactive elements and by equipment such as x-ray and
radiation therapy machines.

Most diagnostic tests that use ionizing radiation (eg, x-rays, CT, radionuclide scanning)
expose patients to relatively low doses of radiation that are generally considered safe.
However, all ionizing radiation is potentially harmful, and there is no threshold below which
no harmful effect occurs, so every effort is made to minimize radiation exposure.

Note; Medical imaging is only one source of exposure to ionizing radiation.

Radiation may be harmful if the total accumulated dose for a person is high, as when multiple
CT scans are done, because CT scans require a higher doses than most other imaging studies.

Radiation exposure is also a concern in certain high-risk situations, as during the following:

• Pregnancy

• Infancy

• Early childhood

• Young adulthood for women who require mammography

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Risk also depends on the tissue being irradiated. Lymphoid tissue, bone marrow, blood, and
the testes, ovaries, and intestines are considered very radiosensitive; in adults the central
nervous and musculoskeletal systems are relatively radioresistant.

Radiation during pregnancy

Risks of radiation depend on

• Dose

• Type of test

• Area being examined

The fetus may be exposed to much less radiation than the mother; exposure to the fetus is
negligible during x-rays of the following:

• Head

• Cervical spine

• Extremities

• Breasts (mammography) when the uterus is shielded

The extent of uterine exposure depends on gestational age and thus uterine size. The effects
of radiation depend on the age of the conceptus (the time from conception).

Recommendations

Diagnostic imaging using ionizing radiation, especially CT, should be done only when clearly
required. Alternatives should be considered. For example, in young children, minor head
injury can often be diagnosed and treated based on clinical findings, and appendicitis can
often be diagnosed by ultrasonography. However, necessary tests should not be withheld,
even if the radiation dose is high (eg, as with CT scans), as long as the benefit outweighs the
potential risk.

Before diagnostic tests are done in women of child-bearing age, pregnancy should be
considered, particularly because risks of radiation exposure are highest during early (1st
trimester), often unrecognized, pregnancy. The uterus should be shielded in such women
when possible.

RADIOGRAPHIC PROTECTION

DEFINITION: radiation protection is the science and practices of protecting people and the
environment from the harmful effects of ionizing radiation. Radiation can be classified
according to the effects it produces on matter into ionizing and non-ionizing radiation. Ionizing
radiation includes cosmic rays, X-rays and the radiation from radioactive materials. Non

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ionizing radiation includes radiant heat, radio waves, microwaves, infrared light, visible light
and ultraviolet light. The purpose of radiation protection is to provide an appropriate level of
protection for humans without unduly limiting the beneficial action giving rise to radiation
exposure.

Radiation protection is to prevent the occurrence of

a. stochastic effects (these are health effects that occur randomly base on
probability. Two types of stochastic effect include cancer induction and
radiation induced hereditary effects)
b. non-stochastic (deterministic) (non-probabilistic) effect (depends on radiation
dose e.g radiation induced cataract, skin reddening )

Fundamental Principle of Radiation protection

1) Justification: any decision that alters the radiation exposure situation should do better
than harm
2) Optimization protection (ALARA; As Low As Reasonably Achievable): dose should
all be kept as low as reasonably achievable taking into account economic and societal
factors
3) Dose limitation (Never exceed dose limits): the total dose to any individual should not
exceed the appropriate limits

Basic Three Factors for Radiation Protection (Working Personnel and patients)

1) TIME: Radiation protection exposure can be accumulated over the time of exposure,
the longer the exposure time the more radiation exposure to reduce the exposure time,
the nurse has to improve her skills in intervention and the radiographer has to check the
x-ray at the correct location at the right moment without blurred image.
2) Distance: A greater length from the radiation source can reduce radiation exposure the
amount of radiation exposure is inversely proportional to the square of the distance
meaning doubling the distance from the radiation exposure can reduce the radiation
exposure not by half but by one quarter
One quarter. Therefore, maintaining a greater distance from the x-ray generator is very
effective method for radiation safety.
3) Shielding: If the source is too intensive and time or distance does not provide sufficient
radiation protection, the shielding must be used. It usually consists of barriers of lead,
concrete or water, there are many materials that can be used for radiation shielding but
it largely depends on the type of radiation to be shielded, its energy and many other
parameters.

In general, alpha, beta, gamma and x-ray radiation can be stooped by;

- Keeping the time of exposure to a minimum

- Maintain distance from the source
- When appropriate, placing a shield between yourself and the source and

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- Protecting yourself against radioactive contamination by using proper protecting
clothing

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