DR. BANGUN NUSANTORO, SP.RAD

Radiology

Medical imaging

techniques and processes used to create images of the human body

RADIOGRAPHY Radiographs / Roentgenographs

named after the discoverer of X-rays

8 November 1895

Wilhelm Conrad Röntgen (1845–1923)

often used for evaluation of bony structures and soft tissue

Figure 1. Diagram of a standard x-ray tube

Taking an X-ray image with early Crookes tube apparatus, late 1800s.

Wilhelm Conrad Röntgen (1845–1923)

X-ray equipmentS

X-ray equipments

X- RAYS DEFINITIONA relatively high-energy photon having a

wavelength in the approximate range from 0.01 to 10 nanometers.

A stream of such photons, used for their penetrating power in radiography, radiology, radiotherapy, and scientific research. Often used in the plural. Also called roentgen ray.

A photograph taken with x-rays.

These previously unknown rays (hence the X) were found to

be a type of electromagnetic radiation.

Fluoroscopy, computed tomography

(1970s), mammography, ultrasound (1970s), and

magnetic resonance imaging (1980s).

SourcesX-ray photons

Sealed X-ray tubes Betatrons, Linear accelerators (linacs)

Gamma rays Gamma rays, Radioactive sources such as Ir -192 have been used.

GRADAtion DENSITy of X-RAY FILM

Very Radiolucent

Moderately radiolucent

Intermediate

Moderately Radiopaqe

Very Radiopaqe

Gas Fatty Tissue Connective tissueMuscle tissueCartilagoEpitheliumCholesterol stonesUric Acid stones

BonesCalsium salt

Heavy metals

CONTRAST AGENTSThree type of contrast agents :

Positive contrast agents : Barium sulphate, Organic Iodine.

Negative contrast agenst : Oxigen, Air, Helium

Double contrast

BIOLOGICAL EFFECTS OF X-RAY EXPOSUREEarly effects : Chemical changes

structure or function of constituent cells.Delayed effects, such as cancer, may also

occur ultimately as a result of DNA damage produced by the radiation in surviving cells.

Earliest visual indications of a high radiation dose erythema or skin reddening

BIOLOGICAL EFFECTS OF X-RAY EXPOSURE

The threshold dose 300 rads (3.0 Gray) The effect erythema occurs within a day of the exposure and

then disappears. The effect may recur 8-14 days later pain in the affected

tissue. After a few days, the skin may return to its normal

appearance but remain highly sensitive. For doses in excess of 5000 rads (50 Gray) blood flow

problems atrophy and ulcerations.

may eventually require the amputation of fingers or major portions of the hand.

Occupational Dose Limits for

External Exposures to Ionizing Radiation.

Quarterly Annual

Whole body; head and trunk; lens of eye; gonads

1.25 rems 5 rems

Hands and forearms; feet and ankles 18.75 rems 18.75 rems

Skin of the whole body 7.5 rems 30 rems

RADIATION PROTECTION

Time

Three factors Distance

Shielding

ALARA : "As Low As Reasonably Achievable".

X-ray equipmentS

Skull and Central Nerve Skull and Central Nerve SystemSystem

1.Foto standart projection a.Foto PA & Lateral b.Towne’s utk fossa

pos. c.Basis, utk lihat

basis cr.. 2. CT ScanTengkorak dpt dilihat dg. 3. Arteriografi 4. Nuclear scintigrafi 5. Ultrasonografi 6 . MRI 7. Pneumoencephalografi

1. Frontal sinus2. Crista galli3. Cribriform plate4. Lesser wing of sphenoid5. Superior orbital fissure6. Superior border of petrous part of temporal bone7. Dense shadow of petrous part of temporal bone8. Perpendicular plate of the ethmoid9. Vomer10. Maxillary sinus11. Inferior concha12. Ramus of mandible13. Body of mandible

1. Bifid spinous process of C32. Superimposed articular processes3. Uncinate processes4. Air filled trachea5. Transverse process of C76. Transverse process of T17. 1st rib8. Clavicle

4th-7th: The bodies of 4th to 7th cervical vertebrae

1. Anterior arch of the atlas2. Dens of axis3. Posterior arch of the atlas4. Soft palate5. Root of the tongue6. Transverse process7. Intervertebral disc8. Inferior articular process9. Superior articular process10. Zygapophyseal (facet) joint11. Spinous process of C7

A 65-year-old man presented with progressive dementia. Sequential axial noncontrast CT (NCCT) image demonstrates a global pattern of cerebral atrophy with prominent compensatory ventriculomegaly. Note the diffuse widening of the subarachnoid spaces over the cerebral convexities and sylvian fissures, which helps to distinguish atrophy from obstructive hydrocephalus.Axial T1-weighted MR image in an infant of the malformation (solid arrow) producing flow artifact across the midline of the image (open arrows) and hydrocephalus of the lateral ventricles (arrowheads).

MRI Normal Brain

Axial brain MRI of a patient with progressive tremorless parkinsonism and frontal-predominant dementia (Mini Mental State Examination = 23/30; Frontal Assessment Battery = 10/18; abnormal clock drawing task and additional constructional impairment) with moderate ideomotor apraxia. The MRI demonstrates predominantly frontal (A) and anterior temporal atrophy (B) suggestive of frontotemporal dementia.

1. Cerebral infarction, yang pada gambaran PA tampak.

a. Initial softening, berupa intra/ekstra sel edema, sehingga densitas menurun dan terjadi SOP. Pada infark, daerah yang infark baru kelihatan setelah 24-48 jam (tampak hipodens/luscent).

b. Colliquation atau pelunakan otak yang terjadi biasanya setelah hari kedua. Colluquation ini terjadi akibat disintegrasi dari medula sheath dan karyolisis dari macroglia.

___________________________________ ___________________________________ CVDCVD

CT scan slice of the brain showing a right-hemispheric cerebral infarct (left side of image).

Cerebral Infarction, Post-Traumatic

Post-traumatic anoxia causing extensive infarction. Axial fluid-attenuated inversion recovery (FLAIR) MRI demonstrates increased signal in basal ganglia and occipital lobes.

Cerebral Infarction, Post-Traumatic

Post-traumatic infarction in a 67-year-old man. Despite evacuation of the subdural hematoma, both anterior cerebral (arrow) and posterior cerebral (arrowhead) artery distribution infarcts are present.

Head Injury

Head Injury

Subdural hematoma with adjacent subarachnoid hemorrhage was the result of a ruptured middle cerebral artery aneurysm. Aneurysms are unusual causes of subdural hematomas.

Late subacute-to-chronic subdural hematoma with a blood-fluid level indicating acute hemorrhage into the chronic collection.

CT scanning performed before and after surgical evacuation of an intracranial epidural hematoma

This MRI demonstrates spinal epidural hematoma.

Axial T1-weighted magnetic resonance imaging demonstrates bilateral subacute subdural hematomas with increased signal intensity. Areas of intermediate intensity represent more acute hemorrhage into the subacute collections.

Subacute subdural hematoma with extension into the anterior interhemispheric cistern. Note that the sutures do not contain the spread of these hemorrhages.

Intracerebral Hemorrhage

When blood vessels within the brain become damaged, they are more likely to burst and cause a hemorrhage.

A ruptured blood vessel will leak blood into the brain, eventually causing the brain to compress due to the added amount of fluid.

Intra Cerebral Hemorrhage

Spontaneous ICH with hydrocephalus on CT scan

Intracranial Hemorrhage

Intracranial hemorrhage. Fluid-attenuated inversion-recovery, T2-weighted, and gradient echo MRI illustration of intracerebral hemorrhage associated with a right frontal arteriovenous malformation.

This CT scan and MRI revealed midbrain intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) associated with a cavernous angioma

Intracranial hemorrhage. CT scan of right frontal intracerebral hemorrhage complicating thrombolysis of an ischemic stroke.

1. Encephalitis. Pada encephalitis terjadi diffuse sweling cerebral substance, densitas turun menyeluruh, mendesak jaringan sekitarnya, ventrikel terdesak ke dalam.

2. Cerebral abcess, tandanya : a. SOP b. Edema perifocal c. Ring form contrast enhances, karena

dinding absces yang sangat vasculer.

3. Spesific granuloma, tandanya : a. SOP, circumscribed altered densitas b. Edema perifocal c. Ring form tidak ada

4. Subdural empyema, terjadi di tepi otak, dengan densitas lebih tinggi dari CSF.

___________________________ ___________________________ INFLAMATIONINFLAMATION

Bacterial Meningitis

Chronic mastoiditis and epidural empyema in a patient with bacterial meningitis. This axial computed tomography scan shows sclerosis of the temporal bone (chronic mastoiditis), an adjacent epidural empyema with marked dural enhancement (arrow), and the absence of left mastoid air.

Bacterial Meningitis

Cerebritis and developing abscess formation in a patient with bacterial meningitis (same patient as in Images 5-6 in Multimedia). This contrast-enhanced axial computed tomography scan shows a ring-enhancing, lobulated, hypoattenuating mass (abscess) in the left basal ganglia.

Meningitis MRI

Pachymeningitis and cerebritis in a patient with bacterial meningitis . This contrast-enhanced, T1-weighted axial magnetic resonance image shows left-sided dural enhancement (pachymeningitis) and focal pial enhancement

Meningitis MRI

Pachymeningitis and cerebritis in a patient with bacterial meningitis (same patient as in Image above). This T2-weighted axial magnetic resonance image shows parenchymal focal edema (cerebritis).

Acute Bacterial Meningitis

This axial nonenhanced computed tomography scan shows mild ventriculomegaly and sulcal effacement.cterial meningitis CT Scan

This contrast-enhanced, axial T1-weighted magnetic resonance image shows leptomeningeal enhancement (arrows).

This axial T2-weighted magnetic resonance image shows only mild ventriculomegaly

Meningitis

Subdural empyema and diffuse cerebral edema in a patient with bacterial meningitis

This axial computed tomography scan shows bilateral subdural effusion (empyema) and parenchymal low-attenuating areas.

Neoplasma menyebabkan SOP. Sop ini menyebabkan displacement of midline, compression of liquor space, dan blockade of liquor flow. Contoh neoplasma yang dapat terjadi :

1. Meningioma, terutama pada durameter, tampak bulat hiperdense, perifocal edema, contras enhancement diffus.

2. Astrocytoma adalah tumor primer otak, merupakan salah satu tipe dari glioma, terbentuk dr transformasi dari sel glia (neuroglia)

______________________________ NEOPLASMA____________________________ NEOPLASMA

Axial CT scan, prekontras and poskontras, menunjukkan astrositoma low grade di lobus frontal

kiri

Astrocytoma, Brain

Definition:Meningothelial or arachnoidal cell neoplasm usually attached to the dura

Cerebellar pilocytic astrocytoma. Coronal T2-weighted MR image shows both the solid (hypointense) (arrows) and cystic (hyperintense) components.

MRI of medulloblastoma. Sagittal T1-weighted image shows hypointense mass in the fourth ventricle.

MRI of medulloblastoma. Axial T2-weighted image shows hypercellular mass with central cyst (arrow).

Kelainannya berupa

1. HNP

2. Spinal canal stenosis, akibat degenerasi canal stenosis,

3. Meningocele sering pada lumbal(Dysrapsia)

4. Tumor:a. Intramedullaryb. Intradural, misal

meningioma, neurofibrous, metastasis

c. Ekstradural, misal HNP, ekstradural abses, retropeitoneal tumor, ekstraspinal.

________________________ MEDULA SPINALIS________________________ MEDULA SPINALIS

Spinal Cord Anatomy

Spinal Cord Anatomy

________________________________ H N P

Hernia Nucleus Pulposus

Diagram Corpus Vertebrae

Hernia Nucleus Pulposus

Hernia Nucleus Pulposus

Hernia Nucleus Pulposus

Spinal Cord Tumors

Pilocytic Astrocytoma cervical spinal cord ...

Intramedullary Spinal Cord Tumors

Pilocytic Astrocytoma cervical spinal cord ...

Typical meningioma (white arrows) on sagittal T2-weighted MR image presents as isointensity on T2-weighted imaging

Glioblastoma multiforme (GBM). Sagittal T2-weighted MR image of the cervical spine demonstrates an extensive cervical thoracic glioblastoma multiforme.

Spinal Cord Tumors

The first panel shows a cervical syrinx. The differential diagnosis for syrinx includes trauma, Chiari malformation, and dysmerogenesis. A syrinx can also be the by product of a tumor, which may be distant anatomically from the associated syrinx. The second panel shows a small enhancing ependymoma of the thoracic spine that was found during the workup for the cervical syrinx.

This is a sagittal image of an enhancing cord lesion in a 41-year-old man with a rapidly progressing severe quadriparesis. A biopsy showed this to be sarcoidosis. Following treatment with steroids, he is now ambulatory with assistance.

This is a sagittal image of an enhancing conus medullaris lesion in a 45-year-old man who presented with midline back pain. This hemangioblastoma was removed completely. The patient remains neurologically intact, and imaging of his neuroaxis did not reveal other lesions.

Dr. Bangun Nusantoro, Sp.Rad

Bone Formation

• Long Bone : Form in cartilage by endochondral/enchondral

ossification process

• Flat Bone : Laid down by direct conversion of a fibrous matrix in intra membranous ossification process

Centers of Ossification :

1.Epiphyseal plate

2.Epiphyse

Blood supply :

1. Nutrient artery

2. Metaphyseal and epiphyseal vessels

3. Periosteal vessels

MRI of the left upper extremity demonstrating focal cortical destruction on the lateral aspect of the proximal humerus (white

arrow) and a 2.6×0.8×3-cm fluid collection anteriorly (black arrow); 279×123 mm (96×96 DPI)

Osteomyelitis of the ribs

Severe combined immunodeficiencies (SCID)

The prognosis of disseminated BCG infection in immunocompro-mised standard therapy is poor.

Was reported successful treatment of dis-seminated BCG infection with granulocyte colony stimulating factor (G-CSF).

After 2 months of G-CSF, in addition to anti-TB treatment, the clinical signs of disseminated BCG infection were improved.

Successful Treatment of Disseminated BCG Infection in a SCID Patient with Granulocyte Colony Stimulating

Factor

Fig. 1 Abscesses on right shoulder at the site of BCG inoculation prior to anti-TB and G-CSF treatment (a). Healed ulcer of right shoulder after 2 months of G-CSF treatment (b). 72

Fig. 2 Anteroposterior roentgenogram of both femurs. Cystic lesion was found at left proximal femur (a, arrow). Improved cystic lesion after 18 months of G-CSF treatment

(b).

2a 2b

RADIOLOGY OF JOINTS

dr. Bangun Nusantoro, SpRad

Classification of Joint

Alignment of Joint

1. Femur2. Patella3. Medial epicondyle of femur4. Lateral epicondyle of femur5. Medial condyle of femur6. Lateral condyle of femur7. Intercondylar eminence8. Intercondylar notch9. Knee joint10. Lateral condyle of tibia11. Medial condyle of tibia12. Tibia13. Fibula

1. Clavicle2. Acromioclavicular joint3. Acromion4. Greater tubercle of humerus5. Head of humerus6. Lesser tubercle of humerus7. Surgical neck of humerus8. Coracoid process9. Glenoid fossa10. Shoulder joint11. Lateral border of scapula

1. Lateral supracondylar ridge2. Medial supracondylar ridge3. Olecranon fossa4. Medial epicondyle5. Lateral epicondyle6. Capitulum7. Olecranon8. Trochlea9. Coronoid process of ulna10. Proximal radioulnar joint11. Head of radius12. Neck of radius13. Tuberosity of radius14. Ulna

1. Supracondylar ridge2. Trochlea3. Olecranon4. Trochlear notch5. Coronoid process of ulna6. Head of radius7. Neck of radius8. Tuberosity of radius9. Ulna

1. Scaphoid2. Lunate3. Styloid process of radius4. Styloid process of ulna5. Head of ulna

6. Radius7. Ulna

8. Tuberosity of radius9. Neck of radius10. Head of radius11. Proximal radioulnar join

I-V: Metacarpals

1. Trapezium2. Trapezoid3. Capitate4. Head of capitate5. Hamate6. Hook of hamate7. Scaphoid8. Lunate9. Triquetrum10. Pisiform11. Styloid process of radius12. Head of ulna13. Styloid process of ulna14. Radiocarpal joint15. Distal radioulnar joint

A. ThumbB. IndexC. Middle fingerD. Ring fingerE. Little finger

I-V. Metacarpal bones

1,4. Distal phalanx2. Middle phalanx3,5. Proximal phalanx6. Sesamoid bones7. Distal interphalangeal joint (DIP)8. Proximal interphalangeal joint (PIP)9. Metacarpophalangeal joint (V.)10. Carpometacarpal joints

11. Trapezium12. Trapezoid13. Capitate14. Hamate15. Scaphoid16. Lunate17. Triquetrum18. Pisiform

19. Radius20. Ulna

A. ThumbB. IndexC. Middle fingerD. Ring fingerE. Little finger

1,4. Distal phalanx2. Middle phalanx3,5. Proximal phalanx6. Sesamoid bones7. Distal interphalangeal joint (DIP)8. Proximal interphalangeal joint (PIP)9. Metacarpophalangeal joint (V.)10. Carpometacarpal joints

11. Trapezium12. Trapezoid13. Capitate14. Hamate15. Scaphoid16. Lunate17. Triquetrum

19. Radius20. Ulna

1. Lateral part of the sacrum2. Gas in colon3. Ilium4. Sacroiliac joint5. Ischial spine6. Superior ramus of pubis7. Inferior ramus of pubis8. Ischial tuberosity9. Obturator foramen10. Intertrochanteric crest11. Pubic symphysis

12. Pubic tubercle13. Lesser trochanter14. Neck of femur15. Greater trochanter16. Head of femur17. Acetabular fossa18. Anterior inferior iliac spine19. Anterior superior iliac spine20. Posterior inferior iliac spine21. Posterior superior iliac spine22. Iliac crest

1. Femur2. Lateral condyle of femur3. Medial condyle of femur4. Fabella5. Patella6. Base of patella

7. Apex of patella8. Intercondylar eminence9. Apex of fibula10. Fibula11. Tibia12. Tibial tuberosity

1. Femur2. Medial condyle of femur3. Lateral condyle of femur4. Knee joint5. Intercondylar eminence6. Lateral condyle of tibia7. Medial condyle of tibia8. Fibula9. Tibia10. Head of fibula11. Neck of fibula

1. Femur2. Knee joint3. Intercondylar eminence4. Tibial tuberosity5. Fibula6. Tibia7. Ankle joint8. Talus9. Calcaneus

1. Fibula2. Tibia3. Distal tibiofibular joint4. Malleolar fossa 5. Lateral malleolus6. Ankle joint7. Medial malleolus8. Talus

1. Fibula2. Tibia3. Ankle joint4. Promontory of tibia5. Trochlear surface of talus6. Talus7. Posterior tubercle of talus8. Calcaneus9. Sustentaculum tali10. Tarsal tunnel11. Navicular12. Cuneiforms13. Cuboid

A-E: Toes 1-5. (A:Great toe)I-V. Metatarsals

1,3: Distal phalax4: Middle phalax2,5: Proximal phalax

6. Interphalangeal joints7. Metatarsophalangeal joints8. Sesamoids9. Head of metatarsal10. Shaft (body) of metatarsal11. Base of metatarsal12. Cuneiforms13. Navicular14. Cuboid15. Talus16. Calcaneus17. Tibia18. Fibula19. Tarsometatarsal joints20. Transverse midtarsal join

A-E: Toes 1-5. (A:Great toe)

1,3: Distal phalax4: Middle phalax2,5: Proximal phalax

6. Interphalangeal joints7. Metatarsophalangeal joints8. Sesamoids9. Head of metatarsal10. Shaft (body) of metatarsal11. Base of metatarsal12. Cuneiforms13. Navicular14. Cuboid15. Talus16. Calcaneus17. Tibia18. Fibula19. Tarsometatarsal joints20. Transverse midtarsal joint

Left parietal skull fracture- 8 months old AP view, lateral view .

Left zygomatic and lateral maxillary wall fractures

Fracture of mandibular ramus (left side) - AP view

Fracture of nasal bones and nasal maxillary spine

C2 fracture with C2-C3 subluxation

C6-C7 subluxation with jumped facet

Humeral surgical neck fracture, displaced.

Posterior shoulder dislocation, axillary view

Radius and ulna distal torus fracture (AP) & lateral view .

Intercondylar fracture, extending vertically-(AP) It is not as obvious in the lateral view

Radial head fracture (lateral) . The AP view shows it well too.

Intertrochanteric fracture-AP , close up

Femoral shaft fracture

Tib/Fib fracture-AP & Lateral view

Ankle dislocation with distal fib frx, medial malleolar frx

Sacral fracture on left side

Sacral fracture on left side with superior pubic ramus fracture