physical theory of us? - semmelweis egyetem |...
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Clinical aspects of US, X-ray and CT
Viktor Bérczi, MD, PhD, DMScprofessor and chairman
Semmelweis University, Budapest, Department of Radiology
Ultrasound
What we need for the Ultrasound examination?
• „Examination tool” – US equipment with transducers
• Proper knowledge – from different anatomical, biophysical, anatomical, biophysical, pathophysiological, radiological, clinical aspects….
Advantages of the US examinations
• We don’t use ionizing radiation• Good accessibility• Relatively short waiting list, short booking time• Relatively low cost (compared to the CT and MR)Relatively low cost (compared to the CT and MR)• With portable US machines, examination at bedside,
at the emergency dept, in the ICU, or in the operating theater is also possible
Disadvantages of US
• Not useable in the gas or bone covered territories (mainly in the chest, skull)
• Poor visualisation in obese patients
• Operator dependent• Operator dependent• Moderately useful in some postoperative
conditions (not good skin contact, difficulties with catheters, bandages)
Physical theory of US?
• Vibration of piezoelectric cristals. Very small ceramic parcels which after electonic vibration produce mechanical vibration -------ULTRASOUND ULTRASOUND
• These piezoelectric cristals work as transmitter and reciever of US, alternatively.
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The US image
• Reflections from different parenchymal organs and surfaces, than the computer collects these transmitted reflections and converts low voltage
informations for a so-called shadow-imageinformations for a so-called shadow-image(this is a real-time image 14-25 frame/sec - compiled with proper, fast computers).
• The reflection of the different tissues are featured with ECHOGENICITY
• The strength of the reflections: ECHODENSITY
Ultrasound terminology- types of US echogenicity
• Anechoic - cystic (good ultrasound transmission)
• Hypoechoic • Hypoechoic • Hyperechoic• Hyperdens (completely reflects the
Ultrasound)
Territories of Ultrasound examinations
• Gynecology – Obstetrics• Cardiology• Emergency Dept• Internal Medicine Dept• Traumatology• Surgery• Surgery• Orthopedics, Rheumatology• Urology• Angiology, Surgery• Dermatology• ORL• Ophtalmology
Different US modes• A – mode (measurement of reflected US
-- distance measurement –Ophtalmology)
M – mode (motion) B – mode (brightness)
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Doppler US Color Doppler US
Power Doppler US Ultrasound
Ultrasound probes
• Convex
• 3,5-5,5 MHz• Deep penetration
• Linear
• 8-10 (or more) MHz• Superficial penetration• Deep penetration
• Poorer resolution
• Superficial penetration
• Better resolution
Konvex vs. linear probeileum
ileum transv.
ileum long.
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If use it, use it well
less gain than needed more gain than needed
proper gain
Vascular examination
a. fem. v. fem.
v. fem. prof.
Vascular examination Ultrasound guided interventions
Fine-needle aspiration biopsy (FNAB) of the right parotid
Endocavital US
transrectal transvaginal
More options
uterus
urinary bladder
Approximately 8 weeks-old pregnancy
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And more…
cardiology
urology
pediatric
Neurology – transcranial doppler (TCD)
X-ray
-- +A-C
3: Evacuated glass envelope
1: Cathode filament
2: Anode – Tungsten target
- +A-C
Window
X-rays
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Indication of chest x-ray
• High fever
• Respiratory symptoms• Physical disorder• Physical disorder• Primary tumor
• Traumatic injury• Abdominal emergency• Pre-, postoperative condition• Chest screening
Method & strategy (chest)
• Zeiss/ Odelca
• 1:1 P-A CXR• Sagittal view• Sagittal view• Fluoroscopy
• CT (CAT)• Perfusion & ventill. lung scintigraphy• Angiography, bronchography
www.medwww.med--ed.virginia.edued.virginia.edu
Pneumonia Tuberculosis
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PTX Metastasis
abdominal emergency• Perforation• Ileus• Crampy pain (gall-stone, renal stone) • Inflammation
appendicitis
Indication of abd xIndication of abd x--ray:ray:
– appendicitis– pancreatitis– diverticulitis– extrauterin gravidity– adnexitis
• mesenterial thrombo-embolism
PERITONITIS - PARALYTIC ILEUS
Method & strategy (abd)
• Chest X-ray!! (free abdominal gas?)• Plain abdominal radiograph & fluoro• Swallow examination• Follow-through examination• Follow-through examination
• Barium enema study (urgent - monocontrast)
• US• CT (CAT)
Free abdominal gas
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Small amount of gas Small amount of gas
2 ml2 ml
Plain abdominal film
Feeding tube positioningFeeding tube positioning Ileus(small-, large bowel) mechanical obstruction
• Stenosis – stricture – obstruction– Congenital : atresia, stenosis, anal imperforation– Aquired
• Inflammation• Inflammation• Tumors• Obstruction• Adhaesion• Strangulation • Hernia• Volvulus• Intussusception
Ileuscaused by inflammatory process
• Regional enteritis (Crohn’s disease)
• Ulcerative colitis• Diverticulitis• Tuberculosis• Tuberculosis
• Actinomycosis
Ileuscaused by obstruction
• Gall-stone
• Foreign body• Helminthiasis• Stercolith • Stercolith
• Tumor
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Ileussmall bowel, mechanical obstructive
Complete small bowel ileus
Large bowel ileus Paralytic ileus
Drug intoxication!Drug intoxication!
Appendicitis
UH
Acute pancreatitis
CT
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Esophageal cancer Epiphrenal diverticulum
Barium enema study
Double contrast
Polyp
Zs, Tarjan PhD
Zs, Tarjan PhD
Colorectal cancer
Apple core sign
Bone tumor
Bidirectional!
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CT-pyelography iv. pyelographia Fracture
Met. cranii
Computed tomography - CT
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Historical steps
• Röntgen, Hounsfield és Cormack• 1967: first CT image (9 days• 1972: prototype• 1974: first clinical CT (skull)• 1974: first clinical CT (skull)• 1976: whole body CT (one slice 20s)• 1979: Nobel prize• 1990: spiral CT• 1992: multislice CT• 2006: 64 slices (more and more slices . . .)
scan of chest or abdomen few seconds only• today: PET-CT, dual-source/dual energy CT
http://www.impactscan.org/slides/impactcourse/basic_principles_of_ct
http://www.impactscan.org/slides/impactcourse/basic_principles_of_ct http://www.impactscan.org/slides/impactcourse/basic_principles_of_ct
http://www.impactscan.org/slides/impactcourse/basic_principles_of_ct http://www.impactscan.org/slides/impactcourse/basic_principles_of_ct
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http://www.impactscan.org/slides/impactcourse/basic_principles_of_ct http://www.impactscan.org/slides/impactcourse/basic_principles_of_ct
http://www.impactscan.org/slides/impactcourse/basic_principles_of_ct http://www.impactscan.org/slides/impactcourse/basic_principles_of_ct
http://www.impactscan.org/slides/impactcourse/basic_principles_of_ct
Digital image
• Pixel: 2D, usually 0.5x0.5 mm
• Voxel: 3D „bricks”, usually 0.5x0.5x0.6-5.0 mm
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Tissue densities
• -1000 HU vacuum
• -100 HU lipid• 0 HU water• 0 HU water• 20 HU dens liquid
• 20 – 80 HU soft tissues• 70 – 100 HU fresh bleeding • 100 – 1000 HU contrast medium,
calcium
Brain window
upperframe:80 HU
lowerframe:0 HU
window width: 80 HU
windowcenter:40 HU
Hounsfield scale (HU)
• Brain window
• WW = 80 HU• WC = 40 HU
Windowing techniques
soft tissue window lung window
Brain window bone window
Spiral (helical) CT Multidetector spiral CT
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Dynamic CT scan
• Iodinated contrast medium i.v. injection
• One or more scans from the same region following contrast medium injection
• The time-course of contrast-enhancement is • The time-course of contrast-enhancement is detected
HRCT (high resolution CT)
• Slim slices
• High resolution images• Larger x-ray dose• Longer scan time• Longer scan time
https://en.wikipedia.org/wiki/High-resolution_computed_tomography#/media/File:Pulmon_fibrosis.PNG
Dual Source/dual energy CT
• Two x-ray tubes and two detectors are used simultaneously
• The two tubes are perpendicular to each other• Dual source: same kV in both tubes• Dual energy: x-ray voltage is 80 kV and 140 kV, • Dual energy: x-ray voltage is 80 kV and 140 kV,
rotation of the two tubes are 180o
• Attenuation of the two x-rays will be different, making fine tissue specification possible
http://www.healthcare.siemens.com
Advantages of dual source CT scan
• Better resolution• Lower x-ray dose• Better tissue differentiation• Direct vessel or bone subtraction• Staging of oncology patients• Staging of oncology patients• Characterisation of vascular plaques
• Differentiation of fluids in emergency medicine
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Anterior communicans artery aneurysma - CTA
Pneumothorax and subcutaneous emphysema
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Virtual colonoscopy CT-guided biopsy
Radiofrequency ablation (RFA) of osteoid osteoma Radiofrequency ablation (RFA) of osteoid osteoma
Radiofrequency ablation (RFA) of osteoid osteomaAortic arch aneurysm rupture
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Aorta B-type dissection Intramural haematoma – native CT
Intramural haematoma – contrast enhanced CT Multiple renal arteries
Renal artery Renal artery aneurysmaneurysm
Volume rendering
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Bilateral renal stents: CTA „curved” reformationBilateral renal stents: CTA „curved” reformationVolume rendering
Lower limb CTALower limb CTAAcknowledgements
• Attila Kollár, consultant radiologist
• Ildikó Kalina, consultant radiologist• Katalin Kiss, consultant radiologist• Peter Magyar, assistant professor• Peter Magyar, assistant professor
• Dóra Kozics, radiology resident
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