Reading Radiographs… Like a CSI

Dr. LeeAnn PackDiplomate ACVR

Requirements for becoming a Veterinary Radiographic CSI

• Doctor of Veterinary Medicine degree• Keen eye for detail• No tunnel vision• Does not give up the search

Tools of the Trade

• Signalment– Breed specific diseases– Age– Gender and reproductive status

• History– Trauma– Past medical history

• Physical Examination

Tools of the Trade

• The radiograph– Film

• Hot light

– Digital• Window/levels

• Quiet, darkened room– Ambient lighting

Normal Anatomy

• You can not recognize abnormal anatomy if you can not recognize normal anatomy

• Young animals– Physis – where are they and when do they close

• Species differences– MD vs. DVM

• An Atlas of Interpretative Radiographic Anatomy – 2nd Ed Arlene Coulson - Blackwell

Cat elbow

Look to a book!

Normal Anatomic Variants

• Can easily be mistaken for pathology• Sesamoids

Pattern Recognition - Normal

• We have an idea of what the film is supposed to look like

Pattern Recognition - Abnormal

• Common pathological appearance of disease– The large breed dog – lame – metaphyseal lysis– Wheezing cat with donuts and rail road tracks– A blown cruciate

What is the most likely diagnosis?

It is hard to see what one is not looking for...

• 8 month old German Shorthair Pointer• Lame – owner thinks right front limb• Physical Exam – pain on manipulation of the

right shoulder

– What are things we are thinking about?– What radiographs should be made?

GSP Ante brachial lateral

Complete radiographic study

• Minimum 2 views made 90 degrees to each other for most parts– Single films rarely suffice

• Pregnancy• Bladder present• Colon size

• Number of views needed = number to demonstrate the abnormality

• Malpractice

The big picture is important... But so are the details

Did you see the abnormality?

Important points

• Be certain to look at the ENTIRE radiograph• Peripherally positioned pathology is more

likely to be missed• Sometimes things are unexpected

– We tend to look for things in the context of patient presentation

• What the owner tells us• What we are suspicious of from our physical exam

Artifacts et al

• Artifacts can mimic pathology– Skin folds vs. pneumothorax

• Artifacts can obscure pathology– Atelectasis due to prolonged recumbency

• If the images are suboptimal– The diagnosis will likely suffer the same fate

What is the diagnosis?

Satisfaction Syndrome

• We tend to stop looking when we find a reason for the patient’s clinical signs– We look for what we think it is...– We find it– We are happy with ourselves– We stop and treat

Meet Chester

• A 5 year old M/N Scotty• History

– Inappropriate urination, hematuria

What is the radiographic diagnosis?

Now what does this add and what does it mean?

Tina

• A 10 year old F/S DSH• History of constipation

– Owner was a pilot and cat did not want to drink when owner was away

– Was given an enema– Esophageal tube placed to give laxative

Tina

Lex

• 8 yo Borizoi• Owner noticed swelling along dog’s back and

ventral abdomen• Abdominal radiographs were made

Lex

What is the radiographic diagnosis?

What questions do we have?

Does this help us answer them?

Rabbit

• Presented to the referring vet for head shaking

• During physical exam DVM took rabbit’s temp• Rabbit moved and thermometer cover

“sucked” into rectum• Oh no... lets take rads and see where it is

Rabbit

Rabbit

Now you see it - Now you don’t

Let’s work a heart case

Another Diagnostic Test

• Sometimes on radiographs we are uncertain of what we see

• What can we do?– Ask another in the practice for an opinion– Send to a radiologist for an opinion– Refer– Another diagnostic test

What do we see?

Does this add anything?

Retrograde + contrast urethrogram

Scratches head – then hangs head

Diagnosis?

Diagnosis?

Diagnosis?

Kelbee

• 8 yo FS Catahoula• Feb - Owner in Cancun – pet sitter said dog

ate part of hand towel• Thought dog vomited it up• Radiographs and US were normal

Kelbee

• End March• Owner said dog ate part of hand towel

– Owner said dog never did this as puppy– Now on second episode

• Back in for more rads

Kelbee March 28th 1pm

Kelbee March 28th 9pm

Kelbee March 31st 3:30pm

Kelbee Ultrasound

Re-certification

• Attending continuing education– General– Specific

• Reputable on-line resources• Reading – books, journal articles

• Why is it important?

What is the radiographic diagnosis?

Be a Radiographic CSI and Don’t Let the Bad Guys Get Away

Questions?