textbook for dental students

Hristina Mihaylova

Diagnostic
Imaging
part I

textbook for dental students

Sofia 2015
Г \ ш CONTENTS

Preface........................................................ page 3
Imaging methods......................................... page 4
Respiratory system...................................... page 8
Cardiovascular system............................... page 23
Gastrointestinal system.............................. page 34
The liver, biliary tract, pancreas and spleen page 56
Genitourinary system................................. page 68
Musculoskeletal system.............................. page 81
Central nervous system.............................. page 115

MAGING
Part I - textbooK iur dental students
Assoc.Prof. Hristina Mihaylova, MD

Reviewer Prof. V. Hadjidekov, MD

Style editor Emilia Nikolova
© Hristina Dyankova Mihaylova - 2015
Set by Rumen Tunevski - [email protected]
Printed and bound by Cyan Press

ISBN 978-954-420-313-9
PREFACE

Radiology is one of the newest medical specialities and it has an exact birthdate - 9th of No­
vember 1895 when the german scientist Wilhelm Conrad Roentgen discovered X-rays - unknown
type of waves till that time, called later radiological ones. This event lays the ground of completely
new section in the medicine which is in the base of the entire clinic diagnostics up to now.
The introduction and use of X-rays in the medical practice as well as the elaboration of radio­
logical appliances are followed by a fast progress of all clinical specialties.
Image intensifier, tomography, computed tomography and digitalization (the transfer of imag­
es to clinician, archiving of images etc.) are introduced.
Image diagnostics is realized mainly by ionizing rays, i.e. by radiological methods. But in 80s
it was enriched with non X-ray image method for soft tissues’ diagnostics - Magnetic Resonance
Imaging. This method allows all soft tissues to be visualized (cerebral, glandular, cartilage, muscular
tissue etc.) which are not presented radiologically.
Image diagnostics includes ultrasonography too. The property of the super sound to reflect
when passing through the tissues with different density is used in the medicine since 70s.
The present study examines briefly the different imaging methods and the diagnostics of dis­
eases in the different systems of human body - respiratory system, digestive system, cardio-vascular
system, bone system etc.

3
IMAGING METHODS
Medical imaging plays a central part in the diagnostic examination of patients, as well I
as in invasive radiological procedures which are increasingly dependent on accurate diag- j
nostic information. Such information can be obtained by applying transmitted, emitted or I
reflected electromagnetic radiation or mechanical vibration (ultrasound).
The following physical phenomena are the basis of modern imaging.
- X rays are absorbed in tissue (X ray examination);
- radiofrequency radiation is obtained by the excitation of atomic nuclei in a magnetic
field (magnetic imagining);
- radioactive isotopes concentrated in certain tissues emit gamma radiation (nuclear
medicine imaging or isotope imaging);
- high frequency beams of compression and rarefaction are reflected back towards a
transmitter sensor (ultrasound examination);
- infrared radiation is emitted spontaneously by tissues (infrared imaging, termogra-
phy).
All of these methods except ultrasound are based on electromagnetic radiation in dif­
ferent energy domains.
Ultrasound imaging is based on the detection of vibration, which is generated in a piezo­
electric crystal. Isotope, ultrasound and magnetic examinations were developed into useful
imaging methods in the seventies and eighties, whereas X radiation was discovered in 1895.
Radiation (X, gamma, beta and alpha radiation) have the property to ionize atoms and dis­
sociate molecules, therefore cause biological damage.
The use of non-ionizing methods like ultrasound and magnetic resonance should generally
be preferred, because of their safety without taking account of their other advantages.
Imaging methods can be divided into:
- X-ray imaging methods;
- non X-ray imaging methods.
X ray imaging methods can be grouped in the following way:
- radiography with a screen and film in cassette and today with a digital cassette; r
- fluoroscopy;
- computerized imaging methods.
Imaging methods can also be grouped according to whether a volume of tissue or a
thin slice of tissue is imaged into:
- conventional X ray examinations - 3 dimentional object is projected into 2 dimentional im- I
age;
- axial imaging - radiation is directed into a thin slice of tissues and 3 dimentional image is
obtained; 3D reconstructions are possible.
Different imaging methods, based on different physical principles project different
views of the anatomy and physiology of organs.
Digital computers play an important role in all modern imaging methods - converting
all image information (measurement, display, archiving, transmission and communication)
into digital form.
X-RAY METHODS
Radiography
X rays after having passed through the patient create an image directly on a radio-
graphic film.
The film is covered usually on both sides by a photographic emulsion. The emultion consists
of a layer of gelatine containing tiny silver bromide crystals. The emulsion is sensitive to pho­
tons having a wide range of energies; X rays, ultraviolet radiation and visible light blacken
the film. The silver bromide crystals are ionized by the proton energy. The varying density of
the silver ions creates a latent image within the emulsion, the images only become visible
after treatment with a liquid developer. When the film is developed black metallic silver is
precipitated from those crystals containing silver ions. The non-ionised silverbromide crys­
tals become unchanged and invisible. After being developed, the film is washed, fixed and
dried. The fixative removes the silver bromide crystals, leaving the metallic silver behind and
4
| *hus making the film intensive to light. In this way the visible image on the radiographic film
i is related to varying degrees of blackening.
The film is placed in the cassette between 2 fluorescent screens, so called intensifying
; screens. The screens are effective absorbers of X rays photons (photo-electric absorbtion).
I In the process light photons are emitted and these protons are the main cause of blackening
i the film.
There are different kinds of intensifying screens and radiographic films. Some screens emit
blue light, and others emit green light. Correspondingly there are films that are especially
sensitive to blue light or green light respectively.
Fluoroscopy
The primary projection image is created on a fluorescent screen. The screen is part of
X-ray image intensifier that enhances the brightness on TV technique.
This technique is used for examination of physiological movements such as swallowing, res­
piration, cardiac contractions etc.
Computed tom ography (CT)
The invention of computed tomography by Sir Godhrey Hounsfield in the early 1970s
represent the greatest step forward in radiology since the discovery of X rays. Together with
Allen Cormack, Hounsfield was awarded the Nobel Prize in 1979.
A CT examination starts with a digital projection radiograph (scanogram) of the anatomical
region to be slice imaged. The X ray tube and detectors are located inside the gantry sur­
rounding the patient.
The image slice of tissue is divided into volume elements, voxels. The attenuation of each
voxel determines the brightness (shade of grey) of the corresponding pixel in the final two-di-
mentional image.
CT scanning allows measurements of tissue attenuation which may have some diagnostic
value. The unit for CT attenuation is named Hounsfield unit (HU) (water is 0; bones are from
+300 - 3000 HU; air is -100 HU; muscles - from +10 - +40 HU etc).
New scanning concept named spiral CT has increased the efficiency of CT scanning. During
the exposure there is a continuous linear movement of the table through the primary fan
beam and simultaneously a continuous rotation of the tube and detector array.
The result is a spiral shaped trajectory of the fan beam through the patient. A large anatomi­
cal area may thus be covered. By providing thin slices spiral CT may reach very high quality
three-dimentional reconstructions. Combined with intravenous bolus injections of contrast
medium and subtraction techniques, CT angiograms may be reconstructed, providing pro­
jection images of the three dimentional vascular tree.
Radionuclide im aging
X ray examination and nuclear medicine have in common the use of ionizing radiation.
All X ray examinations are based upon the detection of radiation having passed through the
patient, e.g. transmitted radiation. Radionuclide imaging on the other hand involves detec­
tion of radiation emitted from a radioactive tracer inside the patient.
Radioactive tracers, termed radiopharmaceuticals may be used for either diagnostic or ther­
apeutic purposes. They all contain radionuclides, which are unstable atoms that decay spon­
taneously with the emission of energy. The ideal radiopharmaceutical is distributed only
to the organs and structures to be imaged. Recording of radioactivity may give important
functional information. The ability to show physiological function is the major advantage of
radionuclid imaging as compared to alternative radiological modalities. A relative disadvan­
tage is the low spatial resolution of the technique.
In radionuclide imaging (also referred to as radioisotope scanning) the vast majority of pro­
cedures are performed with intravenous administration of radiopharmaceutical. Similar to X
- ray computed tomography, radionuclide imaging also has its tomographic techniques. Two
major tomographic methods have developed:
- single photon emission computed tomography (SPECT) and
- positron emission tomography (PET)
SPECT is a widely used technique especially in cardiac and brain study.
PET allows quantitative estimations of radionuclide concentrations and has a great potential
5
in the study of metabolitic process at various diseases. The major disadvantages of positron
emitted radionuclides are their need for production by expensive cyclotrons and their short
half-lives.
NON X-RAY METHODS
Diagnostic ultrasound
In radiology diagnostic ultrasound is used for two major purposes: to make sectional
images and to measure blood flow velocities. The ultrasound imaging technique is named
ultrasonography (US). The most commonly used ultrasonic flow measurement technique is
called Dopier flow measurement.
U ltrasonography
Ultrasound refers to sound waves with frequency above 20000 Hz, e.g. above the hu­
man hearing range. Frequencies in the 2-10 MHz range are most frequently used.
Ultrasonography is performed by transmitting a narrow beam of ultrasound into the body
from the transducer. The ultrasound is reflected from the various tissues back to the trans­
ducer as echoes.
The handheld transducer (consists of one or several piezocrystals) is placed on the skin
of the patient after application of a gel. The real-time dynamic image is displayed on the
monitor. The image may be ’’frozen” and copied or a dynamic scanning sequence may be
recorded on videotape.
Magnetic resonance
Magnetic resonance (MRI) is the latest newcomer of imaging modalities introduced
1982. MR units can provide sectional images in any plane and any part of the body. No ion­
izing radiation is involved.
Compared to ultrasonography and CT the modality is more expensive, technically more ad­
vanced and theoretically more difficult to comprehend.
The most basic components of a MR unit are a very strong magnet, a radiotransmiter, a ra­
dio frequency receiver coil and a computer.
In a magnetic examination a patient on the examination table is exposed to a strong and
very homogenious magnetic field. The field strength can be between 0,04-3 T which is much
bigger than the magnetic field of the Earth. This static magnetic field changes the direction
of the spinning hydrogen nuclei (i.e. protons), so that they are aligned parallel to the direc­
tion of the field. Radio frequency radiation is then applied to tissues where energy quanta
are absorbed by some of the protons. These become excited as a result and while decaying
send quanta of em-radiation to the environment. Protons are detactable and slice images
are reconstructed from the resultant interference pattern (magnetic imaging). During this
procedure magnetic field gradients are utilized to extract three dimentional information.
Similar to CT contrast media increase the diagnostic information. They all have magnetic
properties and they change the signal intensity in the tissues where they are located. The
most commonly used contrast media contain the paramagnetic metal ion gadolinium (GD).
Contrast media are administered by intravenous injection and they have a distribution in the
body similar to water soluble X-ray contrast media.
C ontrast media in d ia g n o stic im aging
All contrast media in diagnostic imaging have one task, to increase the differences be­
tween the different “voxels” in the body regarding their ability to absorb and/or reflect energy
from electro-magnetic radiation or ultrasound.
C ontrast media for X rays exam ination
In conventional radiology and computerized tomography, contrast media may be clas­
sified as positive or negative media.
Negative contrast media (air, carbon dioxide and other gases) attenuate X rays less than the
soft tissues of the body.
Positive contrast media - some of them (e.g. iodine or barium) have a much higher atomic
number than those of the soft tissues. A higher atomic number is generally associated with
an increased ability to attenuate X-rays.
The positive contrast media can either be water soluble or water insoluble contrast media.
Water soluble iodine contrast media
6
These contrast media are used for intravenous urography, angiography, and for con­
trast enchancement in computerized tomography.
Barium contrast media
Barium sulphate is available in two forms:
- powder which is mixed with water before use;
- ready to use suspention.
Two levels of Ba concentrations are clinically used - one for single contrast (the intestinal
lumen is filled with a low density barium suspention); and for double contrast studies (when
Ba sulphate covers the mucosa with a thin layer and the intestinal lumen is distended with
air) a suspension with high density is used.
Organ specific contrast media - lymphography
For lymphography an oily contrast medium (Lipiodol) is used.
The contrast medium is injected directly into a dissected lymphatic vessel, normally simul­
taneously in both lower extremities.
Organ specific contrast media - biliary media
Oral iodine contrast media
The contrast medium is absorbed in the intestines and carried to the liver where it
enters the hepatocytes. The iodine contrast medium is excreted into the bile canaliculi and
thus contrasted the gallbladder.
Intravenous iodine contrast media
For intravenous cholangiography the c.m. is transported in blood to albumine. This
protein bound the contrast medium which is not excreted in urine but by the bile canaliculi in
the bile.
Negative contrast media
The negative contrast media are the gasses air, oxygen, nitric oxide or carbon dioxide
and they may be combined with water suspension of barium sulphate for double contrast
images of the gastrointestinal tract.
C ontrast media in magnetic resonance imaging
They are different for T, and T2 weighted images. The for T1 weighted images are influenced
by paramagnetic contrast media while T weighted images are mainly influenced by super-
paramagnetic contrast media.
Water soluble extracellular contrast media
The first registrated contrast medium, is gadolinium chelate (Magnevist).
Oral contrast media
Just as in computerized tomography the oral contrast medium are used mainly in
abdominal imaging in order to differentiate between intestine and surrounding normal and
pathological tissues.
C ontrast media for ultrasound
The usefulness of ultrasound medium is that it may increase the contrast resolution
between normal and diseased tissue and may improve the identification of deep lying ves­
sels and help in identifying tumours or tumour vessels. The possibility of tissue characteri­
zation might also be increased with different ultrasound contrast media (Echovist, Levovist,
Echogen etc.)

Abbreviations:
SPECT - single photon emission computed tomography
PET - positron emission tomography
MRI - magnetic resonance imaging
CT - computed tomography
c. m. - contrast medium
GD - gadolinium
US - ultrasonography
7
r e s p ir a t o r y s y s t e m
THE LUNGS ANDTHE MEDIASTINUM

Imaging modalities
A chest radiograph is the most frequently performed radiological examination.
Radiographs are often taken not only with connection with diseases of the lungs but also with a
large number of diseases in other organs that indirectly affect the lung. Chest radiograph is also
often taken routinely before operations.
While plain radiographs of the lungs are still the most common examination, the importance of
special techniques such as bronchography, tomography and angiography is now reduced largely
because of computed tomography, a method that is becoming increasingly common for assess­
ment of pathological conditions in the lungs and mediastinum.
Chest radiography
This is the most frequently used radiographic examina­
tion. It can be performed rapidly and can give much valuable
information.
This examination is the first choice in most diseases in the
chest. Using the plain chest radiograph as a starting point sup­
plementary radiographs with special projections may be indi­
cated. Comparison of current film with old films is valuable and
should always be taken if the old films are available.
A plain chest radiograph consists of frontal and lateral views in
a standing patient (Fig. 1a, b).
Use of two projections makes it easier both to find and to local­
Fig. 1 a. Frontal view of chest ize pathological process.
The frontal view is taken with full inspiration and posterior an­
terior (PA) beam direction. The distance from the tube is 1,5 meters (in order the real size of the
heart to be depicted).
Fluoroscopy
Fluoroscopy is the method where the primary projection image is created on a fluorescent
screen. The screen is part of X-ray image intensifier that enhances the brightness on TV tech­
nique.
Fluoroscopy is used for assessment of the thorax - its shape and symmetry; translucency of lung
fields; presence of abnormal findings. It is superior method for analyzing the functional symp­
toms like respiration, cardiac contractions and motion of the diaphragm and mediastinum.
It is used to localize and adjust special projections in order to depict uncertain opacities. It may
be useful for assessing the chest wall, mobility of diaphragm, mediastinal shift etc.
Paresis of the phrenic nerve causes the dome of the affected side of the diaphragm to be elevat­
ed. Paralysis of the phrenic nerve may be a sign of tumour invasion of the mediastinum.
Fluoroscopy is used to differentiate pulmonary from pleura le­
sions by rotating the patient. Pulmonary lesions move with res­
piration whereas mediastinal lesions do not. Spot films are tak­
en during fluoroscopy for detailed assessment of the situation.
Disadvantages of this method are the low contrast; small chang­
es are not distinguished and lack of permanent image if spots
films are not taken (resp. it is very subjective) and it is radiation
loaded.
Bronchography
For this procedure, local anesthesia is given by inhalator
after which a soft catheter is passed into the main bronchus
on the side to be examined. Fluoroscopy is made for guidance.
Bronchial tree is made visible by an iodized contrast medium,
which lines the walls of the bronchial branches.
The main indications are the demonstration of bronchiectasis,
bronchial anomalies, a fistula communicating with the pleural Fig. 1 b. Lateral view of chest
8
cavity, foreign bodies etc.
With the use of bronchoscopy and/or high resolution CT, the
use of bronchography is greatly diminished (Fig. 2).
Angiography
Pulmonary angiography is used to demonstrate the pul­
monary arteries and veins. Using fluoroscopic guidance a cath­
eter is passed into the pulmonary artery. After injection of con­
trast medium a series of film sequences are acquired to follow
the passage of the contrast bo­
lus through the pulmonary cir­
culation. The main indications
are suspected pulmonary em­
bolism, vascular anomalies or
malformations (Fig. 3).
Computed tomography (CT)
CT has better contrast Fi9- 3. Pulmonary arteriography
resolution than conventional
techniques and the organ structures of mediastinum are clearly
demarcated. Measurements of attenuation values sometimes
permits characterization of tissues (fat, clear fluid etc.).
It is often necessary to visualize the vascular structures in the
mediastinum. The CT sections are then exposed immediately
after the injection of a contrast bolus into a vein of a forearm.
The good contrast resolution increases the possibility of demon­
Fig. 2. Bronchography strating small round shadows in the lungs, for example in patient
with presumed solitary metastases; a detailed representation of
pulmonary infiltrates and diffuse conditions of parenchyma. CT is also valuable for demonstrat­
ing localized fluid or air-filled cavities and for defining diseases in thoracic wall (Fig. 4).
Mediastinal or chest wall involvement by pulmonary pathology may also be demonstrated by CT.
CT sections are also of great value for assessing the depth of lesions prior to needle biopsy and
for adjustment of external radiotherapy.
Magnetic resonance imaging (MRI)
This technique is used in selected cases when conventional chest radiograph combined
with CT has not be sufficient to make a diagnosis.
The main advantages of MRI include: a multiplanar facility and a high soft tissue contrast dis­
crimination allowing vascular structures and lesions in the mediastinal and hilar regions to be
defined separately from other tissue without the need of contrast medium.
Disadvantages include respiratory and cardiac motion artifacts and an inability to visualize small
branching pulmonary vessels and bronchy and lung parenchyma. These structures are better
depicted on CT.
MRI provides excellent definition of the mediastinal structures as the high signal of mediastinal
fat on T weighted images provides good contrast. Moreover, the low or absent signal of vascular
structures and airways permits discrimination of these structures without the need for contrast
media (Fig. 5).
MRI is of special value if expansive lesions in the mediastinum
and hilar region is suspected and in the case of occlusion or
aneurysm of mediastinal vessels.
MRI is of small value for assessment of details in lung paren­
chyma and calcifications in pleura, lung and hilar regions will
generally not be visible.
MRI can be considered comparable or preferable to CT in the
following indications: thoracic aortic disease; thoracic venous
disease; pulmonary arterial diseases such as pulmonary ar­
teriovenous malformation; staging of lung cancer for specific
questions such as chest wall invasion, invasion of pericardium Fig. 4. CT of lung - axial slice
9
etc.; staging and post therapy follow up of lymphoma and me­
diastinal masses.
Isotope scanning
Radioactive isotope scanning is frequently used for eval­
uation of suspected pulmonary embolism.
An intravenous injection of radioactive particles is used for per­
fusion scintigraphy.
The main indications for radionuclide scanning are: diagnosis of
pulmonary embolism, evaluation of emphysema, to determine
the extent of parenchymal disease, malignancy and infection
associated with AIDS etc.
Normal anatomy and variations Fig. 5. MRT of lung
Chest wall
The chest wall is made up of thoracic skeleton and the surrounding soft tissues.
The clavicles appear symmetrically on either side of the midline.
Ribs - they are horizontal from behind. Medially they become cartilaginous and are not visible on
the radiograph unless calcified.
Anomalies of the ribs in the form of bridge formation between the two adjacent ribs or Y-shaped
division of a rib in front (bifid rib) may occur and be confused with a lung opacity (Fig. 6).
Cervical ribs usually articulate with the 7th cervical vertebra.
Of the soft tissue structures of the chest wall breasts produce

4
the most obvious shadows. Large breast shadow may cause
insufficient exposure of the underlying parenchyma. After uni­
lateral resection of a breast, the underlying lung area will be
more translucent and this should not be misinterpreted as a
pathologic condition (Fig. 7). In absence of one breast shadow,
the ribs and lungs should be examined for metastases.
The nipple of the breast may be confused with round basal
shadow of the lung. This is generally no problem, as both nip­
ples are seen symmetrically on either side of the midline in the
frontal view while no shadow at the corresponding level is seen
Fig. 6. Chest X-ray - bronchogra in the lateral view.
phy; left bifid rib Other soft tissues structures that can be identified in frontal
views are the lower part of the sternocleidomastoid and pectoral muscules.
Lungs
The lungs are divided into lobes, the lobes into segments. The right lung has three, the
left - two lobes. Right lung has 10, left has 9 segments. They have a triangular shape (Fig. 8).
The bronchial tree divides into bronchial branches to the lobes and these divide again forming a
segmental bronchus to each segment.
Normal aerated bronchi are not visible peripheral to the hi­
lar area unless the X-ray beam is parallel to them. They then
sometimes appear as ring-shaped structures parallel to the
oval dense shadow of the pulmonary vessels.
The lung are divided into three fields - first field is from the top
of the lung to the sternal part of the second rib; second (middle)
field is situated between the sternal parts of second and fourth
rib and the third (lower) field is between the sternal part of the
fourth rib and the diaphragmal doms.
At the transition between the diaphragm and the chest wall the
layers of pleura form a very acute angle, the costophrenic angle
and between the heart and diaphragm-cardiophrenic angle. Fig. 7. Chest X-ray - frontal view
The hilar shadows are chiefly made up of the pulmonary arter­ - higher translucency in the left
ies and veins. The hilar shadow on the left side is a little higher lung (due to left mammecto-
than on the right and has an oval form whereas the form of the my) and bilateral metastases
right hilium is rectangular. (due to breast cancer)
10
The normal lung markings are due to blood in the arteries and
veins that ramify out towards the lung surface. In the upright
position the upper thirds of the lungs are relatively poorly per­
fused because of low pressure in the pulmonary arteries. The
vessels in the upper third therefore contain less blood than the
vessels in the lower third and they seem to be narrower.
Diaphragm
The diaphragm originates from the lumbar vertebrae
posteriorly with its two cruraes.
Fig. 8. Scheme of lobes and seg­ The level of the right dome of the diaphragm is usually some­
ments what higher than the left, while the left has great mobility.
Pathological changes of the lungs
Change in the hilium
In the size:
- one sided enlarged hilium-tumours, lymph node tuberculosis etc;
- two sided enlarged hilium-leucosis, hereditory and acquired diseases, pneumoconiosis
etc.
In the structure:
- homogeneous;
- non homogeneous (calcifications, methastasis, silicosis).
In the delineations :
- smoothy, sharp, polycystic;
- non sharp.
Change in the translucency
- increased air content
- two sided (emphysema)
- one sided (expiratory emphysema)
- decreased air content
- stenosis of bronchus, pneumonia infiltrate at first stages
- lack of translucency (atelectasis)-bronch infiltration, infiltrates etc.
There are three types of changes in bronchial passability:
- stenosis of the bronchus which leads to hypoventilation (volumen pulmonum diminutum)
radiologically expressed with reduced translucency
- valvae stenosis which leads to higher translucency
- obturation which leads to atelectasis
Atelectasis
This is a term that is used to describe volume reduced, collapsed non aerated lung
tissue. Atelectasis is a condition that can be congenital or acquired and the atelectatic areas
may be limited to small parts of a segment, or there may be collapse of a whole lobe or lung.
Atelectasis may be caused by obstruction of a bronchus, or external compression of the lung
tissue.
1. Causes for bronchial obstruction:
- foreign body;
- bronchial cancer;
- benign intrabronchial tumor;
- mucus plug;
- stenosis after infection;
- compression of a bronchus from the outside (tumor,
lymph node).
2. Causes for compression of lung tissue:
- fluid in the pleural cavity - pleuritis;
- air in the pleural cavity - pneumothorax;
- elevated diaphragm;
- deformity of the chest wall;
- deliberate compression by surgery (thoracoplasty etc.). Fig. 9. Atelectasis
11
Radiological findings with lobar or segmental collapse:
- the collapsed segment of the lung appears itself as an
opacity;
- the outlines of the mediastinum, heart or diaphragm
are obliterated because of absence of adjacent aerated lung
tissue;
- change in position of neighbouring structures such as
the mediastinum, diaphragm or lobe of lung in order to compen­
sate for the volume reduction.
Atelectasis of the lung in the frontal view shows the mediasti­
nal outline displaced towards the affected side (Fig. 9).
Radiological findings in the lungs
Shadows in the lungs
Fig. 10. Radiopacity in the lower 1. According to the intensity they are:
right lung - radiopaque - echinococcus, metastasis, calcifications
(Fig. 10)
- radiolucent - pneumothorax
(Fig. 11)
2. According to the structure
they are:
- homogeneous - ecchi-
noccocus, metastasis (Fig. 12)
- non homogeneous-re-
ticulo nodular opacities (Fig.
13)
3. According to the number
Fig. 11. Radiolucent right lung
they are:
- single (ecchinocco- Fig. 13. Non homogenious - re-
cus, infiltrate etc.) (Fig. 14) ticulo nodular opacities
- multiple (inflamma­
tion, metastases, silicosis etc.)
(Fig. 15)
4. According to the location
they could be:
- in the lung:
- apically, under the clav­
icle (tuberculosis);
- in the base of the lung;
Fig. 12. Homogenious radiopacity - in the middle fields (pneu­
moconiosis).
- in the pleural cavity
- in the mediastinum
5. According to the form they are: Fig. 14. Single opacity in the up­
- round (ecchinoccocus, metastasis, tuberculoma) (Fig per field of the right lung
16 );
- triangular (pneumonia, infiltrate) (Fig. 17);
- ring-shaped (cavity, congenital cyst) (Fig. 18 a, b).
Air-fluid-level (mixed shadow):
- in the lung (abscessus, pierced echinococcus cyst,
undrained cavity) (Fig. 19);
- in the pleural cavity - hydropneumothorax (Fig. 20);
- in mediastinum - hydropneumopericard.
6. According to the size shadows are:
- small (up to 1 mm) (Fig. 21); Fig. 15. Multiple opacities in the
- middle (2-4 mm); lungs
12
- large (0,5 cm and more) (Fig. 22).
7. According to the borders they are:
- not clearly defined (spotty) - exudates (Fig. 23);
- sharp - productive process (metastasis, pleuritis, echi­
nococcus) (Fig. 24).
Pathology
Diseases of broncheal tree
Bronchiectasis
In healthy individuals, the bronchial tree has smooth
walls and the caliber of the branches gradually decreases to­
wards the periphery. In bronchiectasis, an irreversible dilatation
of the bronchial branches occurs. This may be due to congeni­
tal or acquired weakness of the wall due to infection with shrinking
and pulling on the wall or to chronic obstruction. There is often
Fig. 16. Round shadow in the a combination of causes. Cylindrical bronchiectasis (acuired) is
middle field of the right lung present when a bronchial branch retains its caliber without nar­
rowing peripherally (Fig. 25).
Other types include cystic (con­
genital) bronchiectasis which
has an appearance mimicking
bunches of grapes, or there
may be multiple successive
dilatations of bronchial branch
(Fig. 26).
Standard radiographs may be
normal. In some cases the di­
lated areas are displayed as
round translucencies. When Fig. 18 a. Single ring-shaped
the dilated bronchi are full with shadow in the upper right field
fluid or pus they appear as ob­
Fig. 17. Triangular shadow in long opacities most often in a
the right lung lobe with reduced volume.
Bronchography has been a
common supplementary examination when bronchiectasis are
suspected and also to clarify the extent of disease before pos­
sible lobectomy. High resolution CT can demonstrate bronchi­
ectasis and the need for bronchography is therefore diminish­
ing (Fig. 27).
Cysts in the lungs
Congenital cysts of the lung Fig. 18 b. Multiple ring-shaped
Congenital cysts of the lung are anomalies in the devel­ shadows in the right lung
opment of the bronchial tree.
They could be:
- solitary or multiple
- unilateral or bilateral
- opened or closed
Solitary opened cyst is a ring-like shadow with very thin wall
(Fig. 28 a).
Multiple cysts could develop in a segment, lobe or in the
whole lung - so called “honeycomb lung ”. Oval and thin cav­
ities with smoothy borders (“wabenlunge”) are seen in the
lung (Fig. 28 b).
Aquired cysts of the lung
Hydatid disease-echinococcosis Fig. 19. Air-fluid-level shadow
In the most common variety due to Echinococcus gran- in the lung
13
ulosus the primary hosts are the dogs. Humans are accidental
intermediate hosts for all species. Man becomes infected by
close contact with dogs or by ingesting foot, water, soil, which
has been contaminated by faeces. When the ova have been
ingested by the host, the walls of the ova are destroyed and
the larvae passed through the mesenteric venules and lym­
phatics. The majority are filtered out by the liver but some pass
through the right side of the heart and then to the lungs. As a
result liver and lungs are the organs most commonly affect­
ed, but larvae also may lodge
in any tissue including soft
tissues and bone. The cyst
may remain clinically silent
Fig. 20. Air-fluid-level shadow for many years, depending
in the pleural cavity very much on the anatomical
site. Many hydatid cysts are a
chance finding on a chest ra­
diograph or abdominal scan.
Occasionally, internal rupture
of the cyst usually following
trauma, may cause an acute
illness.
Hydatid disease in the lungs Fig. 23. Spotty, not clearly de­
Hydatid lung cysts are fined borders of radiopacity
acquired cysts. A chest ra­
diograph is always required
when a hydatid cyst is sus­
pected in the liver or peritone­
Fig. 21. Multiple small shadows
al cavity. Most lung cysts are
bilaterally
clinically silent and present as
well-defined circular homoge­
neous densities in any part of
the lung (Fig. 29. a, b).
If the outer membrane is bro­
ken there may be thin layer of
air between the inner and out­ Fig. 24. Multiple shadows with
er walls - von Keiser‘s symp­ sharp borders
tom (Fig. 30).
If all the fluid has been coughed
up partially - air-fluid opacity is
seen (Fig. 31 a); if drained en­
tirely - the cyst is ring - shaped
Fig. 22. Middle and large shad (Fig. 31b).
ows bilaterally Hydatid cysts are seldom sol­
itary, when they are multiple
and small they resemble me-
tastases.
Lung infections
Lung infection (pneumonia) may be bacterial, viral or
fungal. Various kinds of protozoa can also cause lung infec­
tion. In pneumonia, opacities develop in the affected segments
of the lung (Fig. 32 a).
The opacities may vary considerably in appearance and
distribution. In some types of pneumonia, the opacity consoli- Fig. 25. Bronchography - cylin-
date as the disease progresses. Alveolar consolidation is the drical bronchiectasis
14
most common and may be segmen­
tal and lobar. The appearance varies
considerably depending on whether
only single segments, or whole lobes
of the lung are affected. The opaci­
ties in pneumonia are often bilateral
and are often accompanied by col­
lection of fluid in the pleural cavity.
Lobar pneumonia - it is usu­
ally unifocal and concentrated to
a single lobe where opacity will be
homogeneous with sharp outlines
which follow the borders of the af­
fected lobe (Fig. 32 b). The volume of
Fig. 27. CT - bronchiectasis the affected area is not reduced, the
Fig. 26. Bronchography - bronchial branches may be aerated,
cystic bronchiectasis and a so called air bronchogram-vis-
ible bronchial branches in an opacity
is common.
In bronchopneumonia, the opacities are more scattered
and often seen in several segments. Atelectasis is com­
mon. The opacities in bronchopneumonia are much less
homogenous than in lobar pneumonia, and seem less con­
solidated (Fig. 33).
Stahhylococcal pneumonia
Staphylococcus aureus
is normally present in the nose
and throat of 20% of healthy
people. Stahhylococcal pneu­
Fig. 28 a. Solitary cysts in the
monia is most often seen in
upper field of the lung
children, old people and in
patients who have aspirated
stomach content into the re­
spiratory tract. Complications Fig. 29 a. Frontal view - hydatid
such a lung abscess, empy- cyst in the left lung
ema, and bronchopleural fis-
tulae are frequently seen. The
radiologic appearance is that
of typical bronchopneumonia
with mottled opacities which
are usually multifocal and bi­
Fig. 28 h. Multiple congenital lateral.
cysts "honeycomb lung" Influenza virus - there are se­
ries of different viruses of this
type (influenza A, B and C) with several variants within each
group. They have not special radiological characteristics.
Varicella and herpes zoster are caused by the same vi­
rus and occur mainly in children. X ray shows mottled alveolar
opacities which can vary in size - from nodule-like opacities to
extensive changes which may involve most of the lung.
Mycoplasma pneumonia is most often seen in children
and young people. The radiological symptoms are extreme­
ly variable, but one or both lower lobes are usually involved.
Consolidation is frequently seen. Fig. 29 b. Lateral view - hydatid
Interstitial opacities can be divided into four main cyst
15
types-reticular, nodular, reticulo-nodular and linear. These are
changes seen in the lung tissue itself - i.e. the lung tissue lo­
cated between the alveoli (in the interstitium).
Reticular opacities resemble a network, and are often graded
from fine reticular to coarse reticular (Fig. 34).
Nodular opacities are seen when more node-like lesions arise
in the interstitium.These opacities are homogeneous, well-de­
fined and vary considerably in size.
Reticulo-nodular opacities may be seen when several nodular
opacities fuse forming network-like opacities.
Linear, striped opacities may represent thickening of interal­
veolar clefts or interlobular septa (Kerley A and B lines). In
interstitial opacities a combination of these four main types is
often seen.
Pulm onary tub ercu lo sis
Pulmonary tuberculosis is inflammatory disease caused
Fig. 30. Crescent - shaped radiolu- by mycobacterium tuberculosis,
cency in the upper part of the cyst The primary infection is al­
most always due to inhalation
of mycobacterium tuberculo­
sis, usually to the middle or
apical segments of the lung.
After this spread of bacteria
occurs internally in the lung,
possibly also via lymph chan­
nels, to lymph nodes in the
mediastinum. The tubercle
bacilli are most often implant­
Fig. 32 a. Segmental pneumo­
ed in areas of the lung with a
nia with triangular shape
high oxygen tension, usually
Fig. 31 a. Partially drained hy­
in the apical segments. Ac­
datid cyst
companying enlargement of
lymph nodes in the hilium is
usual. The pulmonary nodule
in the apex of the lang usual­
ly calcify at a later stage. The
same process takes place
in the lymph node of the hil­
ium. The combination of pe­
ripheral pulmonary calcifica­
tion and calcification of hilar
lymph node is called a calci­
fied primary complex and it Fig. 32 b. Lobar pneumonia
is typical finding in primary
tuberculosis. It can be seen
in about 50% of infected pa­
tients (Fig. 35).
Fig. 31 b. Almost entirely drained Reactivation of old tu­
hydatid cyst berculosis infection may oc­
cur many years after the pri­
mary infection and is mostly
frequently localized to the apical and posterior segments of
the upper lobes and to the superior segments of lower lobes.
It is seen as a mottled, poorly defined alveolar infiltrate often Fig. 33. Bronchopneumonia-mot­
with the formation of cavities (Fig. 36 a, b). tled opacities with consolidation
16
In most cases, only one lung is involved, but bilateral changes
are seen in the more advanced cases. At this stage, the lung
changes are very variable - with cavities, single or multiple
nodular opacities, pleural fluid, large consolidating infiltrates
(both lobar and diffusely scattered).
The tuberculosis infection may be disseminated and in­
volve both lungs (acute and chronic miliary tuberculosis). In
the acute form changes are seen with small miliary opacities
diffusely scattered over both lungs everywhere-from the apex
to the base (Fig. 37 a). For the chronic miliary tuberculosis are
typical irregulary spread opacities which are different in size
and duration (Fig. 37 b).
A tuberculoma represents a limited, localized condition of the
parenchyma which heel and calcify - node-like opacity, usually
Fig. 34. Interstitial opacities 1-5 cm in diameter and usually localized in the upper seg­
ments of the lung.
The lung changes in tuberculosis will improve after ad­
equate therapy, but often leave considerable changes with
fibrosis, infiltrates, calcification, shrinking, and pleural thick­
ening and pleural adhaesions. Responce to treatment is in­
dicated by shrinking of infiltrates, reduced wall thickness of
cavities and fibrosis.
However any residual tuberculous process may become
reactivated at any time in the later stages of the disease. Re­
activation often occurs many
years after the initial primary
tuberculous infection.
Fig. 35. Calcified primary tubercu Pneumoconioses
lous complex The common charac-
teristic of this group of diseases of which silicosis and asbes-
tosis are the most important is that they are caused by organ­
ic dust particles that are small enough to reach the alveoli.
With continuing exposure to dust, pulmonary fibrosis gradual­
ly develops, characterized by coarse linear striped opacities,
specially in the middle and upper part of lungs. Diseases such
as asbestosis, silicosis and sarcoidosis all lead to the devel­ Fig. 36 a. Tuberculous infiltrate
opment of pulmonary fibrosis. In pulmonary fibrosis caused in the right lung
by pneumoconioses small, round shadows, 5-8 mm in diame­
ter with a central translucency are seen, giving a honeycomb
appearance. This special fibrosis is typically seen in the upper
lobe, unlike fibrosing alveolitis where the fibrosis is most seen
in the basal lung segments.
S ilico sis
Silicosis was previously a common disease in miners
and is due to inhalation of silicate crystals (silicon dioxide)
into the alveoli. Inhaled silicate crystals develop small nodes
of collagenous hyaline material. The lymph nodes in the hil-
ium of the lung are usually enlarged. Eggshell-like calcifi­
cation in the periphery of these lymph nodes is typical of
silicosis (Fig. 38).
Although corresponding calcifications may be seen in sar­
coidosis, histoplasmosis, scleroderma and amyloidosis, they
are rare than in silicosis.
Patient with silicosis have an increased incidence of pulmo­
nary tuberculosis (Fig. 39). i LivA Fig. 36 b. CT - tuberculous cavity
Neoplasms
Lung cancer is one of the commonest types of cancer in
men. There are different histologycal types and the treatment is
connected with the type.
There are primary and secondary cancer. Radiologically
primary cancer is divided into central or peripheral tumour.
Central cancer could be endobroncheal or peribroncheal.
The first finding in a central endobroncheal cancer (de­
pending on the stage) is ei­
Fig. 37 a. Acute miliary tuberculosis ther change in opacity (due to
in a child branch stenosis) or atelectasis
(due to obturation) of the bron­
chus from the tumour (Fig. 40
a, b). Often a pneumonic opac­
ity as stagnation of secretion
peripheral to an endobronchial
tumour disposes to infection.
The picture may become nor­
mal again with adequate treat­
ment of the pneumonia, since Fig. 39. Silicotuberculosis
the tumour itself is not large
enough to be visible or is hid­
den by the mediastinal shadow.
Fig. 37 b. Chronic miliary
Reccurent pneumonia or atel­
tuberculosis
ectasis of the same lobe must
result in cancer being suspect­
ed and lead to bronchoscopy. It
is important to obtain tissue for
biopsy, and this is done either
using bronchoscopy or by nee­
dle puncture through the chest
Fig. 40 a. Change in the trans-
under guidance of fluoroscopy.
lucency (reduced) of the upper
When the diagnose cancer is
field if the right lung - hypoven­
established an attempt is made
tilation (volumen pulmonum
to classify the tumour by as­
diminutum)
sessing the size and possible
growth into adjacent organ. A
Fig. 38. Silicosis - fibrous nodules search for lymph node metas-
and pulmonary fibrosis tases and distant metastases is
also performed.
Peribroncheal cancer leads to unilateral enlargement of
the hilium, changing its form and opacity with irregular borders
(Fig. 41). CT scan has become a routine method of assessing
invasion of the mediastinum. MRI has been found to be particu­
larly effective for demonstrating invasion of central cardiovascular
structures.
The peripheral tumour look like single opacity with dis­
tinct borders with lobulation and outgrowing strands and may be Fig. 40 b. Atelectasis as a result
confused with hidatid cyst (Fig. 42). Cavities are common - necro­ of full obstruction of upper right
sis in the tumour (Fig. 43). bronchus from carcinoma - col­
A special type of carcinoma (Pancoast or superior sulus lapse of a whole upper lobe -
tumour) is squamous cell carcinoma in the apex of the lung ex­ radiopaque non aerated lung
pressed with destruction of ribs and involvment of brachial plexus. tissue; mediastinal structures
This patients may have shoulder pain as the first symptom. The are displaced towards the af­
extent of the tumour is now optimally evaluated on MRI using fected side
18
sagital and/or coronal planes to determine penetration of tumour
through the apical part with possible infiltration of brachial plexus,
chest wall or neck (Fig. 44).
Metastases
Pulmonary metastases may be solitary or multiple. When
multiple the size differs from one lesion to another (Fig. 45 ).
Preoperative CT scan is necessary in patient with presumably
solitary metastases. It will then be possible to detect additional
matastases located near the mediastinum.
Pleura
The parietal pleura lines the inner side of thoracic cavi- fig- 41. Peribroncheal cancer
ty and the lateral side of mediastinum without passing into the
normal lung fissures. Around the structures in the hilar region, it
crosses to cover the medial surface of the lung and continues as
visceral pleura on the surface of the lobes of the lung. The pleural
cavity is situated between the two layers of pleura and normally
surrounds the whole lung expect the hilar region. Unlike the pari­
etal pleura the visceral pleura follows the surface of the lobes of
the lungs into the fissures.
The fissure between the upper and lower lobe (major in­
terlobar fissure) is found bilaterally. On the right side an addition­
al fissure (the minor interlobar fissure) between the middle and
upper lobes is also presented. This is the only fissure visible in Fig. 42. Peripheral cancer in the
the frontal plane, while the fissures between the upper and lower lower left field
lobes are projected over each other in lateral views. The CT scan
shows the major interlobar fissure on both sides.
A special anatomy found in almost 1% of the population is the
azygos lobe. This is due to the abnormal course of azygos vein
where there are four layers of pleura since the vein lies outside
the pleura throughout its whole course (Fig. 46).
Pleural lesions
The pleural membranes produce pleural fluid which is re­
sorbed through lymph channels in both layers. Increased produc­
tion or diminished resorption leads to pathological accumulation
of fluid in the pleural cavity. Pleurocentesis can be performed un­
der guidance of imaging techniques in order to differentiate differ­
ent types of pleural fluid (exudates, transudate, blood etc.).
Exudates are caused by tuberculosis or other pulmonary
or pleural infections or by a subphrenic abscess. Other causes Fig. 43. Necrosis in peripherial
are lung cancer and systemic connective tissue diseases such as cancer
lupus erythematodes or rheumatoid arthritis.
Blood in the pleural cavity can be caused by open or close thoracic trauma, or haemorrhagic dis­
eases with prolonged bleeding time.
In the upright position small amounts of fluid will accumulate in the costophrenic angle, first pos­
teriorly, then also laterally. The acute angle between the diaphragm and the chest wall is filled by
an opacity, which as volume of fluid increases, gradually streches up along the inside chest wall
like a cloak. The line with updown and latero-medial direction (concave) is called Damoiseaux line
(Fi9-47). M . .
Large volumes may give massive opacities over the entire hemithorax, but usually some aerate
lung tissue is visible in the apex. When this condition is unilateral, the mediastinum will be displaced
towards the other side, a sign that is useful for differentiating this opacity from that seen in total
collapse of the lung (atelectasis). With total collapse the mediastinum will be pulled towards the
involved side.
The pleural fluid may also be loculated in closed pockets which are formed by adhesions between
the visceral and parietal pleura (Fig. 48).
19
SCc Thoracocentesis of loculated fluid can be guid­
frsE/Ц ed by ultrasonography. Free pleural fluid flows
into the fissures as a wedge-shaped (spindled)
opacity with the pointed end towards the hili-
um and the base peripherally. Encapsulated
interlobar fluid also occurs. It usually assumes
biconvex lens shape, using a tangential x-ray
beam, but it may also be globular and be con­
T il
iH i! 1
fused with a tumour (Fig. 49).
Pleural thickening is often caused by
Fig. 44. MRI - Pancoast tumour infections and it is accompanying symptom
in pulmonary truberculosis. The thickening is
often seen at the base, combined with adhaesions in the cost-
ophrenic angle which becomes shallow and right angled. After
tuberculous pleurisy and after
bleeding in the chest cavity,
large calcified pleural plaques
may be formed. The optimal
method for showing pleural
plaques and calcification is by
CT.
Air in the pleural cavi­
ty, pmeumothorax, may arise
Fig. 45. Multiple metastases
spontaneously as a result of
rupture of small subpleural em­
Fig. 48. Encapsulated pleural
physematous cysts or larger
efusion
emphysematous bullae. Air in
the pleural cavity will usually be
seen as a narrow, radiolucent
zone with no vascular marking
along the chest wall. In check
valve pneumothorax, pressure
in the pleural cavity progres­
Fig. 46. Atelectasis of lobus ve sively increases, causing pro­
nae azygos gressive collapse of the lung
with contralateral mediastinal
shift (Fig. 50).
Most cases of pneumothorax
show spontaneous regres­
sion, but the patients must be
checked clinically and radiolog-
ically.
In pneumothorax in a patient Fig. 49. Pleural efusion in the
with pleural fluid upright films major interlobar fissure
will show a horizontal fluid level
Fig. 47. Exsudative pleurisy as a sign of hydropneumotho­
rax. Horizontal fluid level in the
right thoracic cavity shows that both pleural fluid and pneumotho­
rax (hydropneumothorax) must be present (Fiq. 51).
Mediastinum
The mediastinum is the area lying between the medial
parts of the right and left pleura.
Normally, the lower part of the right mediastinal outline is made
by the right atrium and the left ventricle outlines the lower part of
left mediastnal outline. Fig. 50. Pneumothorax
20
Above the hilar region, the right mediastinal outline is made by
superior vena cava and the brachiocephalic vessels.
Above the left hilium, the upper mediastinal outline is made by the
aortic arch and subclavian vessels. A right-sided aortic arch forms
a prominence of the upper right mediastinal outline.This may be
misinterpreted as an expansive process unless the absence of a
normal aortic arch is recognized. The mediastinal lymph nodes
are divided into the anterior, middle and posterior nodes with a
series of subgroups. If lymph node enlargement is suspected one
should systematically inspect the spaces in front of and lateral to
Fig. 51. Hydropneumothorax the trachea, in front of the carina (in the angle between the left
and right main bronchi).
The posterior part of the mediastinal shadow is made of the tho­
racic column and the paravertebral soft tissues.
Mediastinal lesions
Frontal view can be used to divide mediastinum according
to the level of the hilium into superior and inferior.
A lateral view can be used to localize the anterior, superior
or middle mediastinum a mass observed on the frontal view.
The anterior mediastinum consists of the retrosternal space and
heart, the middle consists of structures along the trachea, esoph­
agus and between the hilar shadows; the posterior includes the
area on both sides of the thoracic column.
Anterior mediastinal
Fig. 52. Widened upper left me­
masses may be caused by ret­
diastinal shadow and deviation
rosternal goiter, tumour/cyst in
of the trachea due to goiter
the thymus, dermoid cyst and
other germinal tumours. Goi­
ter usually causes deviation
of and compression of the tra­
chea (Fig. 52).
Widen upper mediasti­
nal shadow (left, right or both)
is a normal finding in children Fig. 54 a. Frontal view of chest
and is due to thymus persistens (overexposed) - teratoma -
(Fig. 53). parts of teeth and bones are
The thymus is examined in pa­ visible
tients with myasthenia gravis;
Fig. 53. Thymus persistens - bi­
rarely tumours (thymoma) of
laterally widened upper medi­
astinal shadow the thymus develop.
The normal width of the
mediastinal shadow could be changed due to lymphoma, aneu­
rism of the ascending aorta, the tumours arising from the sternum
and underlying soft tissues.
Germinal tumours and dermoid cyst (developed from ecto-
derma, fat, sweat glands, hair etc.) and teratoma (from mesoder­
mal and ectodermal origin, sometimes contain teeth or parts of
bones) usually develop in anterior mediastinum (Fig. 54 a, b).
Near the diaphragm, anterior diaphragmal masses are usual­
ly pericardial fat pad, pericardial cyst or anterior diaphragmatic
(Morgagni) hernia.
Masses localized to the middle mediastinum are most fre­
quently aneurisms of the aortic arch, bronchogenic cysts, lesions
of oesophagus and enlarged lymph nodes. Contrast medium in Fig. 54 b. Lateral projection-chang­
the oesophagus can help the correct diagnosis. es in the anterior mediastinum
21
Lymphoma, lympho Sa etc. and enlarged lymph nodes lead to
arch, polycystic enlargement of the mediastinal shadow (Fig. 55).
Posterior mediastinal masses are frequently neurogen­
ic tumours originate from the spinal nerves (Fig. 56).
Expansive processes in lungs and pleura may be adjacent to
the paravertebral soft tissues and resemble mediastinal mass­
es.
In children approximately 40% of the pediatric mediastinal tu­
mours are in the posterior mediastinum. As many as 95% of
these posterior mediastinal
masses are neurogenic in or-
Fig. 55. Lobulated, polycystic jgjn . neuroblastoma, gangli-
enlargement in the middle me- 0neuroblastoma, ganglioneu-
diastinal part .
v roma etc.
CT scans can precisely de­
fine the location of medias­
tinal masses and their effect
on normal structures. MRI is
favored in the evaluation of Fig. 57. Billateraly linear widen
mediastinal masses when a upper and lower mediastinal
vascular mass is suspected shadow

r
or for paracardiac and poste­
Fig. 56. Enlarged right upper me­ rior mediastinal masses.
diastinal shadow - nevrinoma Mediastinitis may arise after
perforation of the esophagus
or thoracotomy and may also cause an increase in width of the
mediastinum. It is generally accompanied by bilateral pleural
fluid (Fig. 57).
Unilateral or bilateral linear widening of the upper mediastinal
shadow may be due to upper mediastinitis - a severe compli­
cation after abscessus or phlegmonas of the floor of the oral
Fig. 58. Mediastinitis - right sid­
cavity (Fig. 58).
ed linear widening of the upper
mediastinal shadow
A bbreviations:
CT - computed tomography
MRI - magnetic resonance imaging

B ibliography:
1. Кирова Г. Образна диагностика на заболяванията на гръдния кош, 2005, К. Реклама
2. Михайлова Хр., П. Станимиров. Инцидент при ендодонтско лечение. Годишен сборник
на ИМАБ, 2004, 2, 108-109
3. Chest sonography, 2008, Springer
4. Corne J, M.Carrol, I.Brown. Chest X-ray made easy, 1998, Churchil Livingstone
5. Diseases of the chest, 2007, Thieme
6. Kirshner J. Chest radiology-a resident’s manual, 2011, Thieme
7. Moeller M, R. Reif. Pocket Atlas of Sectional Anatomy, Vol. 2, Computed Tomography and
Magnetic Resonance Imaging - Thorax, Abdomen and Pelvis, 2001, Thieme
8. Moeller T,E.Reif, Pochet atlas of radiographic positioning, 1998, Thieme
9. Parker M, Melissa L, Rosado-de-Christensone, G. Abbot. Chest imaging case atlas, 2012,
Thieme
10. Slaby F, E. Jakobs. Radiographic anatomy, 1990, Harwal publishing
22
CARDIOVASCULAR SYSTEM
Imaging modalities
Non X-ray methods
Echocardiography
Ultrasound scanning of the heart is the method of choice
for screening and diagnostic of heart diseases and the best meth­
od to evaluation of valve function and intracardial shunts.
Recently Doppler echocardiography is used for determina­
tion of velocity of blood flow. The Doppler technique is very well
suited for detect any pathological changes in the flow of blood
which may occur with atrial septal defect, ventrical septal defect
and pathological changes in the heart waves (pulmonary, mitral
and aortic orifices) (Fig.1 a, b).
Magnetic resonance imaging (MRI)
is used for diagnosis of a few specific types of cardiac disease
(Fig. 2a, b).
Cine MRI is used to identify pathological flow caused by valvular
regurgitation and stenosis.
Fig. 1. a. Vascular ultrasound
Indications for MR examination, incl. MR angiography are:
- normal Doppler colour flow
- congenital diseases of heart;
study of internal carotid artery
- some forms of pericardial disease;
- intracardiac and paracardiac masses;
- pulmonary arterial and venous abnormalities;
- morphological and functional information;
- measuring of shunts and gradient in different cavities;
- myocardial and pulmonal perfusion.
Disadvantages of the method are: duration of the examination and
necessity of sedation.
Contra-indication for the examinatios is the presence of pace­
maker.
X-ray methods
Conventional radiography
The cardiac radiographic study consists of one frontal and
one lateral (or oblique) projection. Fig. 1 b. Vascular ultrasound -
The frontal view is made in full inspiration. The distance between abnormal Doppler colour flow
the film and the X-ray tube should be stan­ study showing occlusion of
dardized in order to permit measurement of carotid artery
cardiac dimentions. The normal focal-film dis­
tance is 1.50 metre. In frontal view the heart appears as a white shadow (radi-
opacity). It is possible to assess changes in shape and size (Fig. 3).
The lateral view is often taken with contrast
medium of esophagus in order to facilitate
the assessment of the position of posterior
outline (left atrium) - size and position (Fig.
4). Intracardiac and pericardial calcification
can be assessed too.
If oblique views are taken - right (left) anterior
oblique means that the right (left) shoulder is
at 45° to the film.
Fluoroscopy is used to localize the heart
movements and intracardiac calcifications.
This modality permits evaluation of motion
Fig. 2 b. MR angi­ of the calcification during the cardiac cycle.
ography a. MRT of heart It can be useful to identify paradoxical move-
23
merits of the ventricle and to examine the relationship between
the heart and mediastinal structures.
Computed tomography (CT)
Computed tomography is not used routinely in the
radiological evaluation of the heart, but CT programs have
been constructed that can follow a contrast bolus through
the heart from the right side through the pulmonary circula­
tion to the left side. Special CT equipment (ultrafast CT or
Cine CT scanner) has also been constructed for dynamic CT
studies of heart.
* Multidetector Computed Tomography (MDCT) is a new epoch in
diagnostic of the heart. It is a non invasive method for estimation
of normal and congenital anomalies of cardio-vascular system (of
aorta, of pulmonary vessels, of
coronary arteries) (Fig. 5), tu­
Fig. 3. Frontal view of lungs and mours of the heart, estimation
heart of pericard, pulmonary venous
and arterial anatomy and con­
genital diseases of cardio-vas­
cular system (Fig. 6). MDCT
coronary angiography is an
superior method for estima­
tion of coronary vessels, incl.
anomalies (Fig. 7), evaluation
of coronary stenoses (Fig. 8)
- visualization and qualitative
evaluation of aterosclerotic Fig. 6. MDCT - congenital anomaly
plaques and study of patients
after by-pass surgery.
Angiocardiography/coronary
angiography
Angiocardiography is used to
Fig. 4. Lateral view of lung and examine the heart chambers
heart and the coronary arteries. Un­
der the guidance of fluorosco­
py, a catheter is inserted usual­
ly via femoral artery to the left
ventricle (left catheterization)
where contrast is injected. This
permits measurements of the
pressure, volume of the left
ventricle and parameters of left Fig. 7. MDCT- 3D reconstruction-
ventricle function. The move­ coronary vessels
ment, and state of the cardiac
valves can also be evaluated.
The catheter is then withdrawn
above the aortic valves so that
Fig. 5. MDCT of abdominal aorta this portion of the ascending
aorta and the aortic valves can
be examined. In addition selective catheterization of left and right
coronary arteries is carried out and films are required in several
projections to assess pathological changes such as stenosis or
occlusion.
When the right side of the heart is examined (cardiac catheter­
ization), the catheter is inserted from either the femoral vein, or Fig* 8. MDCT- coronary stenosis
24
through an antecubital vein to select sites in the right half of the heart
or superior vena cava, depending on the problem under investiga­
tion. At the same time pressure is registered and the oxygen content
is measured (Fig. 9a, b).
Angiography means contrasted vessels - arteriae and veins. It is
named: aortography (Fig. 10), angiopulmograpy (Fig. 11), arteriogra­
phy of a. femorales (Fig. 12), selective arteriography (coronarogra-
phy) (Fig. 13) etc.
The films in angiocardiography and coronary angiography are usu­
ally recorded on cine film. In order to obtain continuous, sharply de­
fined images on movements of the heart, a minimum of 24 frames
per second is often used during these examinations.
Isotope scanning
Isotope scanning of the heart is
a non invasive examination which
Fig. 9 a. Right catheterization provides details of physiological
conditions. This examination can
provide information on function of the
left ventricle; myocardial perfusion;
presence of myocardial infarcts and
presence and volume of intracardiac
shunts. Several radioisotopes are used
in cardiac scintigraphic diagnosis -
technetium, thallium etc.
Normal anatomy
In frontal view of the heart and
lungs the right atrium constitutes Fig. 11. Angiopulmography
the outline of the heart on the right
side. Cranially the right atrium con­
tinues into the superior vena cava.
The opening of superior vena into
the right atrium is situated into the
Fig. 9 b. Scheme of pres­ posterior part of the atrium.
sures in the heart cavities The right ventricle which is the most
anterior part of the heart is sit­
uated adjacent to sternum. The
ventricular septum separates
the right ventricul from the left
ventricul. The cranial part of
posterior outline of the heart is
occupied by the left atrium. In Fig.12. Arteriography of a. fem-
frontal view most of the left bor- orales
der of heart consists of the left
ventricle (Fig. 14).
The outlines of the heart (heart
configuration) in frontal projec-
Fig. 10. Abdominal aortography tion consist of 3 lines on the
right and 3 lines on the left side.
On the right side-above the diagragm is the line of right atrium fol­
lowed by the line corresponding to aorta ascendens (or vena cava
at its upper part) and the line corresponding to truncus bracheo-
cephalicus.
At the left side the outlining of heart (heart configuration) consists
of upper arch of the left ventricle, small convex line of the pulmo­ Fig. 13. Coronarography
nary artery, and convex line of arcus aortae.
25
The point for connecting the lower right and middle arch is named
D. resp.G for the point for connection of lower and middle left arch
(no pulsation during fluoroscopy).
Connection of the lower right outline with diaphragmal dome is
named D,, resp. G1 is the point where lower left line crosses the
left diaphragmal dome.
The line D-G is called wait of heart. It is changed when there are
pathological conditions (Fig. 15).
Right atrium
The right atrium is best visualized by angiocardiography
with injection of contrast material either into the right atrium, su­
Fig. 14. Scheme of the heart in perior vena cava or inferior vena cava. The right atrium is almost
frontal projection globular in shape with appendage (auricle) projecting anteriorly,
cranially and leftward from the body of the chamber.
Right ventricle
The internal anatomy of the right ventricle is demonstrated
by angiocardiography with injection of contrast material either into
the right atrium, superior vena cava or inferior vena cava.
The right ventricle is not usually border forming on a frontal view
of the chest. In a oblique view, the anterior border of the right ven-
trticle forms the anterior outline
of the heart (Fig.16 a, b).
Left atrium
The left atrium is not
globular like the right atrium,
but more flattened anteroposte-
Fig. 15. Normal heart configura­ riorly.
tion In a lateral view the posteri­
or outline of the left atrium is
clearly seen where it lies adjacent to the anterior wall of the con­
trast-filled oesophagus (Fig. 16 b).
Left ventricle
The left ventricle has an elliptical shape with apex anterior­
ly, interiorly and to the left. The aortic and mitral orifices line near
the base of this chamber. The mitral valve is bicuspid, the aortic
Fig. 16 a. Scheme of the heart in
valves - tricuspid.
lateral projection - 1oblique
The internal anatomy of left ventricle is demonstrated by angi­
ography. The mitral valves are assessed by left ventriculography
which permits observation of the flow of unopacified blood from the left
atrium into the left ventricle in order to evaluate the size of mitral orifice.
Coronary arteries
The right and the left coronary arteries arise from the aorta. The left
coronary artery arises from the aor­
tic bulb to the left, posteriorly. The
right coronary artery arises from the
right part of the aortic bulb with its
opening in front and slightly to the
right (Fig. 17).
Pericardium
The pericardium is a two-lay­
ered sac that surrounds the heart.
The two layers of the pericardium
are covered by a serouse mem­ Fig. 16 b. I oblique posi­
brane. In the minimal space be­ tion - heart with contrast­
tween the two membranes there is Fig. 17. Coronarography ed oesophagus
26
i normally about 20 ml clear liquid.
The pericardium completely surrounds the heart and extends
i along the pulmonary veins, azygos vein, superior vena cava and
i inferior vena cava. The pericardium also covers the pulmponary
trunk up to the bifurcation into the right and left pulmonary arteries
and caudal 2 cm of ascending aorta.
The pericardium is not visible as a separate structure on the chest
radiograph, but represents the true border of the heart shadow.
The normal pericardium is easily identified on computed tomog­
raphy and MRT.
Pathology Fig. 18. Frontal view of lung and
The enlarged heart heart
Enlargement of heart may be generalized or involve only
one or two chambers. Enlargement may involve also predominantly one
chamber initially with secondary effects on other chambers. Several
methods of measuring the volume of heart exist.
The simplest and the most usual method is to measure the greatest
transverse diameter of the heart in the frontal view and relate this to the
greatest internal width of thorax. When the size of the heart is normal,
the heart’s greatest transverse diameter is less than half the maximal
internal diameter of the thorax.
Because 2D echocardiography and MRI display the individual cham­
bers these methods provide accurate measurements of chamber vol­
ume and myocardial mass. Assessment of cardiac volumes is most fre­
quently done using 2D echocardiography.
Left ventricular enlargement
Enlargement of the left ventricle is due either to hypertrophy or
dilatation. If the enlargement of the left ventricle or silhouette is consid­ Fig. 19.1oblique position -
erable, it is due to dilatation. The most common signs of enlargement heart with contrasted oe­
of the left ventricle is elongation of the longest axis of the left ventricle sophagus
These changes are seen in the frontal view (Fig. 18).
In lateral view left ventricular enlargement is indicated by the posterior border of the left ventricle
pushing the barium-contrasted oesophagus towards the vertebral column (Fig. 19).
The most frequent causes of the left ventricle enlargement are mitral and/or aortic valvular insuff-
iency, dilated cardiomyopathy, ischaemic cardiomyopathy and decompensated aortic stenosis and
hypertension.
Left atrial enlargement
The most common signs of enlargement of the left atrium are backwards displacement of
the contrasted esophagus, dislocation of the right margin of the atrium posterior to the right atrium
(double contour sign) or dilatation of the left auricle.
The most common cause for enlargement of the left atrium is mitral valve disease (stenosis or in­
sufficiency). Another frequent cause is resistance to left ventricle filling caused by the disease which
reduces compliance, such as aortic stenosis and hypertrophic cardiomyopathy. Enlargement of the
left atrium can occur secondary to hypertrophy and/or dilatation of the left ventricle.
Right ventricular enlargement
The most common radiological signs of enlargement of the right ventricle is filling the ret­
rosternal space with increased contact of right ventricle with the posterior border of the sternum
(on the oblique view). Normally less than one-third of posterior border of the sternum should be in
contact with the right ventricle. On frontal view right ventricular enlargement displaces the left border
of the heart directly laterally in contradistinction to the left ventricular enlargement which causes the
border to extend both laterally and caudally. Cine MRI and ultrafast CT can provide accurate mea­
surement of right ventricular volumes. The most frequent causes for right ventricular enlargement
are rheumatic heart disease affecting the tricuspid valve, advanced mitral stenosis (due to Pu
nary arterial hypertension) and long lasting pulmonary hypertension, frequently accompanie y
simultaneous pulmonary or tricuspid insufficiency.
27
Right atrial enlargement
Enlargement of the right atrium seldom occurs as an isolat­
ed phenomenon. The most common radiological signs are that the
right outline of the heart is projected far rightward, over the right
lung. Right atrial enlargement can also obliterate the retrosternal
space on the lateral view. Enlargement of the right atrium is well
o\ demonstrated by echocardiog­
raphy, ultrafast CT and MRT.
ч\ The most common cause for
If t, enlargement of the right atrium
is tricuspid insufficiency, usual­
Ч\ Г, \Ч ly caused by rheumatic heart
Л disease. Acquired tricuspid ste­
nosis seldom occurs.
Aquired valvular diseases
Fig. 20. Scheme of mitral con­ Mitral valve disease Fig. 22. Mitral stenosis - flat
figuration. Mitral stenosis is usual­ waist and pulmonal edema -
ly caused by rheumatic heart small opacities diffusely scat­
disease and rarely by congen­ tered over both lungs
ital defects or left atrial mixoma.
Mitral regurgitation has many
ethiologies, including mitral valve
prolapse, spontaneous chordal rup­
ture, bacterial endocarditis, post in-
farctional papillary muscle rupture or
dysfunction and rheumatic heart dis­
ease.
When chronical changes develop,
there is scar formation and retraction
Fig. 21 a. Mitral stenosis-flat of the cusps which become thick­
heart waist ened. A combination of stenosis and
insufficiency is usually seen. In late
stages calcification of the cusps may
occur.
Stenosis of the mitral valve causes
increased pressure in the left atri­
Fig. 23 a. Contrasted oe
um which is transmitted retrogradely
sophagus is pushed to
to the pulmonary veins (pulmonary
wards the vertebral col-
venosus hypertension) resulting in
umn due to dilated left
interstitional and later alveolar ede­
ma. At a later stage as a result atrium and ventricle
of development of pulmonary
hypertension, dilatation of the
right ventricle and tricuspid in-
Fig. 21 b. Mitral stenosis-bulg- sufficiency develop. These hae-
ing heart waist modinamic changes lead to so
called mitral configuration of
heart - flat or bulging waist (depending on the size of atriomega-
lia) and presence or absence of pulmonary oedema. In cases of
mitral insufficiency the left ventricle arch is well expressed and the
apex of the heart is downwards (Fig. 20.)
The initial radiological finding is enlargement of the left atrium. Fig* 23 b. Mitral insufficien-
The left auricle is frequently dilatated and seen as a convexity in cy-hypertrophy of left ventricle:
the segment of the left cardiac margin between the pulmonary enlarged lower arc; apex cordis
artery and the left ventricle on the frontal radiograph (Fig. 21 a, b). - round and low
28
The esophagus is dislocated posteriorly and to the left. There may
be signs of pulmonary hypertension or edema and subsequently
right ventricular enlargement (Fig 22).
On the basis of frontal and lateral views of the heart it is possible
to determine whether the dominant abnormality is mitral stenosis
or incuffuency. If there is enlargement of both left atrium and left
ventricle, mitral incufficiency is likely to be, if it is possible to ex­
clude the simultaneous presence of an aortic valve disease (Fiq
23 a, b).
The definitive diagnosis is established by left ventricular angiogra­
phy and echocardiography. In the left ventricular angiography, the
left ventricle is catheterized and contrast medium is injected.
Echocardiography is good for evaluation of the mitral valve mor­
phology and motion.
Tricuspid valvular defects
Fig. 24 a. Scheme of aortic con­ Tricuspid valvular defects arise either as a consequence of
figuration a purely rheumatic process involving the valvular apparatus, or by
a tricuspid valve becoming insufficient because of dilatation of the
right ventricle.
The most common radiological sign is an enlarged right atrium.
It is easy to examine the tricuspid valve by echocardiography. In
the presence of tricuspid defect, cardiac catheterization with in­
sertion of a catheter through the tricuspid orifice to the right ven­
i tricle is difficult.
Aortic valvular disease
Aortic stenosis
Aortic stenosis can occur either on rheumatic basis or as a
result of calcification in adult life of congenitally abnormal valves,
Fig. 24 b. Aortic configura­ usually bicuspid valves.
tion-marked heart waist Aortic stenosis on a rheumatic basis is frequently accompanied
by aortic insufficiency.
The aortic valves are frequently calcified. During the compensat­
ed phase, there is hypertrophy of the left ventricle and radiograph­
ic sign is enlargement of the left ventricle (Fig. 24 a, b).
In decompensated phase moderate enlargement of the heart may
be present but the left ventricles may be increased considerably in
the presence of simultaneous aortic insufficiency (Fig. 25).
Echocardiography provides a good view of the aortic valves and
reduces the necessity of catheterization of the left ventricle, diffi­
cult to perform through stenotic aortic orifice. Fig. 25. Aortic configuration -
Aortic insufficiency hypertrophy of left ventricle,
The radiographic features are different for acute and chron­ round apex cordis
ic aortic insufficiency.
Acute aortic insufficiency is usually caused by bacterial endocar­
ditis and produces a rapid increase in the left ventricle and dia­
stolic pressure.
Chronic aortic insufficiency is most often a result of congenital val­
vular defect or rheumatic heart disease. Bicuspid valves are the
most common from congenital anomaly. Rheumatic heart disease
usually leads to destruction of the valvular apparatus resulting in
combined aortic stenosis and insufficiency (Fig. 26).
Difference between aortic stenosis and insufficiency is made by
fluoroscopy - in stenosis the silhouette is swinging (pulsus celer et
Fig. 26. Aortic configuration -
altus); in insufficiency - pulsations are slow (pulsus altus et rarus).
heart like a duck
The diagnosis and the amount of regurgitation from the ascending
29
aorta to the left ventricle in diastole can be estimated by Doppler
echocardiography.
Right - sided catheterization is usually performed in addition to left
angiography in order to evaluate the right sided valve and pulmo­
nary arterial pressure.
Left ventricular angiography is used to assess the function of
the left ventricle. Aortic insufficiency is graded angiographically
(grades l-IV) according to the amount of contrast medium reflux­
ing into the left ventricle after its injection into the ascending aorta.
Cardiomyopathy
Cardiomyopathy may be caused by infection, collagen
vascular diseases, atherosclerosis or metabolic disease. Use of
alchohol and drugs may produce dilated (congestive) cardiomy­
Fig. 27 a. Scheme of a myopath­ opathy. Endomyocardial fibrosis also causes a form of cardiomy­
ic configuration opathy. However most cases of dilated cardiomyopaty are idio­
pathic.
Generally myocard diseases could be divided into myocarditis -
inflammatory diseases in the myocard intersticium and myocar­
dosis - dystrophic degenerative changes in muscle fibres (due to
bad feeding of heart muscle because of artherosclerosis, anemia,
exogenic or endogenic intoxications, endocrinic disorders etc.).
Both of them can develop myocardiosclerosis, resp. myopatic con­
figuration.
In the dilated form of cardiomyopathy the heart is considerably
Fig. 27 b. Myopathic configura­ enlarged and there is also pulmonary venous congestion and/or
tion - heart is triangular w ith­ edema (Fig. 27 a, b). This kind of heart configuration is typical for
out typical outlines pericarditis too.
The differential diagnosis between hypertrophic cardiomyopathy
and pericarditis is made by the clinical status - myopatic configuration is not changed after treatment;
pericarditis is a dynamic process; under fluoroscopy pulsations are slow, superficial and faded ev­
erywhere in a heart with cardiomyopathy, but normal - in the aortal part of the heart in pericarditis.
Echocardiography, angiography and MRI are used to evaluate the severity and distribution of hyper­
trophy throughout the left ventricle.
Pericardial diseases
Pericardial cysts
Pericardial cysts are congenital and filled by clear serous fluid. They may communicate with
pericardial space. On the chest radiograph it is impossible to differentiate between cysts and peri­
cardial fat pads, but the differential diagnosis is established by 2D echography, CT or MRT.
Pericardial tumours
Pericardial tumours are very unusual. Mesothelioma is the most frequently seen tumour. Der­
moid is a benign tumor of the pericardium. Methastases are seen more often.
Pericardial fluid
Pericardial effusion may be caused by a number of conditions, the most common being car­
diovascular, infectious, malignant, metabolitic or iatrogenic. Common cases are congestive heart
failure, uremia, acute viral pericarditis and myocardial infarction.
The diagnosis is difficult to be made with certainty on the chest ra­
diograph, but easy to be made using echocardiography, CT and MRI.
Pericarditis
Previously tuberculosis was a frequent cause for pericar­
ditis, but it is rare today. Frequent types are purulent and uremic
pericarditis. Non purulent pericarditis is seen after heart surgery
(postpericardiotomy syndrome) which occurs in about 10% of all
patients who have undergone heart surgery.
There are three types of pericarditis:
- pericarditis sicca - Ro - negative; Fig. 28. Pericarditis
30
- pericarditis exsudativa - pericardial liquid more then 70-80 ml in
the pericardial sac;
- pericarditis adhaesiva - if pericarditis heals with fibrosis.
In chest radiograph pericardial fluid is diagnosed on the basis of
generally enlarged heart without any special part of the heart pre­
dominating (Fig. 28). There are changes in cardiophrenic angles,
shortening of vessel outlining and slow and superficial pulsations
at fluoroscopy.
Pericarditis adhaesiva appears after pericarditis sicca, or after re­
sorption of pericarditis excudativa.
Accretion between two layers of the pericard is called concretio
pericardii; accretion between the pericard and adjacent organs -
acretio pericardii and accretion between the pericard and pleura
- pleuropericarditis adhaesiva - due to different pleurutis (medias­
tinal, diaphragmal etc.)
Fig. 29. Calcifications after peri­ When pericarditis heals with fibrosis or calcifications the pericar­
carditis - "Panzerherz" dium become stiff, reducing the capability to expand in diastole.
This diagnosis may be evident on chest radiographs due to cal­
cifications (Fig. 29.) CT and MRI can establish this diagnose ex­
pressing the thickening of the pericardium.
Congenital heart diseases
Congenital heart diseases are classified by the presence
or absence of cyanosis with the radiologic appearance of pulmo­
nary vascularity.They are also called “blue”- right-left shunt and
Fig. 30. Scheme of patent duc­ “white” - left-right shunt defects.
tus arteriosus 1. Septal defects
Atrial septal defect - foramen ovale apertum
Atrial septal defect (ASD) often occurs as an isolated le­
sion. Usually foramen ovale
closes up to 2 years old. If not,
blood passes from the left atri­
um to the right atrium and into
the right heart and pulmonary
vascular bed. The left atrium is
В IE Dissecting

not enlarged since blood is im­ Fig. 32 a. Scheme of different

mediately shunted left to right kinds of aneurisms
across the ASD. In patient with
moderate-sized defect there is
enlargement of right atrium and
hyperthrophy of right ventricle,
distended a. pulmonalis - flat
Fig. 31. Scheme of coarctation waist (mitral configuration), a
of descending aorta normal left atrium and a normal
sized aorta.
Combination of atrial septal defect and mitral stenosis is known as
Lutenbasher syndrome.
Ventricular septal defect (VSD) - septum intraventriculorum ap­
ertum (M. Roger)
VSDs may involve the membranous or perimembranous
portion of the septum (70-80%), the muscular septum (10%), co-
nal region (5%) or posterior septum as part of atrioventricular ca­
nal defects. Fig. 32. b, c - CT angio and 3-di-
The haemodynamics of VSD are determined by the size of the mentional reconstruction of
defect and the pressure difference between the right and left ven­
aneurism of abdominal aorta
tricle. In patients with small or moderate VSDs there is shunting of
31
blood from the high pressure left ventricle to the low pressure right
ventricle and low resistant lungs.
The chest radiograph in patients with small or moderate VSDs is
normal. In patients with moderate to large VSDs there is hyper­
trophy of right ventricle; increased pressure in a. puimonalis and
bulging of the middle left heart arc. Due to the volume extraload
the left atrium is usually enlarged. This is best seen in lateral view
- posterior impression on the barium-filled esophagus.
2. Vessel’s defects Fig. 33. Enlarged heart due
Patent ductus arteriosus (PDA)-ductus Botalli apertus
to congenital defect - Ebstein
During fetal life ductus arteriosus shunts blood from the pul­
anomaly
monary artery to the aorta; this allows blood to pass the non-aer-
ated lungs. Functional closure usually occurs by 24 hours of age
(Fig. 30). PDA produces a left-to right shunt with a characteristic
murmur.
There are two groups of patients with PDA. The majority are grown
up children with a murmur. Most patients have a small PDA with
a completely normal chest radiograph. Moderate to large PDAs
show increase vascularity of the shunt type. The vessels and
chambers through which blood circulates are enlarged.
Due to increased aortic pressure there is rushing of blood in a.
puimonalis and lungs and resp. enlargement of the main pulmo­
nary artery (bulging heart waist), pulmonary vessels (intense lung
marking) and right ventricle hypertrophy.
Doppler sonography is important in diagnosting a PDA in infants.
Premature infants usually require surgical closure of PDA.
Coarctation of the aorta
Coarctation is congenital narrowing of the aorta. Usually Fig. 34. 3D MR angiography
it is embarrassment of the istmic part of aorta (transition of ar­
cus aortae into aorta descendence). Coarctation leads to left ventricle hypertrophy and widened
ascending aorta - aortic configuration. Sometimes there is rib notching (of the lower edge) due to
pressure erosion caused by dilated intercostals arteries (Fig. 31).
MRI has replaced cardiac catheterization and angiocardiography in older patients with coarc­
tation.
Aneurisms
Aneurism is a local extention of the wall of the vessels (Fig. 32 a, b, c).
They may be divided into 3 different types:
- true - involve all three layers of the arterial wall;
- false aneurysms - caused by interruption of the intima and media;
- dissecting aneurysms - caused by a dissection of the arterial wall, usually the intima and/or media
with formation of a false lumen between the arterial wall layers.
3. Combined congenital defects of heart and big vessels-defects of Fallot
“ blue diseases” - Morbus coeruleus
- trilogy of Fallot - stenosis of a. puimonalis, right ventricular hypertrophy and interatrial defect
- tetralogy of Fallot - stenosis of a. puimonalis, right ventricular hypertrophy, interventricular defect +
dextra position of the aortae - it is between the two ventricles - “overriding of the aorta ”
Cyanosis is usually present.
X - ray features are these of enlarged heart with abnormal shape
- pentalogy of Fallot -like tetralogy + atrial septal defect (foramen ovale persistens)
Echocardiography is diagnostic method. Angiography is frequently performed prior surgery. MRT is
becoming increasingly important in demonstrating the main, right and left pulmonary arteries.
Ebstein anomaly
In this anomaly there is stenosis of the right ventricular valve. This causes a functional ob­
struction to the emptying mechanism of the right atrium as well as tricuspid regurgitation. An inter­
atrial communications (either patient foramen ovale or ASD) are always present.
32
1 Radiographic findings depend on severity of the anomaly. Infants with Ebstein present with severe
) cyanosis and may have decreased pulmonary vascularity and massive cardiomegaly due to right
i atrial enlargement (Fig. 33).
' THE PERIPHERAL VESSELS
f Vascular imaging
Arterial system
For vascular imaging the new non invasive modalities like ultrasound, CT and MRT have part­
ly replaced angiography for diagnostic purposes.
As a screening tool ultrasound has gained an important role in diagnose of aneurismal disease including
dissections of aorta and obturation of the vessels. Colour Doppler scanning allow flow measurements and
is used to assess stenosis and occlusion of peripheral arteries and for follow up studies after bypass pro­
cedure. Colour Doppler is the non-invasive method of choice for evaluation of artherosclerotic disease of
I the neck vessels and for peripheral AV malformations and AV-fistula. Duplex and colour Doppler scanning
i is also used in diagnosing venous pathology such as deep vein thrombosis and venous valve income etc.
CT is an excellent method for demonstrating pathology of aorta and pelvic vessels as aneu­
rysms, dissections, rupture, thrombous formation and calcifications as well as paravascular struc-
' tures.
MR angiography
MR angiography has great advantage that vascular structures may be seen in great detail without
using contrast material. MR angiography has the advantage that any plane in all 3 dimentions may
be selected (Fig. 34).
Venous system
Ascending phlebography (venography)
The most common method for visualization of the low limb veins with contrast medium from
the level of the foot to the lower cava is ascending phlebography.
Ultrasound
Ultrasound can be used for the non-invasive examination of veins and their surrounding tis­
sues, or by combining the image with pulse Doppler determination of vascular flow.
MRI.CT
The two imaging modalities have a role in venous imaging similar to their value in imaging
arteries.
CT examinations require the use of contrast media for venous opacification.
In MR angiography the vessels may be imaged and the flow rate determinated directly without the
use of paramagnetic contrast media.

Abbreviations:
MDCT - Multidetector Computed Tomography
CHID - congenital heart disease
VSD - ventricular septal defect
PDA - patent ductus arteriosus
ASD - atrial septal defect
AV - arterio-venous

Bibliography
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радиология, 2005,3, 166-175
2. Рентгенология и радиология, учебно помагало за студенти по стоматология, 1995, игмалион
3. Brant W, C.Helms. Fundaments of diagnostic radiology, 2007, Lippicott Williams and Wilkins
4. Claussen C., Cardiac imaging, 2008, Thieme
5. Evidence-Based Imaging, 2006, Springer
6. Lisle D. Imaging for students, 2012, Hodder Arnold
7. Moeller M, R.Reif. Pocket Atlas of Radiographic Anatomy, 2000, Thieme
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33
GASTROINTESTINAL SYSTEM
For the investigation of upper gastrointestinal tract two methods are used - methods of ra­
diology and endoscopy - barium study and flexible oesophago-gastro-duodenoscopy.
Most gastrointestinal examinations are performed with 'barium sulfate”. If there is a risk of aspi­
ration or perforation, a water-soluble, non-ionic contrast medium should be used. Water-soluble
contrast is also preferred if obstruction is suspected.
OESOPHAGUS
Imaging modalities
Examination of oesophagus begins with fluoroscopy of thorax and abdomen.
A swallow of barium sulfate is taken from the patient in oblique position and traced under fluo­
roscopic guidance; lateral and anteroposterior views of oesophagus are taken after coating with
barium. After the first single bolus is taken, the mucosal relief is examined. The whole quality of
barium is taken and the motility of oesophagus assessed.
The examination of oesophagus is multiphasic - including double and single contrast examination
- double contrast erect views are used in order to see mucosal details.
Anatomy
Oesophagus consists of 3 parts - cervical, thoracic and abdominal part and has 4 phisio-
logical narrow areas: oesophago-pharingeal, at arcus aortae, at
tracheal bifurcation and at cardial part (Fig. 1).
Pathology
Generally pathological conditions of oesophagus consist
of changes in the position, form and lumen of oesophagus.They
could be:
- along the oesophagus: narrowing or extensions which
could be organic or functional;
- local: narrowings from inflammatory, neoplastic or neu­
rogenic origin or extentions (oesophageal diverticula).
Congenital anomalies
Oesophageal atresia and tracheoesophageal fistula
Oesophageal atresia and tracheoesophageal fistula is a
complex of congenital anomalies characterized by failure of for­
mation of oesophagus or an abnormal communication between
Fig. 1. Contrasted oesophagus the oesophagus and trachea. It occurs approximately 1 in 5000
births. The complex includes pure oesophageal atresia without a
fistula; oesophageal atresia with a fistula that may be proximal, distal, or proximal and distal; and
a tracheoesophageal fistula without oesophageal atresia.
Contrast examination may be performed to verify the diagnosis of oesophageal atresia and demon­
strate or exclude a fistula within the upper segment of the oesophagus and the trachea. Water-solu­
ble, non-ionic, iso-osmolar contrast media should be used.
Oesophagial m otility disorders
The barium swallow is a simple and sensitive method of
assessment of oesophageal motility. Patients with motor disor­
ders of oesophagus present with dysphagia and/or chest pain.
Primary disorders of oesophageal motility include achalasia,
diffuse oesophageal spasm and conditions that cause second­
ary motility disorders including systemic sclerosis, diabetes and
neurological disorders.
Oesophagitis
Endoscopy is better than radiology methods in the diag­
nosis of oesophagitis.
Barium studies are accurate for moderate and severe grades
of oesophagitis and insensitive for mild oesophagitis. Severe
grades of oesophagitis demonstrate multiple erosions or ulcer­
ations, plaque-like “pseudomembranes” which may mimic infil­
trative carcinoma. Fig. 2. Strictures of oesophagus
34
Caustic oesophagitis
Alkalis are the most common causes
for caustic oesophagitis, usually ingested in
the form of drain cleaners and other liquids.
While acids can produce oesophageal dam­
age, they tend to predominantly affect the
stomach. Chest radiographs and supine and
erect films should be performed to detect
signs of perforation, pneumomediastinum or
pneumoperitoneum. Contrast studies may
be required. If perforation is suspected, wa­
ter soluble iodine contrast should be used.
Fibrous tissue is formed especially in the
places of physiological narrowing and stric­
tures are made.
Fig. 3. Pulsion diver­ Fig. 4. Hypopharyngeal (Zen­ Strictures
ticulum of the thoracal ker's) diverticulum Most reflux-associated strictures oc­
part of oesophagus cur in the distal oesophagus near the gas-
tro-oesophageal junction. A hiatus hernia is
almost always present. Most structures should be inspected endosdopically and biopsied to ex­
clude malignancy.
Stricures due to caustic oesophagitis are examined with contrast studies in a chronical phase.
There are narrowing areas of the oesophagus with prestenotic dilatation (Fig. 2).
Oesophageal diverticula
Oesophageal diverticula could be divided into:
- congenital or acquired;
- true or faulse.
According to the origin they could be:
- pulsion diverticula;
- traction diverticula;
- functional diverticula.
Most oesophageal diverticula are aquired false diverticula and so comprise mucosa with or with­
out submucosa. The majority are pulsion diverticula. On the contrast study they are presented as
a local enlargement of the lumen of oesophagus (usually in the cervical and thoracic part). Pulsion
diverticula tend to change in shape and size and more longitudinally with oesophageal peristalsis
(Fig. 3).
Flypopharyngeal (Zenker’s) diverticula occurs at the junction of hypopharinx and oesophagus.
Dysphagia occurs as the pouch fills preferentially with food and
obstructs the lumen of oesophagus (Fig. 4).
Other common sites for the pulsion diverticula are around the
carina, at a level between the aortic arch and the left main bron­
chus and in the distal oesophagus (epiphrenic).
Epiphrenic diverticula may be multiple and are associated with
gastro oesophageal reflux and hiatus hernias and are connect­
ed with dysmotility. Oesophageal diverticula hardly ever cause
symptoms.
Tractional diverticula are due to pulling from outside. They
usually are accompanying pleuritis, pericardidtis, lymphadenitis etc.
Functional diverticula (Barsony-Polgar) usually are due
to psycho-neurologic disturbances. They seem as variable ex­
pansions which take turns with spastic areas.They change their
location and form during examination (Fig. 5).
Oesophageal varices Fig. 5. Functional diverticula (Bar­
Oesophageal varices usually are due to spleno-portal dis­
turbances as a result of cirrhosis, thrombophlebitis etc. sony-Polgar)
35
On the barium study after sticking to the
walls, the mucosa is coated with barium and
multiple views are taken.
Radiologically the varices are seen as serpig­
inous filling defects usually along the line of
the longitudinal folds in the distal oesopha­
gus. Distinction must be made from the rare
varicoid carcinoma; unlike varices, the con­
figuration of the latter will not change with oe­
sophageal distinction (Fig. 6).
Tumours of oesophagus
Tumours of oesophagus are divided
into: benign and malignant. Tumours lead to
stenosis of oesophagus and stenosis leads to
dysphagia (late symptom).
Fig. 6. Oesophageal varices Fig. 7. Benign tu­ Benign tumours most often are:
mour of oesoph­ - papillomas;
agus - leiomyomas - oesophagial smooth muscule
tumours.
Benign mucosal tumours do not cause luminal narrowing. The most common are squamous ti
papillomas seen as small polypoid lesions on double contrast radiography.
Submucosal benign tumours are much more common; the vast majority of these are leiomyomas.
Unlike leyomyomas in the gastro-intestinal tract, oesophagial smooth muscle tumours are hardly
ever malignant, nor they ulcerate. They may be an incidental finding or cause dysphagia. Being
of smooth muscule origin they occur in the mid or distal oesophagus. In profile they appear radio­
graphically as smooth filling defects with sharp borders (Fig. 7).
Other benign submucosal tumours (fibromas, neural tumours, lipomas) are rare.
Oesophageal carcinoma
Radilogy has an important role in diagnosis, staging and post-treatment follow-up of this
common neoplasm.
Using contrast study multiple projections are needed for demonstration of the tumour.
We are looking for the direct sign - irregular filling defect with arc like cuttings and for the indirect
signs - slow tracing of barium, lack of mucosal relief and lack of oesophageal peristalsis.
Most neoplasms are squamous carcinomas; the minority are adenocarcinomas arising in
Barrett’s oesophagus. Most patients present with advanced disease. Tumours could be divided
into:
- intraluminal fungating tumour - oesophagus changes its form, size, borders and relief;
irregular narrowing - irregular filling defect with arc like cuttings could be seen. If there is necrosis
in the mass - ulceration oc-
curs (Fig. 8 a, b).
- infiltrative type (annular can­
cer): local narrowing of oe­
sophagus is noticed; barium
passes by a thin stream; no
oesophageal peristalsis is ob­
served;
- ulcerative tumour which is
relatively flat and with ulcer­
ation;
- varicoid tumour (resembling
varices with thickened serpig­
inous folds due to submucosal
spread).
Computed tomography and Fig. 8 a Advanced carcinoma of Fig. 8 b Distal carcinoma of oe­
endoscopic ultrasound are oesophagus sophagus
36
the most accurate methods for staging oesophageal carcinoma
(Fig. 9).
Oesophageal foreign body
Most foreign bodies that are swallowed pass through the
gastrointestinal tract without complication. Occasionally, a for­
eign body lodges in the oesophagus and require removal. Oe­
sophageal foreign bodies may be found at the thoracic inlet (75
%). thoracic oesophagus at the level of the carina (20%), or dis­
tal oesophagus at the gastroesophageal junction (5%).
Foreign bodies in oesophagus could be: Ro-positive (radiopaque
foreign bodies) and Ro-negative (non opaque) foreign bodies.
Radiopaque foreign bodies (some metals, minerals, fish or
chicken bones) are seen on conventional radiographs (Fig. 10).
Contrast examination is required to demonstrate non-opaque
(plastic toys, vegetable material, food particles) foreign bodies. If
Fig. 9. CT-thickened oesopha­ no foreign body is seen (e.g. it is Ro-negative) on plain X ray, a
geal wall small cotton ball soaked in barium may show it.
A contrast swallow of water-soluble non-ionic iodine contrast is
given if perforation is suspected.
Oesophageal foreign bodies may be removed at endoscopy or
by catheter with fluoroscopic control. After removal of the foreign
body, a contrast examination should be performed to exclude
any oesophageal abnormality.
STOMACH AND DUODENUM
Imaging modalities
For the investigation of the stomach and duodenum flexi­
ble endoscopy (oesophago-gastro-duodenoscopy) is “method of
choice”.
X-ray methods
Contrast studies
The routine contrast examination for gastroduodenal
diseases is the double contrast barium meal (DCBM) which is
superior to single contrast studies. There are many variations
Fig. 10. Plain X-ray. A coin in oe­ in technique for performance of the DCBM, but frequently used
sophagus method is bifasic - one that incorporates elements of the single
contrast examination with distention of stomach with air under
fluoroscopic control. Fluoroscopy shows:
- morphologic manifestations;
- functional manifestations - peristaltic waves; evacuation func­
tion.
Multiple views (spot films) are taken during fluoroscopy, incl.
compression.
After sticking to the walls (method of sticking), the whole barium
is swallowed (method of casting); patient is turned from prone to
supine and to prone again, left-to right to fill the gastric fundus
with barium and then supine to see the cardia. Multiple views
are taken in supine-oblique and prone - oblique projections with
patient in a Trendelenburg position for the examination of fornix
of the stomach (Fig. 11).
Water-soluble iodinated contrast media are used where there is
suspected perforation or where a recent anastomosis is made.
The most popular contrast is ’’Gastrografin”. However this is con­
traindicated if there is a risk of air aspiration or suspicion of an Fig. 11. Contrasted stomach and
oesophago-tracheal fistula. Non-ionic iodinated contrast media
duodenum
are then used.
37
The aim of DCBM is to see by appropriate positioning all parts
of the oesophagus, stomach and proximal duodenum in double
contrast with good mucosal barium coating. A measure for good
coating is the visualization of the areae gastricae, which are
seen as a mosaic-like pattern in the stomach. These represent
the areas about 1-4 mm in diameter, in the center of which the
gastric glands open. Their visualization depends on radiographic
technique, barium density and the amount of mucus in the stom­
ach. They are most often seen on the gastric antrum and body.
An increase in size of the areas and their presence in the proxi­
mal stomach are associated with increased acid production.
Focal abnormalities of the areae gastricae are more important.
Distortion or enlargement may be seen in the gastritis, around
an ulcer or due to superficial infiltration by carcinoma.
Other anatomical features seen in the stomach by DCBM include
the rugal folds.The folds in the antrum are effaced with distention
of gas; if they persists this suggest antral gastritis. The rugae in
the fundus and proximal body should be smooth and relatively
straight in the distended stomach.
The modern biphasic barium includes double and single contrast
oesophagograms, compression views of the gastric antrum and
duodenal cap as well as double contrast images of the stomach
and duodenum and assessment of oesophageal and stomach
motility. Second and third part of duodenum have to be outlined
too.
If the examination is being per­
formed for suspected gastro­
duodenal perforation, a water
soluble iodine contrast is used.
Computed tom ography (CT)
CT is useful in gastro­
duodenal disease for staging
Fig. 13. Contrasted stomach - of neoplasms and assessment
normotonic form of extramural disease. Disten­
tion of the gut with oral con­
trast medium is essential. A dynamic sequential scan following
intravenous bolus administration of contrast is used to show vas­
cular structures and for the identification of liver metastases.
CT is also a useful technique in suspected gastroduodenal per­
forations being able to detect very small volumes of free intra-
peritoneal gas.
Fig. 14. Contrasted stomach -
Anatomy
hypotonic form
Stomach consists of body (with lesser and greater curves),
fornical part (containing air), cardial part (junction with oesoph­
agus), antrum (horisontal part of the stomach) and pylor (outlet
of the stomach) (Fig. 12).
Depending on the tone of the stomach there are three forms:
- normotonic - most frequent form - bottom of the stomach
is at the biiliac line; it has form of a hook or J (Fig. 13);
- hypotonic - bottom of the stomach is beneath the biiliac
line; it has a form of elongated hook (Fig. 14);
- hypertonic - higher location; horn like form; crosses the
vertebral column (Fig. 15);
- atonic form - pathological form - usually due to stenosis Fig. 15. Contrasted stomach -
of the pylor-bottom of the stomach is situated very low - in the hypertonic form
38
pelvic region (Fig. 16).
Pathology
Gastritis
Radiology is limited in the diagnosis of gastritis and other
superficial mucosal diseases. Some of the symptoms are ero­
sions, thickening or atrophy folds, hyper-rugosity and wall thick­
ening. Disturbance of area gastricae pattern is a further indica­
tion of mucosal disease.
Erosive gastritis may be acute or chronic and may be asymptom­
atic or accompanied by dyspeptic symptoms or bleeding. Causes
include alcohol, aspirin and other non-steroidal and inflammato­
ry drugs, but many are idiopathic. Two pattern of erosive gas­
tritis are seen - varioliform gastritis-multiple aphtous erosions
surrounded by a lot of radiolucent oedema, usually orientated
along the longitudinal folds and tending to be concentrated in
Fig. 16. Contrasted stomack - the antrum and second form is flat erosions without a halo of
atonic form oedema.
Hypertrophic gastropathy is a group of entities charac­
terized radiologically by hyper-rugosity of the stomach. Such
conditions include hyperacidity states such as Zollinger-Ellison
syndrome and chronic renal
falure, Menetrier’s disease and
hypertrophic gastritis and the
mimicked by infiltration lym­
phoma or submucosal spread
of carcinoma (Fig. 17).
Gastric ulceration
Fig. 17. Menetrier's disease and On barium study gastric
hypertrophic gastritis ulcers are seen as niches or
collections of barium. In profile,
ulcers are seen as barium filled collections extending beyond the
lumen (“niche en profile”).There are direct and indirect symp­
toms for gastric ulceration seen on a barium study (Fig. 18).
Direct symptoms are:
- “niche” or collection of barium seen as additional (+) shadow on
the lesser or greater curve (barium filled collections extending Fig. 18. Gastric ulceration -
beyond the lumen); "niche en profile"
- radiating folds towards the ulcera;
- sagging (inflammation bank) at the base of the ulcera;
- lack of peristaltic in the area of the ulcera (Frankel’s symptom)
on fluoroscopy.
Indirect symptoms are:
- spastic incisura - opposite the ulcera (Faulhaber symp­
tom);
- hypersecretion, hyperperistaltic on fluoroscopy.
When viewed en face, ulcers on the posterior or anterior wall
(“niche en face”) are apparent as barium collections when full of
' contrast, or ring shadows when empty, with or without radiating
folds (Fig. 19). On the anterior surface they are seen en face as
ring shadows. Anterior wall lesions may not be easily seen with­
out erect and prone compression views.
The majority of benign gastric ulcers occur on the lesser curve
or in the antrium (usually posterior wall).
1 Greater curve ulcers are more suggestive of malignancy, but Fig. 19. Gastric ulceration -
i even benign ulcer in this site may have a malignant appearance. "niche en face"
39
Pyloric and prepyloric ulcers
are usually small and benign.
When become big, they lead to
stenosis of pylor, resp. atonic
form of the stomach
Size of the ulceration is
not a good indicator of benign
or malignant nature; giant ul­
cers are often benign.
Depending on the depth ulcus
of the stomach ulcers could be
divided into:
- ulcus simplex - includ­
ing the mucouse and submu-
couse layer (Fig. 20);
Fig. 20. Ulcus simplex Fig. 21. Ulcus callosum - ulcus callosum - in­
cluding deaper muscule layers
and serouse (Fig. 21);
- ulcus penetrans - destroying of serouse and penetration
in adjacent organs (Fig. 22);
- ulcus perforans - when ulceration is suspected wa­
ter-soluble iodinated contrast media are used.
On the plain X-ray of the chest a sickle radiolucency beneath the
dom of the diaphragm is seen
(Fig. 23).
As ulcer healing occurs
the crater diminishes in size
and the oedematous edges
disappear. The radiating folds
become more apparent as
scarring progresses.
Fig. 22. Ulcus penetrans Due to healing expansion of fi­
brous tissue leads to constant
deformation of the stomach: Fig. 23. Plain - X ray of the chest
- like sand watch (when the ulceration is in the middle of the - sickle radiolucency beneath
stomach) (Fig. 24); the right dom of the diaphragm
- like snail (when ulceration is in the antrum of the stomach).
Summerizing-complica-
tions connected with ulceration
of the stomach are: bleeding,
perforation and deformity of
stomach.
Gastric diverticula
These true (congenital)
lesions occur in the postero­
medial wall just distal to the
cardia. They are seen as local
extentions of the stomach often
with gastric folds running into
them (Fig. 25).
Gastric tum ours
Benign tumours
Mucosal polyps Fig. 25. Gastric diverticulum in
They appear as rounded filling Fig. 24. Contrast study-sand the cardial part and resection of
defects in the barium contrast watch stomach stomach
40
(Fig. 26 ).
They may be pedunculated or sessile. The majority are hyper­
plastic and possibly result from regeneration following gastritis.
The minority are adenomas and are important because of their
malignant potential. There is an increased risk of carcinoma in
the same stomach when adenomas are present.
Gastric carcinoma
The diagnosis of gastric carcinoma is usually made by
endoscopy or barium meal. Early gastric cancers are those lim­
ited to mucosa and submucosa. There are different differenti­
1 Fig. 26. Stomach polyps
ations: they can appear as type I - polypoid (elevated, flat or
depressed,) and type II - superficial. Mixed types occur.
The surfaces of early polipoid lesions on DCBM is lobular or
granular and simulates the area gastricae. Differentiation is re­
quired from adenomas and hyperplastic polyps.
Advanced gastric cancers involve muscularis propria or
deeper layers.They can develop on the ulcer base - cancer ex
ulcer or on the base of polyps - cancer ex polypus.
They may be classified as polypoid, ulcerative with raised mar­
gins, ulcerating type or infiltrative type.
Advanced cancers are seen as an irregular filling defect with arc
like cuttings in late phase; folds radiating towards the lesion are
changed by form, location and continuity; it may show evidence
of infiltration such as nodularity and lack of peristaltic during flu­
oroscopy (Fig. 27).
Advanced ulcerative or raised
cancers are often large and
Fig. 27. Advanced cancer of fun­ obvious radiologically (Fig. 28).
dus of the stomach Infiltrative type is often seen
as constructing tumour in the
antrum. Stomach changes its
form and size - resembling a
pipe. No relief, no peristaltic
in this area are noticed (Fig.
29 a).
Gastric lymphoma
These constitute 1-3%
of all gastric malignancies.
Most are of non-Hodgkin’s lym­
phoma type and lesion may be
localized in the stomach with or Fig. 29 a. Diffuse infiltrative
without regional nodes or part cancer
of a generalized involvement.
Infiltrative, nodular, ulcerative,
polypoid or mixed forms occur.
Fig. 28. Advanced ulcerative Often it is not possible to dis­
cancer with central ulceration tinguish lymphoma from carci­
noma. Distinction is important
since the prognosis is considerably more favourable for lympho
ma than for carcinoma.
Staging
It is very important especially for early gastric cancer to
Fig. 29 b. Infiltrative cancer -
determine therapy and prognosis and where non-surgical endo­
thickened antral mucosis to­
scopic treatment is planned. This is best achieved by CT and en­
doscopy. CT visualizes the thickened gastric wall and its relation- wards the lumen
41
ship to adjacent structures (Fig. 29 b). CT can detect lymph node
enlargement but is non specific, because is unable to distinguish
reactive from malignant nodes. The criterion for enlargement is
usually taken as more then 10 mm.
Endoscopic methods are highly accurate in distinguishing early
gastric cancer from advanced cancer.
The post - operative stomach
In the early post-operative period following gastric sur­
gery, contrast studies are required to test for anatomic leackage
and for gastric emptying (Fig. 30).
Hiatus hernias and gastric rotation (volvus of the stomach)
A hiatus hernia is present if the gastroesophageal junction
(cardial part of stomach) herniates through the diaphragmatic hi­
atus into the chest. The size of the herniated proximal stomach is
variable. Small sliding hernias are very common findings and are
Fig. 30. Resection of stomach often asymptomatic. The major association of sliding hiatus her­
nias is gastro-oesophageal reflux - the retrograde flow of gastric
contents into the oesophagus.
Radiologic findings of hiatus hernia include high location of car-
dial part of the stomach, gastric mucosal folds above the hiatus,
wide hiatus with wide oesophagus above it, and large part of the
stomach above the diaphragm in the chest (Fig. 31).
Paraoesophageal hernias
The gastro-oesophageal junction lies below the dia­
phragm, but all or part of the gastric fornix is above the dia­
phragm and lies adjacent to the distal oesophagus, usually to
the left. Most para-oesophageal hernias are non-reducible. They
may be recognized on a chest radiograph by an air-fluid level be­
hind the heart, the nature of which may be confirmed by repeat­
Fig. 31. Congenital hiatus her­ ing the radiograph after the
nia in a child patient takes a few mouthfuls
of barium. Most patients with
para-oesophageal hernias are asymptomatic, but complications
are mechanical. Dysphagia may occur when the intrathoracic
portion of the stomach fills during a meal and obstructs the distal
oesophagus. Obstruction of herniated portion of stomach may
cause strangulation and perforation.
The stomach can undergo two main types of rotation and
they are often associated with herniation of the stomach (volvu­
lus of the stomach).
- organo-axial rotation is a twist along the organic axis of the
Fig. 32. Mesenterico-axial vol-
stomach - that is the line drawn from the fornix to pylor. If the
vulus
stomach was horizontally orientated then the result is a reversal
of the normal lesser and greater curves. When the stomach is
more vertically orientated, the fundus lies to the right and the
antrum points to the left - so called “mirror image” stomach. Or­
gano-axial rotation is rarely associated with severe symptoms.
- mesentero-axial rotation is less common, but more often asso­
ciated with obstruction and strangulation. The stomach rotates
around the axis joining greater and lesser curves and perpendic­
ular to its long organic axis so that the resulting configuration is
an “upside-down” stomach (Fig. 32).
DUODENUM
Imaging modalities
Contrast examination of duodenum is part of the DCBM. Fig. 33. Scheme of duodenum
42
US, CT, endoscopy and endoscopic retrograde cholangiopan­
creatography help duodenography in imaging of periampullary
and pancreatic lesions.
Anatomy
The duodenum is extending from the pylorus to the du­
odenojejunal flexture; it is approximately 25-30 cm long. It is di­
vided into four parts. The first part - bulbus duodeni, (the “cap")
is about 5 cm in length and extends posteriorly, superiorly and
to the right from the pylor. It is triangular in shape on barium
studies. The proximal 2-3 cm is intraperitoneal; the rest of the
duodenum is retroperitoneal. The second part extends from the
superior duodenal flexture, at the end of the first part, interiorly
to the inferior flexture. At the apex of the superior flexture there
is often a thick mucosa fold which may be mistaken for a lesion
on contrast studies. On the posteromedial wall of the descending
Fig. 34. Duodenal ulcer duodenum is the major papilla which appears on hypotonic du­
odenography as a rounded or oval filling defect. The fourth part
begins where the duodenum becomes more vertical and directed superiorly towards the duode-
i nojejunal flexture. The duodenum terminates at the suspensory ligament of Treitz (Fig. 33).
Pathology
Duodenal ulcerations
Duodenal ulcerations are the most common disease of duodenum. They are linear, round­
ed or irregular in shape on barium studies. About 10% are multiple and about half occur on the
- anterior wall and such are more difficult to diagnose; compression and profile views, including
prone-oblique views are needed. When ulceration is acute there may be little or no associated wall
deformity.
On contrast study direct symptom - niches or collections of barium are seen and inflammation
bank (radiolucency) around the nish. Indirect symptoms are shorten recessus and enlargement of
the opposite recessus (Fig. 34).
Radiating folds and cap deformity are more commonly seen when the ulcer is more longstanding.
The healing process causes fibrosis, deformity and delated contralateral recessus. Approximately
i 5% of duodenal ulcers occur distal to the cap; most of these occur on the medial wall proximal
' to the papilla of Vater. They are often difficult to demonstrate radiologically due to accompany-
! ing spasm and oedema. Healing often leads to strictures. Ulcers distal to papilla should suggest
. Zollinger-Ellison syndrome.
1Complications due to ulceration of duodenum:
- acute bleeding - presents as haematemesis and/or melaena;
- ulcer perforation presents as “acute abdomen”- usually free intraperitoneal gas is seen asa sickle
radiolucency under the diaphragm on plain abdominal radiographs. A water soluble iodine con­
trast may be required for confirmation;
- an ulcer may penetrate into adjacent structures: involvement of the pancreas may present as
an acute pancreatitis; penetration into the bile duct will also present acutely with gas seen in the
biliary system on plain films.
Zollinger-Ellison syndrome
This syndrome is due to the hyper secretion of gastric acid
in response of gastrin-secreting tumour. The tumours are usually
in the pancreas, but could be also extrapancreatic. Between 40-
70% of tumours are malignant, but slow growing. Although 75%
1of associated peptic ulcers are gastric or in the duodenal bulb,
1distal duodenal ulcers and/or multiple ulcers should suggest the
diagnosis.
Duodenal diverticula
These are frequent findings on upper gastrointestinal
barium studies. They are regarded as acquired pulsion-type. Di­
verticula may be single or multiple. They are seen as additional
shadow with mucosal relief in the neck of the diverticula. The most common site is the medial wall 1
of the descending duodenum. Differentiation from ulcers is made: the appearance of mucosal fold I
extending into the neck of the diverticula and variability in shape during examination. Duodenal 1
diverticula are nearly always asymptomatic, but occasionally give rise to complications e.g. diver­
ticulitis (Fig. 35).
Duodenal neoplasms
True primary neoplasms of the duodenum are rare. Usually endoscopy and biopsy are
necessary for diagnosis. Adenomas tend to occur in the first or second parts of duodenum and
may be sessile or pedunculated, appearing as filling defects or ring shadows on barium studies.
In polyposis syndrome they may be multiple.
Primary malignant neoplasms are most commonly adenocarcinomas, but lymphomas, smooth
muscule tumours and carcinoids are also seen. Peri-ampullary carcinomas may arise from duodenal
mucosa, the ampulla of Vater, from pancreatic tissue or from the bile duct. There is an association of
periampullary duodenal carcinoma with familial polyposis, particulary Gardner’s syndrome.
Secondary malignant tumours affecting the duodenum usually result from direct spread
from neighbouring organs such as colon, gallbladder, pancreas and right kidney.
THE SMALL INTESTINE
The length of the small intestine varies among individuals between 3-10 metres.
The normal mucosal pattern of the small bowel depends on the method of examination. On en-
teroclysis when there is optimal distention they extend “ladder-like” across the whole width of the
lumen. The folds are more prominent in the jejunum and are often absent in the distal ileum. On
small bowel meal (barium follow through) examination the mucosal pattern is featherly due to sec­
ondary mucosal folds which are effaced on enteroclysis.
Imaging modalities
Plain radiographs
They are limited - in patients with abdominal pain when subacute or recurrent obstruction
is suspected.
Contrast studies
There are two types of barium study - an enteroclysis examination (small bowel enema- in -.
tubation study) and small bowel series (small bowel meal).
Enteroclysis
Enteroclysis is the more accurate examination for depiction of changes in the proximal
intestine, strictures and mucosal abnormalities. The infusion of contrast at enteroclysis leads to
continuous flow through the small bowel and assures maximum distention allowing detection of
small narrowing and the examination of individual loop with compression. Enteroclysis require
greater technical skills, discomfort for the patient because of the passage of nasojejunal tube and
greater radiation exposure.
The small bowel enema or enteroclysis examination is performed when a nasogastric tube is
placed into the stomach under local anesthesia and then guided through the duodenum to the du­
odenojejunal flexture. Barium is injected rapidly through the tube into the small bowel giving a dou­
ble contrast effect. Some radiologist use a single-contrast dilute barium, others - a double-contrast
or air to provide double contrast. Fluoroscopic screening is carried out with spot films of jejunum
and ileum with compression. Enteroclysis has largely been replaced in modern practice by CT or
MRI enterography as well as a variety of endoscopic techniques.
The small bowel meal - the dilute barium suspention to a volume of 300-600 ml is taken
orally by the patient. The patients drink lying on their right side and the rate of drinking is kept until
barium reaches the pylorus.
Contraindications to both techniques include suspected bowel perforation and large bowel ob­
struction.
Contrast studies are useful for:
- lumen changes: strictures, dilatation, compression, pseudodiverticula;
- wall abnormalities: wall thickening, displacement of adjacent bowel loops;
- mucosal fold abnormalities: thickened folds, nodularity, fold effacement;
- ulcerations;
- nodules and filling defects, polyps;
44
- - fistulae: to other parts of the bowel, to other hollow organs or skin.
) Computed tomography
The ability of CT to demonstrate bowel wall thickening, extramural and mesenteric disease
i is used for suspected small bowel pathology. It is necessary to give adequate oral contrast to pro-
' vide good luminal distension. Up to a litre or more of dilute water-soluble contrast or dilute barium
i is given in divided doses starting one hour prior the scan (so called CT enterography).
Ultrasonography
Bowel imaging and US have limitations by the presence of bowel gas and faeces. However
abnormal bowel loops can be imagined when there is thickening of the wall - these have sonolu-
cent periphery due to oedema or infiltration and echogenic center. Omental and mesenteric mass­
es may be identified as well as enlarged lymph nodes, which are usually sonolucent.
Magnetic resonance imaging
The development of MR applications in the abdomen has been limited by motion artifacts
and limitation in tissue contrast. MR enterography - injestion of fluid to distend the small intestine
is usefull for diagnosis and follow up of young patients with Crohn’s disease or other chronic con­
ditions of the small bowel that may require repeated follow-up examinations. MR can help distin­
guish active inflammation from fibrosis in inflammatory disease and accurately delineate enteric
fistulae and abscesses.
Pathology
Congenital abnormalities
Meckel’s diverticulum
Meckel’s diverticulum is congenital abnormality and occurs in 2% of population. It is a blind
ending sac on the anti-mesenteric side of the ileum. Its length is 1-7 cm; and is 20-80 cm from
ileo-caecal valve.
Of those individuals with this congenital abnormality approximately 20-49% will develop symp­
toms and most commonly melaena. If inflammated differential diagnose is made with appendicitis.
No single imaging method is entirely reliable at detecting Meckel’s diverticula.
Nuclear medicine studies are valuable, technetium pertechnetate is given intervenously and is
taken by normal and heterotopic gastric mucosa. The diverticulum is seen as focal uptake, usually
in the right lower quadrant of the abdomen.
Enterpoclysis is more sensitive due to the greater luminal distention and the possibility for com­
pression under careful fluoroscopy.
Recognition depends on a blind ending sac on the anti-mesenteric side of the ileum.
Complications of Meckel’s diverticulum are bleeding, diverticulitis, volvulus and intussussception.
Inflammatory diseases
Crohn’s disease
This is nonspecific chronical inflammatory process of the terminal part of ileum-(ileitis ter-
minalis). There are 2 forms of
ileitis terminalis:
- stenotic form (Morbus Crohn)
- in terminal ileum - effaced
folds and lumenal narrowing
- non-stenotic form (Morbus
Golden) - polypoid mucosa.
Cross-sectional imaging tech­
niques, CT enterography and
MR enterography are being
used with increasing frequen­
cy in diagnosis of Crohn’s dis­
ease.
The features seen on small
bowel contrast studies can be
classified as superficial, trans­ Fig. 36 a. Crohn's disease - aph- Fig. 36 b. CT-thickened wall of
mural and extramural abnor­ toid ulcers, punctuate collections terminal ileum (due to oede­
malities. of barium and small nodules ma)
45
Superficial abnormalities - “early” changes that are described

1 include thickened folds, aphtoid ulcers, punctuate collections of

barium and small nodules. These may occur alone or in combi­
nation.

« *8lb Transmural abnormalities - Crohn’s disease is typically a trans­

mural process; the signs associated with this constitute the clas­
sic features of this disease - ulcers, thickened bowel wall and
luminal narrowing can be seen.
Extramural abnormalities-fibrosis in the mesentery leads to
shortening of the mesenteric and redundance of the antimesen-
Fig. 37. Multiple diverticula teric border. They require US and/or CT for imaging.
Complications of Crohn’s disease are strictures which often lead
to obstructive symptoms. It may be extremely difficult to distin­
guish bowel narrowing due to active Crohn’s disease from fibrot-
ic strictures. MRI may be useful (Fig. 36 a, b).
The differential diagnosis of Crohn’s disease on contrast studies
is wide:
- small bowel (ileo-cecal) tuberculosis may be indistinguishable
from Crohn’s disease. Features in favour tuberculosis include a
relatively abrupt change from normal to abnormal bowel, pre­
dominantly transverse ulcers and marked caecal involvement
with disproportionately less terminal ileal disease;
- primary adenocarcinoma of the ileum may mimic Crohn’s dis­
ease, but typically demonstrates convexity of a neoplasm;
- large excavated ulcers and discrete larger nodules without
signs of mucosal inflammation favour lymphoma.
Fig. 38. Ileocoecal tuberculosis - Jejunal diverticulosis
strictures in the distal ileum Diverticula are local aquired weakness of the wall of the
intestine and are seen in the middle aged and eldery patients.
Although mostly asymptomatic, a variety of complications occur. The diverticula tend to be larger
and more frequent in the proximal small intestine.
On barium examination they are seen as multiple barium-containing outpouching on the mesen­
teric surface with mucousal folds in the neck (Fig. 37).
If they are small, may be missed on a small bowel meal; enteroclysis is more sensitive due to lu­
minal distention achieved and opportunity for compression.
Strictures or adhaesions from diverticulitis may lead to recurrent bowel obstruction. Other compli­
cations include volvulus, pneumoperitoneum without peritonitis and a chronic pseudo-obstruction
syndrome due to hypomotility.
Infections
Tuberculosis
Tuberculosis is the most common chronic inflammatory disease of the small bowel. It is now
increasingly seen in the developed world in association with HIV infection in immunocompromised
hosts.
There are some typical features:
- ususally it is secondary - less of 50% of patients have demonstrable pulmonary tuberculosis;
- the ileocaecal region is the most common site;
- ulcerations lead to multiple stenotic areas;
- thickening of the mucosal pattern and nodularity in the terminal ileum;
- spasm of a coecum with a narrowed and ulcerated distal ileum;
- strictures in the distal ileum;
- Shtirlin symptom - effaced folds in the ileocecal region.
The radiological features may be indistinguishable from Crohn’s disease. Ulcerative and hyper­
trophic forms have been described. Early signs include thickening of the mucosal pattern and
nodularity in the terminal ileum. Later the caecum becomes contracted and retracted ending
in fibrosis. Strictures in the distal ileum are typical (Fig. 38). Complications include fistulas and
46
perforations which are usually localized. CT will demonstrate
the thick-walled bowel and may show tuberculous ascites and
lymph node enlargement which is typically greater than that
seen in Crohn’s disease.
Ascariasis
The Nematode round worm, Ascaris lumbricoides, most
inhabit the small bowel, a few will be in the stomach or duode­
num, but the majority will be in the lower ileum, coecum and
colon.
In the small bowel their movements can be seen by ultrasound
or barium enema.
US is more accurate. The body of the warm shows as two hyper-
echoechoic lines on either side of a hyperechoechoic space when seen on a longitudinal scan rel­
ative to warm. If scanned transversally there will be a round, hyperechoechoic center (the warm’s
alimentary canal) surrounded by a hyperechoechoic ring (the warm’s body). This is the character­
istic ’’target sign” and may also be seen in biliary tract.
Ascaris is the only intestinal worm which ingests barium and there will be one or more white lines
(the warm alimentary canal) within the colon or small bowl (Fig. 39).
Ascaris is the most common cause of intestinal obstruction in children and the most common
cause of jaundice in children in Africa, Asia and South America.
Tumours
A variety of benign tumours occur including adenomas, leiomyomas and vascular tumours.
These are most common in the jejunum, whereas malignant lesions with the exception of adeno­
carcinoma are more common in the ileum. Adenomas may be part of polyposis syndromes but are
less frequent than in duodenum. A combination of enteroclysis and CT scanning can now detect
and suggest the diagnosis in the majority of tumours. Lipomas,
leiomyomas, leiomyosarcomas and carcinoid tumours can give
a characteristic pattern on CT. Adenocarcinoma and lymphoma
are more difficult to diagnose (Fig. 40).
Carcinoid tumours
The majority of small bowel carcinoids occur in the distal
ileum. Tumours are considered malignant if there is local inva­
sion or distant metastasis, since differentiation on histological
criteria may be difficult. Lesions larger than 2 cm in size are con­
sistently malignant. Up to 70% of carcinoid tumours are invasive.
Radiological signs may be due to the primary lesion seen as a
filling defect or annular lesion on barium examination or due to
the secondary mass in the mesentery which typically provokes
stretching. Fig. 40. Adenocarcinoma in the
Small bowel lymphoma jejunum
Lymphomas usually (non-Hodgkin’s type) constitute about
40% of small bowel malignancies and most frequently affects
the ileum. They may be primary lesions or part of disseminated
disease. There are a lot of radiological appearances:
- narrowing of the lumen with mucosal destruction and a hallow
ulcesrs;
- bowel wall thickening with a normal or dilated lumen;
- ulcerations which can lead to large cavitating or excavating ex-
tralumnal masses - these may fistulate. Differentiation with other
pathologies, particularly Crohn’s disease may be difficult.
LARGE BOWEL
Imaging modalities
Plain radiography is useful mainly in cases of acute ab­
domen, when obstruction is suspected.
For most indications including weight loss, anaemia of un- Fig. 41. Virtual colonoscopy
47
known origin lower gastroin­
testinal bleeding and screen­
ing for presence of colorectal
carcinoma or polyps, barium
enema has been replaced
with colonoscopy.
When colonoscopy is con­
traindicated or incomplete,
imaging assessment of
large bowel is best per­
formed with CT colonos­
copy also known as virtual
colonoscopy (Fig. 41).
CT colonoscopy is a
multidetector CT technique, it
Fig. 42. Contrast barium enema - a; after evacuation of contrast - b has a sensitivity over 90% for
detection of polyps measur­
ing 10 mm or more. Limitation of CT colonoscopy are:
- inability to identify flat adenomas or mucosal inflammation;
- biopsy and polipectomy can not be performed.
Optical colonography can not replace colonoscopy.
Contrast enema studies are still used for investigation of large bowel pathology.
They could be single contrast barium enema and double contrast barium enema.
The double contrast barium enema (DCBE) is now the contrast examination of choice in most
patients suspected large bowel pathology.
For routine studies, single or double contrast, colon cleansing is essential. Colonic cleansing ene­
ma may be given the evening and 45-60 minutes before examination can be performed.
Barium is introduced via a rectal tube under fluoroscopic control making spot films for the suspect­
ed regions (Fig. 42 a, b).
The barium used for DCBE are of high density. Low density, dilute barium should be used for the
single contrast barium studies. Ionic water soluble contrast is used when there is suspected perfo­
ration or in obstruction when the patient is expected to be operated soon after the study.
Performance of DCBE means insufflation of carbon dioxide in the colon. Views of the large bowel
taken during the DCBE are designed to show all parts of the bowel in double contrast. Optimal
positioning for spot films is determined by fluoroscopy (Fig. 43 a, b).
Contraindications to DCBE include obstruction (use single contrast), potential technical difficulties
(immobility etc.), severe inflammatory disease, acute diverticulitis (use water-soluble contrast or
preferably CT scanning) and deep biopsy within the last 6-7 days (superficial mucosal biopsy is
a contraindication). ^
Contraindications to single
contrast barium enema in- I t
elude acute severe colitis, I
suspected perforation (use W ^ M
water-soluble contrast and H
deep biopsy). 'яж
As in small bowel dis- як
ease, transabdominal US may "Y..
be useful in the delineation of Y7
extramural disease such as pV A
paracolic abscess but its ap-
plication is limited by bowel «L.--

CT scanning is still |
method of choice for imaging
Fig. 43 b. DCBM - after insuffla­
of extramulral colorectal dis- Fig. 43 a. Barium enema
tion of air
48
ease. Major applications include the staging of neoplasms and
the assessment of paraaortic inflammation and abscesses in in­
flammatory bowel disease and diverticulitis (Fig. 44). There are
limitations of CT. Bowel wall thickening is largely non-specific
and in neoplastic disease the depth of intramural invasion can
not be determined; the demonstration of enlarged lymph nodes
is also non-specific and metastatic disease may occur in nor­
mal sized nodes. The technique for CT scanning in large bowel
must include adequate oral contrast administration to allow good
luminal distention and opacification. In most cases intravenous
contrast should be given to outline vascular structures and the
Fig. 44. MDCT - reconstructive im­ urinary tract. Dynamic intravenous bolus contrast techniques are
aging of abdomen - coronal slice used to image gastro-intestinal lesions and for detection of liver
metastases in colorectal staging.
MRI is used for detection of fistulae and abscesses in inflammatory bowel disease, staging
in invasive rectal carcinoma and in the diagnosis of presacral recurrent tumour following abdomi-
no-perineal resection.
Pathology
Anorectal malformation
Anorectal malformation includes a group of related anomalies of the termination of the
hindgut. In most patients, there is communication of the hindgut
with the perineum, genital tract, or urinary system. In other -
there is atresia of anal part of the rectum (Fig. 45).
The precise diagnosis and proper surgery are very important for
these patients. Frequency of anorectal malformations is approx­
imately 1 in 5000 live births, with males affected usually more
frequently than females. There are frequently other visceral and
skeletal anomalies in patients with anorectal malformations.
These include abnormalities of the spine (sacral anomalies), uri­
nary tract (neurogenic bladder), gastrointestinal tract (atresia,
traheo-oesophageal fistla ) and cardiovascular system (congen­
ital heart disease).
Congenital abnormalities
Anomalies in location, length and width of colon:
- in location - interpositio colonis - insertion of part of colon trans-
versum between the diaphragm and the liver (Chilaiditi symptom);
- coecum mobile - low situated colon; Fig. 45. Atresia ani et recti
- dolichocolon, dolichosigma.
Hirschsprung disease
Hirschsprung disease refers to an aganglionic segment
of distal large bowl. The most common form of Hirshprung dis­
ease is a short distal aganglionic segment which causes distal
large bowel obstruction. Normally innervated bowel proximal to
the aganglionic segment is dilated.

I
Hirshprung disease usually presents in neonats with abdomi­
nal distention and constipation. The frequency is approximately
1/5000 births. The radiologic diagnosis of Hirschsprung disease
requires a barium enema; contrast enemas are performed and
contrast is injected slowly through a catheter. The transition from
narrowed aganglionic colon to dilated normal bowel is clearly
demonstrated. The barium enema is highly accurate for the diag­

I
nosis of Hirschsprung disease, even in the newborns; the diagno­
sis is confirmed by rectal biopsy before surgical repair (Fig. 46). Fig. 46. Dilated large bowel in
Hirschsprung disease
Inflammatory diseases 49
The most common are ulcerative colitis and Crohn s disease.
The extent and severity of disease may be apparent from the
visualized mucosal fold pattern. Mucosal pseudopolyposis, sub­
mucosal oedema and wall thickening can be seen where luminal
air provides adequate radiographic contrast. Contraindications
to the double contrast examination is acute colitis. Contraindi­
cations to any contrast enema study include toxic dilatation and
perforation.
Method of choice is flexible endoscopy.
Other modalities that are employed in investigation of inflam­
matory bowl disease include radionuclide - labelled white cell
scanning to assess activity and severity of disease and US and
CT imaging for extramural complications.
CT will demonstrate (in more severe ulcerative colitis) thickened
bowel wall, transmular ulcers and pericolic inflammation or ab­
Fig. 47 a. DCBE - ulcerative colitis scesses.
Ulcerative colitis
The disease is characterized by episodes of exacerbation and
remission. The main category of involvements are proctitis, dis-
tal/or left sided colitis and so called ’’extensive colitis” - where
the whole colon is involved. The earliest sign of ulcerative colitis
on DCBE is a finely granular mucosal pattern which is homo-
genious and confluent. Progression is manifest as superficial
erosions which give a stippled appearance to the mucosa. Ex­
tensive acute ulceration results
in island of relatively intact mu­
cosa between ulcers. This in­
Fig. 47 b. CT - ulcerative colitis
tact and usually hyperplastic,
oedematous mucosa appears polyp-like on contrast studies-so
called pseudopolyposis (Fig. 47 a, b).
In longstanding chronically active ulcerative colitis there is loss
of haustral folds and the whole affected colon become narrowed,
shortened and featureless (Fig. 48).
The complications of longstanding ulcerative colitis include be­
nign strictures and colonic malignancies. Endoscopic byopsies is
usually required to exclude malignancies and dysplastic chang­
es. There is significantly increased risk of colonic neoplasm in
ulcerative colitis in patient with total colitis of greater then 10
years duration.
Crohn’s colitis
Fig. 48. Colitis in pars descendens
Crohn’s disease is a chronic disorder with exacerbations.
of the colon and carcinoma in the
The transmural nature of abnormality explains the tendency of
transversal part of the colon
fistula and stricture formation. Approximately 15% of patients
with this disease have colonic involvement only. The small bow­
el is affected in 30% and ileocolic involvement is present in
55%.
At early stages discrete aphtoid ulcers may be demonstrated
on DCBE surrounded by normal mucosa. The accompanying
submucosal oedema is less prominent than seen in small bowel
Crohn’s disease and the haustral pattern and mucosal folds may
therefore be normal.
More advanced disease is characterized by discontinuous asym­
metrical changes, serpiginous longitudinal and transverse ulcers
with or without cobblestoning, strictures and fistulae are seen as Fig.49. CT - Acute apendicitis-en-
in small bowel Crohn’s disease. Abscesses may be imaged by larged with involvement of sur-
US, CT or MRI scanning. rounding periapendicular tissue
50
Appendicitis
Acute appendicitis is the most frequent condition requir­
ing abdominal surgery in children. Imaging is performed only if
the clinical presentation is confusing.
Plain films of the abdomen may be completely normal in patients
with acute appendicitis. An appendicolith is present in up to 2 %
of cases. A common manifestation of perforated appendicitis is
small-bowel obstruction.
Sensitivity and specificity of US for the diagnosis of appendicitis
in children is between 80 and 90%. Compression in patients with
Fig. 50 a. Barium enema - diver­ US shows a noncompressible appendix, an overall diameter of
ticula more than 6 mm, thickening of the appendiceal wall, dilatation of
the appendiceal lumen, and occasionally an appendicolith.
CT is the imaging modality of choice for evaluating patients with
complicated appendicitis and possible abdominal abscess for­
mation (Fig. 49).
Diverticular disease
Colonic diverticula are of pulsion type. Diverticula are
seen predominantly in the sigmoid and distal descending colon
and occur laterally between the mesenteric and antimesenteric
teniae or sometimes in the antimesenteric inter-taenial area in
Fig. 50 b. CT slice - diverticula which position they are often small or intramural. In 10% they
are seen in the right side of the colon only and in 17% they are
scattered throughout the colon.
The term “diverticulosis” is often used for multiple diverticula in asymptomatic individuals; “diver­
ticular disease” is used when there are symptoms and “divertic­
ulitis” when there is associated inflammation.
The appearance of diverticula on barium enema depends on
the angle from which they are viewed, the degree of filling with
barium and and/or air and whether they are retained faceoliths
within them.
En face they are seen as rounded collection of barium of vari­
able size or to contain an air/barium level on decubitus or erect
views or as ring shadows. Compression of the sigmoid colon
should be done to demonstrate small polyps as filling defects
within the dilute barium.
When viewed on profile or obliquely diverticula appears as bar­
ium coated or barium filled outpouchings (Fig. 50 a, b).
Diverticulitis
CT examination is preferred - more comfortable for the
patient, able to confirm presence of diverticula and the site of Fig. 51 a. Single contrast enema
the disease, demonstrate pericolic inflammation-assess ab­ - polyps in a child
scess formation and help plan management, describe the wall
thickening and peridiverticular inflammatory infiltrate.
US (if CT is unavailable) can show pericolic abscess, but bowel
gas is limitation.
If contrast enema is performed during the acute attack, wa­
ter-soluble contrast should be used and introduced with care.
Polyps
Most are in the rectosigmoid region, but there are rel­
atively often met at the right side of the colon with increasing
of age. They are multiple in about 50% of patients. In those
with polyposis syndromes they may be innumerable. The im­
portance of benign polyps lies in their malignant potential.
Lesions may be pedunculated or sessile. They may rise to a Fig. 51 b.DCBM-polyp
51
characteristic “carpet like” growth. Double-contrast method is
superior to single contrast and it may detect up to 90% of pol­
yps greater than 10 mm in diameter.
A polyp will appear intraluminal or on all views within the bari­
um pool as a feeling defect with a stalk. It is necessary to dis­
tinguish the shadows of polypus and diverticula.
Diverticula are usually seen on at least one view as extralumi­
nal when image tangently or obliquely or to contain barium and/
or air (Fig. 51 a, b).
Combination of DCBE and flexible sigmoidoscopy increases
sensitivity. In determining whether a radiologically demonstrat­
ed polyp is currently benign or malignant, size is only reliable
indicator. 1-2% of lesions of 5-10 mm in diameter are malig­
nant, about 10% of 1-2 cm polyps are malignant while the in­
cidence increases approximately 50% for polyps greater than
Fig. 52. Circular narrowing of 2 cm. Pedunculated polyps are less likely to be malignant than
rectum sessible ones.
Polyposis syndrom es
Gardner’s syndrome is associated with multiple, usually
r innumerable colonic polyps, soft tissue desmoid tumours and
osteomas.
M ir Juvenile polyps are a form of hyperplastic benign lesion,
usually solitary and pedunculated.
Peutz-Jegher syndrome is associated with hamartomas
L Ш -V* in the bowel but rarely malignant degeneration can occur.
4Щ Colorectal neoplasms
It is generally accepted that the great majority of col­
W |
f orectal cancers develop in pre-existing benign adenomas and
i i polyps and their detection and removal should be a prevention.
| Colonoscopy is superior to barium studies in demonstrating
small polyps and tumours and has the potential for polypecto­
<
my and this is the preferred examination with a combination of
DCBE and flexible sigmoidoscopy in persons with occult bleed­
Fig. 53. Polycystic filling defect ing.
of colon Colorectal carcinoma
The rectum and the sigmoid regions are the most com­
mon sites for carcinoma. Multiple cancers are seen in about 5% or there are benign polyps
present in the same colon, frequently so called “sentinel” polyps that occur near the malignant
tumour.
Colorectal carcinomas arise due to malignant transformation of polyps and are located primarily
in the rectum and sigmoid colon. Almost all colorectal carcinomas are adenocarcinomas.
Metastases develop primarily in regional lymph nodes. Distant metastases occurs relatively late
in the liver and lungs. As is the case with stomach, the primary role of CT is not to confirm the
presence of the tumor, but to determine how far the metastases has spread. Colorectal tumors
are often an incidental finding.
The double contrast barium enema detect approximately 90-95% of colonic cancers. Most
missed tumours are in sigmoid, often when there is co-existing diverticular disease and in the
coecum. The vascular majority of tumours are adenocarcinomas. The radiographic appearance
on barium studies are:
- circular constricting lesions - the most common - “apple-core’ segments of narrowing; destruc­
tion of the mucosal pattern; ulceration may be present; (Fig. 52)
- polypoid lesions which are fungating and intraluminal producing a large mass with irregular
surfaces and an withdrawn base; (Fig. 53 )
- infiltrating lesions - like lesions with submucosal spread, similar to linitis plastica;
- ulcerating tumours with deep excavating craters and raised margins;
52
- mixed types.
The acute abdomen
Imaging modalities
When bowel wall lesions or obstruction are suspected, plain films are often followed by
barium studies. In cases where abdominal cavity is involved abdominal CT and US will follow.
CT and transabdominal ultrasound are usually chosen for the examination of masses, parenchy­
matous organs, retroperitoneal structures, the abdominal walls and the inquinal regions.
Chest studies are often included in patients with upper abdominal symptoms and angiography
and/or interventional techniques may be required in patients presenting with gastrointestinal
bleeding.
Image interpretation
In order to recognize pathology, a knowledge of normal abdominal anatomy is essential.
Areas of calsifications, soft-tissue masses and fluid collections have to be interpreted knowing
the patient’s history.
Gas collections
Gas is seen as dark black areas on the radiograph and is normally presented in the stomach,
large bowel and rectum. Deviation from the normal appearances are seen as abnormally dis­
tributed or abnormally large collections of air either within the lumen indicating obstruction, or
outside the bowel as a result of perforation.
Normally there is some air in the stomach and this results in an air-fluid level which is seen just
underneath the left hemi-diaphragm close to the midline. Every other air-fluid level found may
signify abnormality.
Calcifications
Intraabdominal, well defined, shell-like benign areas of calcification may be found along
the midline representing calcified lymph nodes or lying centrally in the true pelvis, may be seen
in the myomatous uterus.
Punctate calcification may be found in the prostatic gland in eldery men, or in phleboliths often
symmetrically distributed in the pelvis. They may be difficult to differentiate from a stone in the
ureter which is oval in shape and homogenious.
In old people calcifications may be seen in the aorta and in the iliac and splenic arteries.
The parenchymal organs
The liver is seen as an homogenious soft-tissue structure beneath the right hemidia-
phragm. Its right lower tip streches down to the iliac crest.
In most patients the kidneys are outlined. The right kidney is usually located higher and some­
what caudal to the left. The spleen is usually located laterally just under the left hemi-diaphragm
but is sometimes obscured by the stomach and colonic flexure.
The normal pancreas, adrenal and prostate are invisible on the plain film as is the normal uter­
us, but calcified myomata is often present. The normal gall bladder is not seen on plain films as
well as the urinary bladder.
Pathology
Calcifications
Calcifications are radio-opaque, well defined and round.
Multiple facetted and multilayered stones may be found in gall
bladder and the urinary bladder. Single or multiple stones may
be seen on the renal pelvis and ureters and occasionally in the
biliary tree and pancreatic duct.
Benign lesions such as myomata of the uterus, adenomata of
the adrenals, organized haematomas, leyomyomas, renal cyst
walls and dermoid may calcify.
The areas of calcifications associated with inflammatory lesions
are usually multiple and small and found in the pancreatic gland
as a sign of chronic pancreatitis. Shell-like or homogenious calci­ Fig. 54. Plain X - ray of the chest
fication may be seen in patients with eccinococcosis of the liver. - sickle radiolucency beneath
the dom of the diaphragm (due
Pneumoperitoneum
Perforation of a bowel loop allows air to pass into the to air in abdomen)
53
abdominal cavity. Large volumes of
air may be found after open abdomi­
nal surgery or following perforation of
the large bowel.
Ascites
Ascites can be detected by
abdominal ultrasound or CT.
Perforation
Perforation of gastrointestinal
tract may be due to:
- peptic ulceration;
- inflammation, incl. acute appendici­
tis;
- blunt or penetrating injury (incl. iat­
rogenic trauma).
Fig. 55. Small bowel illeus - Fig. 56. Large bowel ob- Perforation of the stomach, small in­
air-fluid levels in the small struction due to ileo-cae- testine and colon produces air in the
bowel cal intussusception peritoneal cavity. Perforation of the
duodenum and posterior rectum re­
sults in free peritoneal air.
Radiographic signs of air in the erect plain X-ray is air beneath the diaphragm, and on the
supine X ray of abdomen - gas outlines anatomical structures such as liver and spleen and
bowel are well seen as white lines outlined by air on both sides (inside and outside) the bowel
lumen (Fig. 54).
Mechanical bowel obstruction
Bowel obstruction leads to a mechanical or dynamic ileus which may be intermittent in
cases where the obstruction is incomplete. There are a variety of causes including post opera­
tive adhesions and peritoneal bands, an obstructing bowel tumour, infiltration from malignancy
adjacent to the bowel, invagination, strangulation, internal or external herniation. On abdominal
survey films the proximal air-filled bowel loops appear as air-fluid shadows with different height
depending on whether the obstruction is of the small or large bowel.
If contrast studies are used to see the obstructed bowel they should be iodine (Gastrografin).
Small bowel illeus
Organic obstruction of the small bowel leads to proximal dilatation with emptying of the
bowel distal to the site of the obstruction. The fewer the number of dilated loops seen, the higher
the level of obstruction. The presence of multiple air-fluid levels in the small bowel are situated
on a large base and are short and indicates the distally located obstruction (Fig. 55).
Large bowel illeus
The more distal the obstruction the more colon is dilat­
ed proximally while the bowel below the lesion and rectum are
empty. Even if the obstruction has lasted for only a few hours
the small bowel may be dilated. The large bowel obstruction
is characterized with air-fluid levels which are on a small base
and are high (Fig. 56).
Intussusception (Invagination )
Intussusception is an invagination of a segment of intes­
tine into adjacent bowel (Fig. 57). More than 95 % of intussus­
ceptions in children are ileocolic or ileocaecal and are not patho­
logic; these idiopathic cases are probably due to hypertrophy of
lymphoid tissue in the terminal ileum.
At adults they are secondary - accompanying polyps, tumours
and ascarides.
Plain film findings include - air-fluid level up to 3 hours after ileus.
Introducing barium per clismam leads to desinvagination of the Fig.57. Scheme of intussuscep­
loop. tion
Intussusception may also be diagnosed by US; a soft-tissue mass with concentric layers of
echogenicity produces a sign of onion-like formation.
Gallstone ileus
In patients with chronic cholecystitis a gallstone may erode through a fistula from the
gallbladder to the bowel. Depending on the size of the stone and the level of the fistulas commu­
nication (duodenum, ileum or right colonic flexure) the stone may get stuck at one of a number
of different levels, 6.g. the bulb, the sigmoid colon or as is most often the distal ileum. Air passes
spontaneously through the fistula into the gallbladder and biliary tree and this combination of
biliary gas and mechanical obstruction is pathognomonic for gallstone ileus.
Strangulation
Depletion of the supply of oxygenated blood of the bowel creates alarming symptoms and
affected bowel loop soon fills with haemmorrhagic fluid.
Small bowel volvulus
Rotation of the small bowel around its mesentery is a rare entity. Dilated bowel loops are
seen like air-fluid shadows in the mid abdomen.
Large bowel volvulus
Colonic volvulus is much more common than small bowel volvulus. The cause is an in­
complete fixation of the bowel which may form slings. The most common volvulus occurs in the
sigmoid.
Radilogically an air filled sigmoid loop is seen which may reach up to the right upper guardant.
Patients with a definitive diagnosis of mechanical obstruction should be examined by CT which
often not only confirms the diagnosis but also establishes the underlying cause such as an ab­
scess or a malignant lesion.
US technique is used but a large amount of air present in patient with dynamic ileus makes the
diagnose difficult. Intussusception is usually easy to reveal with ultrasound.
Paralytic ileus
A dynamic ileus is often seen after abdominal surgery and as a secondary complication
of peritonitis and circulatory insufficiency, but it can also occur as a sequel to longstanding dy­
namic ileus.
The abdominal survey films show slightly air-distended small bowel loops with long air-fluid
levels signifying lack of bowel activity, e.g. “silent abdomen”. If there is peritonitis as well fluid is
present in the peritoneal cavity.
The radiological evaluation of acute abdomen is often difficult and it is essential for the
radiologist to be familiar with the appearances of the normal abdomen. The assessment of any
abnormalities is based on a variety of radiological observations including the detection of ab­
normal collections of air or fluid inside or outside the gastrointestinal tract; the presence of cal­
cifications, masses and enlargement or displacement of organs. Any radiological interpretation
should always be undertaken according to the patient’s history and clinical presentation.

Abbreviations:
DCBM - double contrast barium meal
DCBE - double contrast barium enema

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1. Рентгенология и радиология, учебно помагало за студенти по стоматология, 1995,
Пигмалион
2. Bates J. Abdominal ultrasound-how, why, when, 2004, Churchil Livingstone
3. Direct diagnosis in radiology, gastrointestinal imaging, 2008, Thieme
4. Jovitas Skucas. Advanced imaging of abdomen, Springer, 2006
5. Lisle D. Imaging for students, Hodder Arnold, 2012
6. Lorenz J. Rad cases-gastrointestinal imaging, 2011, Thieme
7. Moeller M, R.Reif. Pocket Atlas of Sectional Anatomy, Vol. 2, Computed Tomography and
Magnetic Resonance Imaging - Thorax, Abdomen and Pelvis, 2001, Thieme
8. Ultrasound of the gastrointestinal tract, 2007, Springer
55
THE LIVER, BILIARY TRACT, PANCREAS AND SPLEEN
THE LIVER
Imaging modalities
With the introduction of cross-sectional imaging methods such as US, CT and MRI, direct imaging
of the liver parenchyma became possible where previously only angiography and radionuclide imaging
had been available.
Non X-ray methods
Ultrasonography
Ultrasonography is usually the first method chosen for explo­
ration of liver. It is widely available, easily performed and has no con­
traindications.
Ultrasound gives information about the size and structure of the liver
and demonstrates both localized lesions (e.g. hepatic tumours, cysts
and abscesses) and diffuse disease (Fig. 1). Intrahepatic structures,
such as portal vessels and biliary ducts can be identified. The vascu­
lar systems in the liver may be studied with Doppler US, which can
Fig. 1. US examination of liver give important differential diagnostic information.
Magnetic resonance imaging
MRI is in many aspects, equal to CT in imaging of the liver. It
has however certain advantages, that probably make it the best avail­
able method for studying disease in this organ. The free choice of
imaging planes permits better anatomical orientation and the utiliza­
tion of multiple imaging sequences and facilitates the identification of
smaller lesions, especially those associated with oedema. MRI gives
new information on parenchymal and metabolic disease, 3-dimen­
sional imaging enables visualization of the biliary tree and the liver hi-
lum and MR-angiography delineates the blood vessels. Various types
Fig. 2. MRI of liver before and of magnetic and paramagnetic contrast media that increase the sig­
after application of contrast nal intensity of either the lesion or the parenchyma, add significantly
medium precision of MR studies (Fig. 2).
Disadvantages of MRI include its sensitivity to movement artefacts
and the rather long duration of study, although with new technology and rapid sequences examination
time can be considerably reduced.
X-ray methods
Computed tomography
A CT study of the liver include 10 mm thick slices, usually before and after the intravenous injec­
tion of contrast medium. Because of its iron content, the density of the liver is slightly higher than that of
other intraabdominal organs, usually of 65 ± 5 HU. Most pathological lesions have a density less than that
of normal parenchyma. This difference is well seen after a contrast medium injection (Fig. 3). Sequential
scans after a bolus of contrast medium are useful for determining contrast enhancement dynamics which
are of great importance in the diagnosis of, for example, a haemangioma. By CT we can evaluate the
size of the liver and information on both focal and diffuse parenchymal disease. Newer CT technology
has also made it possible to visualize blood vessels (CT-angiography, CT-portography) and to perform
3-dimensional reconstructions which are important for studying anatomically complex areas such as the
liver hilum.
Angiography
Arteriography used to be the most precise method for evaluat­
ing liver disease, but its diagnostic use is now limited to the investiga­
tion of certain special problems such as the pre-operative visualiza­
tion of liver vessels or the detailed evaluation of certain liver tumours.
- therapeutic angiography is particularly important in the liver as the
organ has a dual blood supply (making embolization a relatively safe
procedure) and interventional procedures are associated with a far
lower morbidity than surgery in cases of acute arterial bleeding and
porto-systemic shunting; Fig. 3. CT of liver
56
- hepatic venography is valuable in the evaluation of the Budd-Chiari
syndrome;
- percutaneous transhepatic portography is used for studying the
portal circulation or for venous sampling of the pancreas.
Radionuclide imaging
Radionuclide imaging used to be an important method for
studying the liver, particularly focal lesions in the organ, but it has di­
minished its importance mainly because of its poor spatial resolution
and non-specificity in comparison with other methods. Nevertheless,
several specialised agents may be useful for imaging specific pathol­
Fig. 4. Plain X-ray. Calcified hi- ogy, such as radiolabelled leucocytes for intrahepatic abscess.
datid cysts Normal anatomy
The liver is the largest of the parenchymal organs and weights
apporoximately 1500 grams. It is situated in the upper right hypo-
chondrium and extends from the right across the midline. It may
reach as far left as the spleen. Superiorly the liver reaches the di­
aphragm and in the sagittal direction it extends from the ventral to
the dorsal abdominal wall. The liver is divided into a right and left
lobe, and for surgical purposes the border between these extends
obliquely from the gallbladder fossa to the vena cava in the plane of
the middle hepatic vein. The caudate lobe is usually considered as
a separate entity and is situated between the inferior vena cava and
the portal vein at the liver hilium.
Pathology
Fig. 5. MRT. Hidatid cysts Cysts
Cysts of varying sizes are
frequently seen in the liver and may be solitary or multiple.
On US a cyst has characteristic features with well-defined sharp bor­
ders, echo-free contents and peripheral echo enhancement.
On CT the lesions are well defined, with contents approximating to
the density of water and exhibiting no contrast enhancement of either
their contents or walls. Cyst walls may rarely be calcified.
Hydatid cysts of the liver are common in endemic areas; they may be Fig. 6. Haemangioma of the liv­
seen on plain film if calcified (Fig. 4). It has characteristic apearance er - with i.v. contrast medium
especialty on CT and MRT with septa and wall that are frequently - a characteristic enhancement
calcified (Fig. 5). from periphery to center
Benign tumours
The three most important benign tumours of the liver are: cav­
ernous haemangioma, adenoma, and focal nodular hyperplasia.
Haemangioma is the most frequently occurring liver tumour,
both in adults and children, and is a lesion to make differential diag­
nosis with malignant tumours.
On US a haemangioma is often seen as a hyper-echogenic localized

I
lesion.

On unenhanced CT it is seen as a low-attenuation lesion but with in­

travenous contrast medium it exhibits a characteristic enhancement
from periphery to centre within a few minutes (Fig. 6), a phenomenon
that is particularly evident in large tumours.
On MRI a haemangioma shows a high signal intensity on T2-
weighted images with similar contrast dynamics to those seen on
CT (Fig. 7). Fig. 7. MRT - haemangioma of
The diagnosis is usually made on a combination of CT and MRI the liver - axial multislices
methods and angiography is rarely necessary. 57
Malignant tumours
mour of the liver. They are the most common in male than in females.
Cirrhosis and hepatitis B are predisposing factors. They are usually
well shown on US, with both hypo- and hyper-echogenic areas.
On non-enhanced CT the tumour may be isodense and identified
only by the fact that it is a space-occuping lesion, but on contrast-en­
hanced CT the tumour is characterized by an uneven pattern of
contrast enhancement usually with area of diminsihed density in the
(necrotic) centre. There is often evidence of portal or hepatic venous
invasion. It is important for surgical planning to delineate the tumour
Fig. 8. CT - hepatocellular carci­ border and localize the lesion. This also applies to grading of the
tumour, resp. the extrahepatic spread (Fig. 8).
noma
MR I may offer some advantage over CT, because of its multiplanar
feature (Fig. 9). The tumour may require differentiation from a chol-
angiocarcinoma.
The most frequent malignant tumours in the liver are metastases
from other primary carcinomas. On US metastatic deposits may be
seen as lesions which may be hypo- or hyper-echogenic in compari­
son to the surrounding parenchyma, or may show mixed echogenic­
ity. Metastatic lesions are usually multiple.
On CT metastases are often seen as hypodense lesions that remain
as such after the injection of contrast medium (Fig. 10). Certain me­
tastases (e.g. hypenephroma) are hypervascular and therefore show
Fig. 9. MRT coronal slice - hepa­ increased contrast enhancement.
tocellular carcinoma - lobulated MRI seems to be the most sensitive method for detecting liver metas­
tumour with high signal intensity tases and the accuracy of the method may be enhanced by the use
of magnetic contrast agents.
Other focal lesions
Abscesses usually result from systemic infections, but may also result from a focus of infection
elsewhere in the body, or is amoebic in origin. The abscesses may be solitary or multiple and vary in size
and shape.
On US an abscess is well seen, but the findings are non-specific.
On CT abscesses are hypodense with contrast enhancement of their
peripheral wall.
On MRI there may be increased signal intensity on T2- weighted im­
ages (Fig. 11), with contrast features similar to those seen in CT.
Fine-needle biopsy is usually necessary to establish the diagnosis.
Trauma to the abdomen may result in rupture of the liver, with
the formation of an intraparenchimal and/or subcapsular haemato-
ma. In these cases the other parenchymal organs have to be studied
for traumatic lesions as well.
On US a rupture of haematoma is seen as a hypo-echoic area.
The imaging method of choice in traumatic cases is contrast-en- Fig. 10. CT - multiple metastases
hanced CT (Fig. 12), which makes it possible to differentiate between
haematoma, other fluid collections (bile) and normal parenchyma.
On MRI a haematoma is seen usually as a lesion with increased
signal.
Parenchymal disease
Fatty degeneration of the liver is fairly common, especially
with certain diseases such as alcoholism, diabetes or chronic infec­
tions.
On ultrasound this condition may give increased echogenicity of the
liver parenchyma (“bright liver”).
CT allows direct density measurements of the liver and since fat
shows low attenuation this permits quantitative evaluation of the dis­ Fig. 11. MRT-T2- abscess in the
ease. The degree of fatty infiltration may change rather rapidly, ac- liver
58
cording to the stage of the underlying disease. An attenuation of less
than 30 HU is a clear indication for fatty infiltration. The changes may
only be segmental or focal. A fatty liver is usually larger than a normal
liver.
Liver cirrhosis may vary in appearance and depending on its aetiolo­
gy the liver may be either smaller or larger than normal (Fig. 13).
Interventional procedures
One of the most common and important interventional tech­
Fig.12. CT - rupture of liver niques is guided fine-needle biopsy which is most easily performed
under US-control.
Needle biopsies are important since neither focal nor diffuse liver
disease are necessarily with diagnostic difficulties.
Liver tumours may be treated by embolization or direct ethanol injec­
tion. Embolization can be particularly useful in the palliative treatment
of endocrine metastases in the liver.
Hepatic bleeding from trauma, biopsy, aneurysm or other causes is
often most effectively treated by embolization.
THE BILIARY TRACT
Imaging the gallbladder has changed dramatically in the
Fig. 13. Liver cirrhosis - patho­ past two decades. Peroral cholecystography used to be the primary
logical pattern of perfusion method for studying the gallbladder. In recent years however, ultra­
sonography has almost completely replaced this technique. Ultraso­
nography is also important in imaging the biliary ducts, but a complete assessment still relies on their
opacification with contrast medium.
Imaging modalities
Non X-ray methods
Ultrasonograhy
Ultrasonography has become the primary imaging technique in the evaluation of the gallbladder.
It has the advantages of being precise, easy and quick to perform. It gives information about the contents
and wall of the organ, as well as the surrounding tissues (Fig. 14). Stones, inflammation and tumours
are all diagnosed with great precision. Ultrasound is also the primary
method for studying the intrahepatic and proximal extrahepatic biliary
ducts, giving information on ductal calibre.
The gallbladder is studied by US with a 3.5 - 5 mHz transduc­
er. The organ is studied in both its longitudinal and transverse axes,
with the patient lying supine. Views are also obtained with the patient
turned to the left and upright views are sometimes required. Position­
al changes help in the diagnosis of gallstones that move with gravity.
The extrahepatic biliary ducts are well seen by US but the intrahepat­
ic ducts are more difficult to image unless they are dilated. The most
distal part of the common bile duct is not usually seen, because of
interference with the image by gas in the duodenum. The diagnostic Fig. 14. Ultrasonography - fun­
accuracy of US of the gallbladder is 90-95%. dus of gall bladder
Magnetic resonance imaging
The value of MRI (Fig. 15) has yet to be established in the
study of the biliary ducts but techniques like MRI-cholangiography is
extremely valuable. In gallbladder cancer MRI may be important in
both diagnosis and staging.
X-ray methods
Peroral cholecystography
Peroral cholecystography was the primary method for imag­
ing the gallbladder for over 80 years (since its introduction in 1925),
until ultrasonography largely replaced it in the I980's. It is a useful
secondary method if the findings on US are unclear, if there is a Fig. 15. MRT of gallbladder with
discrepancy between the clinical assessment and the US findings, a stone
59
or if non-operative treatment of
gallstones is planned.
In peroral cholecystography the
contrast medium is administered
by mouth as tablets, absorbed
through the intestinal mucosa,
bound to albumin in the blood
and transported to the liver. From
the liver the medium is excreted
into the biliary ducts and con­
centrated in the gallbladder.
The concentration of contrast
medium reaches its maximum
10-15 hours after ingestion and
imaging usually takes place on
the day following ingestion.
Non-opacification of the gall­
bladder may indicate gallbladder
disease, such as obstruction of the cystic duct. It may, however also result from liver disease or disorders
resulting in disturbances in the absorption of contrast medium from the gut, e.g. diarrhoea.
The gallbladder is radiographed in multiple projections. The study is completed by exposing a so-called
contraction film of the gallbladder 45 min -1 h. after the ingestion of meals which provoke contraction of
the bladder, so called “Boyden breakfast” (Fig. 16 a, b).
The diagnostic accuracy of cholecystography in diagnosing galls stone is 85- 90%, i.e. slightly less than
that of US though the method is complementary.
Peroral cholecystography is still used as being a relatively easily performed and accurate diagnostic
method, especially in calculus disease.
Cholangiography, biligraphy, cholangiocholecystography
Visualization of the extrahepatic biliary ducts require the intravenous administration of contrast
medium. On intravenous cholangiography the contrast medium is given intravenously.The extrahepatic
biliary ducts are seen first and after that the gall bladder is visualized (Fig. 17). Contractile ability is diag­
nosed by “Boyden breakfast”.
The diagnostic accuracy of the method is only 50-60% and it should be employed when other
available methods (US, ERC, PTC, CT) are unhelpful.
Percutaneous transhepatic cholangiography
Percutaneous transhepatic cholangiography (PTC) give direct information concerning the biliary
tree. It requires the puncture of an intrahepatic biliary duct by a percutaneously introduced needle. The
procedure is performed under US guidance.The biliary ducts are filled with contrast medium through the
needle. Through the needle a guide wire can be negotiated into the
biliary ducts, for the introduction of various catheters or instruments.
Endoscopic retrograde cholangiography
Endoscopic retrograde cholangiography (ERC) give direct in­
formation about the biliary tree. It requires cannulation of the papilla
of Vater through an endoscope introduced via the stomach into the
duodenum. Contrast medium (low osmolar) is injected through the
cannula retrogradely into the common bile duct filling the extra- and
intrahepatic biliary ducts and the pancreatic duct. The contrast medi­
um injection is performed under fluoroscopic control. Radiographs in
various projections when the injection is complete are made.
Peroperative cholangiography
Peroperative cholangiography is performed during operative
procedures involving the biliary ducts, require the injection of contrast
medium directly into the exposed biliary ducts through a needle or
cannula. Several injections may be necessary during the study for Fig. 17. Cholangyocholecystog-
maximum diagnostic value.
raphy
60
Peroperative cholangiography is performed in order to diagnose or exclude the existence of concretions
in the biliary tree or to demonstrate a biliary leak.
Postoperative cholangiography
Postoperative cholangiography requires the injection of contrast medium through theT-tube used
to decompress the biliary tree following operative procedures. The procedure is usually performed 7-10
days after cholecystectomy to check for any residual biliary concretions. The procedure is performed un­
der fluoroscopic control and films are exposed in various projections. Care should be taken to avoid the
introduction of air into the biliary tract, because this may simulate stones.
Computed tomography is performed if gallbladder cancer is suspected. CT gives additional information
concerning the biliary tree and surrounding structures.
Radionuclide imaging
Radionuclide imaging or gamma scintigraphy is performed to evalutae biliary dynamics. The most
commonly used agent is 99m Tc-HIDA which is injected intravenously, where it is bound to albumin and
then excreted through the liver into the bile. The study gives information on hepatic function and biliary
flow. Radionuclide imaging of the biliary tree has lost much of its importance with the introduction of other
imaging methods, such as US, CT and MRI, but may still be useful in special cases where information
about biliary dynamics is important, where direct visualization of the biliary tree with injected contrast
medium is unsuccessful, or if the patient is strongly allergic to contrast medium.
Normal anatomy
The biliary ducts
The intrahepatic biliary ducts from the right and left lobes connect at the hilium to form the com­
mon hepatic duct. The hepatic duct runs caudally and medially towards the duodenum. The cystic duct,
3 - 4 cm in length joins the hepatic duct to form the common bile duct. This is 6 - 8 cm long and approxi­
mately 6 mm wide. It joins the pancreatic duct and enters the duodenum in the major papilla of Vater.
The gallbladder
The gallbladder lies on the inferior surface of the liver, and its own inferior surface is covered by
peritoneum. It is 7 -10 cm long and 3 cm in diameter with a volume
of 30-50 ml. The thickness of its wall is 2 - 3 mm (Fig. 18).
Pathology
Gallbladder
Gallbladder anomalies occur the most common being a
septum, usually situated in the fundus which partially divides the
organ. Very infrequently agenesis occurs resulting in absence of
the gallbladder. Common
bile
Duplication (Fig. 19) or even triplication of the gallbladder may occur duct

but these anomalies are very rare.

Gallstone disease
Stones frequently develope in the gallbladder. Clinically the — Pancreatic duct

stones do not occur in isolation but as a part of an entity, called gall­ Ampulla of Vater
stone disease. Stones are about twice as frequently in women as Sphincter of Oddi

Duodenum
in men. The majority of stones are cholesterol stones and less than
10% are pigment stones. Approximately 15 - 20% of calculi contain
calcium and can be seen on a plain radiograph (Fig. 20). Due to this g. 18. Anatomy of gallbladder
gallstones are divided into two: id biliary ducts
- opaque (X-ray positive);
- non opaque (X-ray negative).
Ultrasound is the primary method for identifying gallstones. A
stone is seen as a rounded, echodense structure, with a typical acous­
tic shadow behind it (Fig. 21). Sometimes, especially if the gallblader
is small and deformed, only the acoustic shadow is seen, the stone
itself being difficult to visualize. There are a multitude of US features
associated with the presence of gallbladder stones and the accuracy
of detection of stones on US is very high, approximately 95 - 98%.
In contrast, stones in the extrahepatic bile ducts may be difficult to
visualize on US, bowel gas often interfering with interpretation. 19. Folded and double bile
I.
Oral cholecys­
tography has tra­
ditionally been
regarded as
one of the most
accurate radio­
logical methods
as the diagnosis
of gallstones is
concerned but
its accuracy is
only 85 - 90%.
Gallstones are
seen in the con­
trast-filled gall­
Fig. 20. Plain X-ray - different radiopaque stones in the gallbladder bladder as filling
defects (Fig. 22).
The disadvantage of oral cholecystography is that a diseased gallbladder does not concentrate contrast
medium which means that in some cases when the gallbladder wall is inflamed or fibrotic, or the cystic
duct obliterated, the organ remains unopacified.
Plain film or CT scaning (Fig. 23) may give some information about composition of stones. Cholesterol
stones are usually uncalcified but if calcium is present, it often occurs
as a ring-like structure in the stone. In pigment stones the calcium is
usually centrally located. Cholesterol stones may be lighter than the
contrast-filled bile and may thus be “floating” on oral cholecystogra­
phy (Fig. 24).
Cholecystitis
Cholecystitis may be acute or chronic. Acute cholecystitis
used to be a diagnosis in which imaging was unhelpful. Peroral cho­
lecystography could only show that the gallbladder was “non-func­
tioning” as the inflamed organ does not concentrate oral contrast me­
dium. Ultrasound has become the primary method for imaging acute
cholecystitis, because the technique demonstrates not only the gall­
bladder wall and its contents but also the adjacent tissues. On US an
inflamed gallbladder wall appears thicker than normal (over 3 mm). Fig. 21. US - stone in gallblad­
Other diseases such as pancreatitis and liver disease, however may der
also cause thickening of the bladder wall. Changes in the surround­
ing tissues may include oedema or fluid collections. The gallbladder
often contains gallstones (present in 90 - 95 % of cases) or sedimen­
tation of its contents (“sludge”), but these are non-specific findings
which may occur in the absence of cholecystitis.
In so-called acalculous cholecystitis, stones are not present although
the other signs of acute cholecystitis described above are often pres­
ent.
CT may show the same findings
as US, but any changes present
in the surrounding tissues may
be better shown on CT (Fig. 25).
As a result of chronic cholecys­
titis, the gallbladder wall may
calcify and appear on the plain
film as a so-called “porcelain
gallbladder” (Fig. 26). Fig. 22. Oral cholecystography -
Gallbladder carcinoma Fig. 23. CT ■ multiple stones in non-opaque stone in fundus of
Gallbladder carcinoma is gallbladder the gallbladder
62
relatively rare seen in approx­
imately 0,1 % of patients with
gallstones.
On US a carcinoma can be
seen as a space-occupying le­
sion in the gallbladder area, as
a hypo-echoic mass within the
gallbladder, or as a generalised
thickening of the bladder wall
(Fig. 27).
It is important to note any exten­
sion of the tumour into the sur­
rounding tissues but this may be
difficult to define on US.
CT may show similar chang-
es to ultrasound but usually ^ ra cholecystography ■ multiple non-opaque polygonal
demonstrates the extent of the s*ones ’n *he gallbladder and cystic duct
tumour better than the latter technique and should always be obtained in order to assess the potential
operability of the lesion.
Biliary duct disease
Gallstone in the extra-hepatic biliary ducts are difficult to evaluate by US, which has an accuracy
of 20 - 50% in this examination. The biliary tree is difficult to visualize
throughout its length and the common bile duct can be obscured by
bowel contents and gas. A stone in a normal duct, under 6 mm, may
be difficult to be seen, whereas
a stone in a dilated duct is eas­
ier to be seen. In non-diagnostic
or doubtful cases contrast me­
dia studies such as intravenous
cholangiography, ERC or PTC
should be undertaken.
Fig. 25. CT-calculous cholecys­ Thin-slice computed tomography
titis - thickening of a bladder may also be helpful but without
wall and a stone oral contrast medium (which may
obscure a calculus in the lower Fig. 27. US - gallbladder carcino­
common bile duct). ma - exophytic growth of a lob-
In some cases MRT may also be ulated tumour
used (Fig. 28).
THE PANCREAS
Imaging modalities
Non X-ray methods
Ultrasonography
The primary method for
studying pancreatic disease is
ultrasonography (US). The pan­
creas may be visualized by ultra­
sonography in approximately 85
Fig. 26. Plain X ray-calcium pre­ % of cases, because the organ
cipitation in the wall porce is partly or wholly obscured by
lain gallbladder" bowel gas or other bowel con­
tents.
The echogenicity of the pancreas is normally greater than that of
the liver. In most individuals, the normal pancreatic duct is seen as a
narrow line in the pancreatic parenchyma (Fig. 29); the caudal por- Fig. 28. MRT - stone in t e com
tion of the common bile duct is also seen as it enters the head of the mon bile duct
63
pancreas. It is important to assess the calibre of the pancreatic and
choledochal ducts which are normally 1 - 3 mm and approxinrntely 5
mm, respectively. Dilated pancreatic ducts indicate either obstruction
or duct ectasia in chronic pancreatitis.
Doppler US is useful to assess the peripancreatic blood vessels
which may be involved in acute and chronic pancreatitis or by pan­
creatic neoplasms. Intra-pancreatic vessels may also be visualized;
vascularity may be useful in tumour diagnosis.
Ultrasound and CT are complementary techniques in the diagnosis
of pancreatic disease.
Magnetic resonance imaging
Fig. 29. US - pancreatic duct The changes found in pancreatitis and pancreatic tumours
are better demonstrated by CT and US than by magnetic resonance
imaging.
The free choice of MR imaging planes is however an advantage of
the technique. Shorter imaging times with fast sequences and oral
and intravenous contrast agents increase the role of MRT in pancre­
atic disease (Fig. 30).
X-ray methods
The plain radiography
The plain radiograph is of limited value in the diagnosis of dis­
orders of the pancreas. The pancreas itself is not seen on the plain ra­
Fig. 30. MR cholangiopancrea­ diograph, because the organ does not normally contain contrast-form­
tography ing elements and its surrounding fat planes are not visible. Areas of
calcification, however, are well seen, and this finding is of diagnostic
value. Characteristic types of calcification may be seen in the pancreatic duct following chronic pancreatitis,
in the walls of calcified pseudocysts or in the pancreatic parenchyma in hereditary pancreatitis (Fig. 31).
Duodenography
Enlargement of the head of the pancreas, e.g. from a pancreatic cancer or cyst, lead to change
in the duodenal loop (Frostberg’s sign, or the “inverted 3” sign). This may be seen on a single or dou­
ble-contrast barium study. The sign is indirect and only seen with marked expansion of the pancreatic
head. Barium duodenography has decreased in importance with
the greater use of cross-sectional imaging techniques such as ul­
trasound and CT.
Computed tomography
CT provides important information that cannot be obtained by
US alone and together, the two techniques are the most important im­
aging methods for the organ. The retro-peritoneal fat that surrounds
the pancreas in many patients affords good delineation of the organ
on CT, even in the presence of dilated bowel loops and oedema,
circumstances which considerably diminish the diagnostic efficiency
of ultrasound. Image quality may be affected by patient movement in
cases with abdominal pain. Both cysts and areas of calcification are Fig. 31. Plain X-ray of abdo­
imaged with great clarity and the use of intravenous contrast medium men-calcifications in pancreas
enhances the detection of pathological changes in many situations
(Fig. 32).
Tumours, for instance, show slower contrast enhancement than
normal pancreatic parenchyma. Cysts do not enhance with con­
trast medium. In addition to the pancreas itself, neighbouring or­
gans are better seen on CT than US e.g. the biliary ducts, kidneys,
spleen, bowel and mesentery and this allows for the precise grad­
ing of pancreatic disease by CT. Opacification of the bowel with
oral contrast medium is important in order to differentiate between
bowel loops and some type of pancreatic pathology such as tu­ Fig. 32. CT axial slice at the level
mours or cysts. Fast CT scanners improve the diagnostic capabil- of the liver and pancreatic gland
64
ities of computed tomography in the pancreas
ERCP
At endoscopic retrograde cholangiopancreatography (ERCP)
the papilla of Vater is cannulated under direct visual control through
an endoscope which has been introduced via the oesophagus and
stomach into the duodenum, and water soluble contrast medium is
injected into the pancreatic duct (Fig. 33). The study provides infor­
mation about the ductal system but not about the pancreatic paren­
chyma.
Pancreatitis is a complication of the technique which can result from
either the manipulation required for duct catheterization or the action
of the contrast medium on the pancreas. Images of the ductal system
are taken in various projections under fluoroscopic control.
ERCP shows changes such as distortion or obstruction of the
main ducts or their branches as may occur in cancer, or may show
communications between the ducts and pancreatic cysts. The
Fig. 33. ERCP
main value of ERCP is in the mapping and grading of changes
in chronic pancreatitis and in fully delineating the pancreatic duct
Islets
before pancreatic resection. In the evaluation of changes in the
head of the pancreas it is also important to visualize the common
bile duct.
Angiography
Angiography used to be the definitive method for the di­
Pancreas
agnosis of pancreatic tumours. Since the introduction of US, CT,
MRI and ERCP as direct imaging methods however, the role of
angiography has been reduced to the diagnosis and preopera­
tive localization of endocrine tumours. They are often very vas­
Fig. 34. Anatomy of pancreas cular and appear as enhancing structures on angiography which
means that the technique can often detect lesions too small to be
identified on US or CT (0.5- 1 cm).
Normal anatomy
The pancreas is 12 -15 cm long, 3 - 6 cm wide and 2 - 4 cm thick and weighs 65 - 70 g.The organ
is surrounded by a layer of fat of varying thickness. The head lies adjacent to the duodenal loop to the
right of the midline and the uncinate process extends behind the superior mesenteric vessels. The body
runs in a S-shaped loop up to the left; the tail is extending to the hilum of the spleen. The drainage duct of
the exocrine pancreas, the duct of Wirsung opens together with the choledochal duct in the major papilla
of Vater in the middle of the second part of the duodenum (Fig. 34).
The secondary duct, the duct of Santorini, opens into the minor papilla approximately 2 - 3 cm above

!(
the major papilla. Retroperitoneal location of the pancreas is important to a proper understanding of the
secondary effects of pancreatic diseases.

Pathology
Acute pancreatitis
The term acute pancreatitis implies primarily inflammation of
the organ itself, but there are often associated secondary inflamma­
tory changes in the surrounding tissue and organs. The complica­
tions of acute pancreatitis include necrosis of the pancreatic paren­
chyma, so-called necrotic or haemorrhagic pancreatitis and cyst and
abscess formation. Fig. 35. CT - acute pancreati­
Computed tomography, particularly contrast-enhanced CT, has tis-enlarged pancreas and fluid
proved to be very important in both the diagnosis of disease in pararenal spaces
and the grading of its severity. The CT examination starts with 65
the organ and its surrounding tissues is made - presence of oedema, abcesses, cysts etc. Fol­
low-up studies are performed at regular intervals depending on the patient’s progress (Fig. 35).
Chronic pancreatitis
Chronic pancreatitis is diagnosed by means of US, CT and ERCP. Ultrasound provide information
concerning the size and parenchymal volume of the pancreas, the calibre of the pancreatic duct and
the presence of cysts or other abnormal features. On CT the parenchyma is displayed with great preci­
sion, the pancreatic duct is sometimes seen and any area of calcification that may be present are better
demonstrated than on either US or the plain film. Contrast enhancement often improves the quality of
the imaging and allows more accurate distinction between various entities such as cysts, abscesses,
oedema, fluid collections and adjacent bowel loop.
The ductal anatomy is best seen on ERCP. With this method in chronic pancreatitis ductal changes such
as dilatation, ectasia, local narrowing and possible communication with cysts are seen very well.
Pancreatic tumours
When a pancreatic tumour is suspected, the first imaging studies undertaken is ultrasound. A tu­
mour is seen as an area of abnormal echogenicity which is usually hypoechoic in relation to the surrounding
parenchyma. A careful assessment is made of the tumour’s location, its possible effect on the pancreatic
and/or common bile ducts its relationship to vascular structures and the extent to which it may be invading
neighbouring organs. Fine-needle biopsy of the tumour can also be performed under US-guidance.
Computed tomography is often performed in addition to ultrasound because of the superior anatomical
details it affords the same features are looked for on CT as described above for US. Any extension into
the surrounding areas is better shown on CT than US, as are metastases and the regional lymph nodes.
Trauma
In abdominal trauma the bowel loops are often distended and computed tomography (particularly
contrast-enhanced CT) is therefore the method of choice when evaluating traumatic lesions. A disruption
of the pancreas is then seen as a discontinuity in the pancreatic parenchyma.
Interventional procedures
Interventional techniques in the pancreas consist mainly of biopsy, drainage and embo­
lization procedures. Fine-needle aspiration biopsy may be performed under US, CT or ERCP
guidance. Guided fine-needle biopsy has considerably improved the accuracy of diagnosis. As­
piration of a cyst allows analysis of its contents, and permits the identification of for instance,
complicating infection. Abscesses and cysts may be drained through a percutaneous catheter
or drain.
Arterial embolization is extremely useful in the management of pancreatic aneurysms and may be
life-saving in cases of acute bleeding.
THE SPLEEN
Imaging modalities
Non X-ray methods
Ultrasonography
US gives good information on the shape and size of the spleen and on any pathological changes
that may be present. Splenomegaly can be identified and measured. Cysts are seen as well-demarcated
echo-free structures.
Tumours and metastases have an echogenicity differing from that of normal splenic parenchyma, being
either hypo- or hyper-echogenic.
Traumatic changes, such as rupture of the spleen and haemorrhage, are clearly seen on US, as infarc­
tions and abscesses.
Magnetic resonance imaging
On MRI diffuse infiltrates in lymphoma, may be seen more clearly than on US and CT; MRI and
CT are of equal value. The free choice of imaging plane may be one advantage offered by MRI.
X-ray methods
Plain radiography
The size of the spleen may be roughly estimated on the plain film especially if the organ is en­
larged. Calcified lesions such as granulomas or cyst walls are well seen.
Computed tomography
The best images of the spleen are obtained by CT, which also gives information about any calcifi­
cation present, e.g. in granulomas or cyst walls and allows precise measurement of splenic size (Fig. 36).
66
Radionuclide imaging
Localized changes, such as cysts, metastatic deposits, tu­
mours and infarcts can be shown by radionuclide imaging, though
the specificity and spatial resolution of the technique are not so qood
as US and CT.
Angiography
Angiography is not often used for diagnostic purposes (ex­
cept in acute bleeding) but may be used as a step in embolizing the
spleen or splenic artery in the treatment of hypersplenism, trauma or
aneurysm.
Fig. 36. CT - spleen withouth ab- Normal anatomy
normalitis The spleen is located posterolaterally in the left hypochondri-
um. It is 10 -12 cm in length and 6 - 8 cm in width, and weighs 150 - 200 g. The most common anatomical
variant to be seen is an accessory spleen, i.e. one or more splenunculi that usually lie near the splenic
hilum. The size of the spleen, especially its length, may be estimated on plain radiography but is best
evaluated by US, CT or MRI.
Pathology
Splenomegaly
US is usually the first imaging modality to be employed in the investigation of splenomegaly. The
organ size and the structure of the splenic parenchyma can be assesed by CT or MRI and may be useful
in certain individuals to characterize the cause of the splenic enlargement.
Abscess, infection
With US and contrast-enhanced CT, absceses are typically seen as localized lesions with thick
and contrast-enhancing walls.
Trauma
Splenic rupture is not uncommon in abdominal injury, and
is diagnosed by US and/or contrast-enhanced CT. Parenchymal le­
sions and intracapsular bleeding are seen with equal clarity using
either method, but any changes in the surrounding region, such as
may occur with rupture of the splenic capsule, are better shown on
CT (Fig. 37).
Angiography can be performed in order to map the vascular anatomy
in detail or to embolize.
Interventional procedures
The most important interventional procedures are guided
fine-needle biopsy, the percutaneous drainage of splenic abscesses
and embolization of the splenic artery in bleeding or splenomegaly. Fig. 37. CT - acute splenic rup­
ture
Abbreviations:
PTC - percutaneous transhepatic cholangiography
ERC - endoscopic retrograde cholangiography
ERCP - endoscopic retrograde cholangiopancreatography
i.v. - intravenous

Bibliography
1. Крупев M. Пропедевтика в образната диагностика на черния дроб, 2012
2. Aguri A, A. Dailey. Grant’s atlas of anatomy, 2009, Lippicott Williams and Wilkins
3. Block B. Color Atlas of Ultrasound Anatomy, 2004, Thieme
4. Hofer M. CT teaching manual, 2007, Thieme
5. Hofer M. US teaching manual, 1999, Thieme
6. Skucas J. Advanced imaging of abdomen, Springer, 2006
7. Liver Imaging-current trends and new techniques, 1992, Andover Medical Pubishers, Inc,
8. Moeller M, R.Reif. Pocket Atlas of Sectional Anatomy, Vol. 2, Computed Tomography and Magnetic
Resonance Imaging - Thorax, Abdomen and Pelvis, 2001, Thieme
9. Schmidt. Ultrasound, 2007, Thieme
67
GENITOURINARY SYSTEM
Imaging modalities
Imaging modalities could be divided into:
Non X-ray methods:
Ultrasonography
Ultrasonography has a main role in genito-urinary imaging. It has a diagnostic potential in
almost every part of the genito-urinary tract. It is easy, cheap and non-invasive.
Several special probes have been developed for ultrasonographic
examination of the genito-urinary tract. First of all are the tradi­
tional abdominal transducers which are useful for examination of
kidneys and the adrenals and overview examination of the pelvic
organs. If the examination with the probe is inadequate one can
supplement by using a transrectal (proximal urethta, prostatae),
transvaginal (female genitals, posterior part of the bladder) or
transurethral probe (bladder wall).
Traditional ultrasonography gives information about mor­
phology e.g. (solid vs. cyst), but not about function (Fig. 1). Perfu-
sional data requires Doppler or color Doppler. By flow characteris­
Fig. 1. Ultrasonography-normal tics and frequency shifts color Doppler can detect arterial stenosis
right kidney and demonstrate the vascular nature of various lesions.
Ultrasonography is superb for guidance in interventional
procedures like nephrostomy, biopsy and drainage.
Magnetic Resonance Imaging (MRI)
The role of MR in the imaging of the urinary tract is not
completely established whereas it has assumed a very important
role in the imaging of genital organs. Principally the examination
is performed in the same way as it is performed of other regions.
Special coils (endovaginal and endorectal) are available for pelvic
uroradiologic imaging. A role of MR angiography within the next
years may replace X-ray angiography. Pelvic imaging (bladder,
prostate, uterus and genital organs) are for the time being the
major area for MRI within the genitourinary system. It seems very
Fig. 2. MRT - coronal reconstruc­ useful for local staging of various types of cancers; preliminary
tion indications are that it may surpass the sensitivity of CT in detect­
ing enchancement of small lesions. At present MRI, including MR
urography is used in the kidneys usually for cases which can not be solved with CT and US, when
iodinated contrast media is contraindicated, and for vascular lesions (Fig. 2).
X-ray methods
KUB (kidney-ureter-bladder survey)
A plain film of the kidney and bladder is useful for the di­
agnosis of opaque stones and soft tissue calcifications. It is an
important part of all conventional X-ray examination of the urinary
tract. It should always be performed prior to contrast medium in­
jection. On the plain film of kidney form, size and localization of
kidneys could be seen and the presence of Ro-positive stones
(opaque stones) (Fig. 3).
Contrast studies
Intravenous urography (descendent, excretory urography)
Contrast medium (1 ml per kg body weight) is injected into
a cubital vein. Film over the kidney region is taken 5 minutes post
contrast. If there are no contraindications (e.g hydronephrosis,
aortic aneurism, recent surgery, big abdominal tumour) abdomi­
nal compression is applied in order to retain the opacified urine in
the pelvis and ureter. Five minutes after that additional exposures
of kidneys are taken. The compression is then removed and a ig. 3. Plain X-ray of abdomen
68
full abdominal exposure is obtained. When
the bladder is well filled exposure of it is
taken (Fig. 4).
Urography includes standart expo­
sures, but it should be principally individu­
alized. Advantages of urography are:
- rapid overview of the entire uri­
nary tract;
- detailed anatomy of the collecting
system;
- demonstration of non-opaque cal­
cifications;
- obstruction is well seen.
The disadvantages are:
- it depends on kidney function;
Fig. 4. Intravenous urog­ Fig. 5. Cystography
- it provides little assessment of pa­
raphy
renchymal structure (e.g. cystic vs. solid);
- it does not show the whole renal contour and may miss masses arising from the anterior or
posterior part of kidney.
The ability of urography to show detailed calyceal anatomy and the overlying parenchyma makes it
useful for diagnosis of papillary necrosis, urothelial neoplasms, sponge kidney, adult polycystic kid­
ney disease and urogenital tuberculosis. It is able to demonstrate the majority of calcifications within
the urinary tract, but it is not as sensitive as CT.
Congenital anomalies such as fusions, rotation anomalies, calyceal variants and duplications
are well demonstrated by intravenous urography.
It is the most important examination for evaluation of the renal function - if urinary secretion
is normal, slow or abscent.
Direct pyelography (retrograde, ascendent, transvesical, urography)
Direct pyelography (retrograde, ascendent urography) means direct injection of contrast me­
dium into the upper urinary tract. It may be performed through a catheter placed in the ureter during
cystoscopy (retrogradly). It gives possibilities for better evaluation of morphological changes of pel­
vis, calices and ureters but can not evaluate the function.
The examination is good for demonstration of:
- small mucosal abnormalities;
- diverticula and cavities;
- obstructing process in the upper urinary tract when intravenous urography has not be convincing.
The indications for direct pyelography are:
- non visualization of the upper urinary tract on intravenous urography (unless there is an obvious
cause such as a large tumour, in which case CT would be preferred);
- unexplained hematuria in which intravenous urography did not completely delineate the entire ure­
ter and/or pelvic cavity;
- as an aid in the diagnosis of renal failure, e.g. renal papillary necrosis;
- possibility of upper urinary tract obstruction (as a result of stricture, calculus).
Cystography
Cystography means specific examination of the bladder with contrast medium. It can be per­
formed following intravenous injection of contrast medium (in conjunction with intravenous urogra­
phy) or following direct installation of contrast medium through a urethtral catheter.
Indications for cystography are:
- vesico-ureteral reflux;
- posttraumatic or post - operative urinary extravasation;
- divertivula.
It is used for evaluation of mucosal relief and presence of papillomas or cancer lesions (Fig. 5).
Hysterosalpingography
Today hysterosalpingography is primary used in the survey of female infertility and visua iza
tion in the tubes (anomalies, strictures, enlargement). Cone-tipped obturator is placed in the externa
69
cervical orifice or a tiny catheter is inserted in the uterine cavity. A
water-soluble contrast medium is used. It is injected slowly in or­
der to demonstrate the situation of the tubes - their form, size and
passability - if the contrast spreads freely in the peritoneal space
or there are changes like dilatation, narrowing, impassability etc.
(Fig. 6).
Angiography
Angiography of genitourinary system does not differ from
the same examination of other organ systems. A catheter is in­
troduced into the venous or arterial system using Seldinger tech­
Fig. 6. Hysterosalpingography nique. The catheter is placed during fluoroscopic guidance in a
vessel of the region of interest.
Renal arteriography to diagnose and differentiate renal masses
is rarely performed now due to the advent of ultrasonography and
especially CT.
Angiography may be performed in the planning of surgery on an
anomaly (e.g. horseshue kidney) or partial nephrectomy.
Other indications for renal arteriography includes suspected renal
artery stenosis, vasculities (e.g.poliarteriitis nodosa), aneurysms
and arterio-venous fistulae.
Arteriography is necessary during vascular interventions such as
embolization, stenting and balloon dilatation of the renal vessels
(Fig. 7).
Fig. 7. Abdominal aortography Computed tomography (CT)
CT has assumed an important role in the visualization of
the urinary system. Within a few minutes after injection of contrast medium the entire urinary tract
can be visualized including the surrounding tissues.
CT is excellent in detecting and differentiating renal masses and in staging renal malignancies. It is
very sensitive in identifying calcifications, even non-opaque stones.
CT is the method of choice for evaluating renal injuries. It is the
best modality to demonstrate the normal adrenal glands in detail
and it has become the basic method for diagnosing and differenti­
ating adrenal pathology (Fig. 8, 9).
Nuclear medicine
Nuclear medical examinations give functional information
about the genitourinary system, especially about the kidneys and
adrenals. Their role in imaging of lower urinary tract and genital
organs is limited.
In contrast to conventional X-ray, the ionizing radiation is internal
and generated by radionuclides which emit radiation that is de­ Fig. 8. CT - axial slice - adrenal
tected by a gamma camera or Single Photon Emission Computer tumour
Tomography (SPECT). Many radiopharmaceuticals are available
for examination of the genitourinary tract. The most frequently
used are Tc, Mag, Tc DTPA etc.
Scintigraphy is useful for diagnosis of urinary leackage, and
isotope cystography is an alternative to conventional cystogra­
phy for diagnosis of vesico-ureteral reflux. Special radiophar­
maceuticals are available for both cortical and medullary adre­
nal imaging.
KIDNEY AND URINARY TRACT
Anatomy
Kidney
The kidneys are located in the retroperitoneum and mea­
sure approximately 12 cm (height), 6 cm (width) and 4 - 5 cm
(depth). Fig. 9. Contrast enchanced MDCT
70
The right kidney is lower then the left one because of the liver; the last
rib crosses the upper part of the right kidney and passes through the
middle part of the left one. Axes of kidneys cross at Th (Fig 10).
Radiologically using contrast medium renal pelvis, calices, ureters
and urinally bladder become visible (Fig. 11).
There are different kinds of pelvices: ampular and linear. Ampullar
pelvis is with wider medial part, calices are more shortened and
wide and linear pelvis is like continuation of the ureter, calices are
longer and more narrow (Fig.12).
At ultrasonography the parenchyma is echopoor whereas the re­
nal pelvis and the surrounding sinus tissue (mostly fat) is echorich
(Fig. 13).
At CT it is not possible to distinguish cortex and medulla on unen­
hanced exposures, whereas on images taken during the first 60
seconds after the contrast medium has reached the kidney, there
Fig. 10 is a clear demarcation between medulla and cortex; during the ex­
cretion phase the attenuation of
the two areas is again the same
(Fig. 14).
On T,-weighted MRI the renal
parenchyma is bright whereas
the medulla has lower signal
intensity than the cortex on un­
enhanced T1 weighted images
(Fig. 15).
Ureter ____
The ureters course
Fig. 13. Ultrasonography of kid­
along the psoas muscles from
ney
the renal pelvis, pass over the
common iliac vessels, and en­
ter the bladder deep in the pel­
vis dorsolaterally. Visualization
Fig. 11. Intravenous urography of the normal ureter requires in
the majority of patients intralu­
minal contrast.
Ureter has 3 curves: flexura
renalis, flexura marginalis and
flexura vesicalis.
Bladder
The urinary bladder is Fig. 14. CT - axial slice of kidneys
best examined when it is full,
when it fills the anterior part of
the pelvis. The top of a filled
bladder may extend into the
abdomen. Normally the blad­
der contains between 200 and
Fig. 12. Ampular and linear pel- 500 ml. The bladder wall is
vices thicker in men than women and
decreases from 2 cm to 2 mm
during filling. In males the bladder is located ventral to the an­
terior wall of the rectum with the seminal vesicles posterior. The
outlet of the bladder (e.g. neck) is separated from the membra­
nous urethra by the prostate. In females the uterus and vagina
are located behind and underneath the bladder and the urethra, Fig. 15. MRI - axial slice of kid­
whereas the salpinges and the ovaries are located supero-lat- neys
71
erally to the empty bladder. The upper onethird of the bladder is
intraperitoneal (Fig. 16).
Urethra
The male urethra consists of four parts: pars prostatica in
which the ejaculatory ducts empty; pars membranacea, the short­
est part, is the part of the urethra, which transverses the urogen­
ital diaphragm and is followed by pars bulbosa and pars pendula.
Taken together the prostatic and membraneous parts are defined
as the posterior urethra while the bulbous and pendular portions
are known as the anterior urethra.
Fig. 16. Urinary bladder filled The female urethra is 2 to 3 cm in length and is located
with contrast anterior to the vagina. It is surrounded by the internal and the ex­
ternal sphincter.
Pathology
Renal pathology
Anom alies
Renal agenesis is often an incidental radiological
finding. Usually there is compensatory hypertrophy of the
contralateral kidney. If this is lacking we should search for
an ectopic kidney.
Renal ectopia is an abnormal position of a kidney.
It may be due to failure of complete ascent of the kidney
from its primitive location at the S12 level or to excessive
cranial migration beyond its normal location.
Dystopia renis means change in the normal place of the
kidney. It could be:
- pelvic dystopy - at the level of sacrum;
- iliac dystopy;
Fig. 17. Direct Fig. 18. Linked kidneys - lumbal dystopy - at the level of L24 (Fig. 17).
pyelography A nonvisualizing kidney on urography caused by renal
( a s c e n d e n t agenesis can be confirmed by ultrasound or CT. Ultrasonography can evaluate
urography) - the renal fossae, but CT is more effective in evaluating the lower abdomen for
pelvic distopy a small ectopic kidney. Renal anomalies, especially agenesis, are associated
with a significant incidence of seminal vesicle anomalies, and in the female with
utero-vaginal anomalies.
Fusion anomalies of the kidney are often asymptomatic. Intravenous urography will show the abnon-
nal axis of fusion and delineate the ureters. There are several types of fusion anomalies:
- Linked kidneys (ren arcuatus - horseshoe kidney);
- L - formed;
- S - formed;
- Square kidney.
Renal fusion is the union of two kidneys (Fig. 18).
Horseshoe kidney is the most common type of renal fusion. There is fusion of the lower pole of
the two kidneys across the
midline by an isthmus, which
usually lies anterior of the
aorta and inferior vena cava.
The diagnosis may be made
by excretory urography or
US (Fig. 19 a, b).
Complications associated
with horseshoe kidney in­
clude hydronephrosis and re­
nal stones. There is also an
increased incidence of Wilms Fig. 19 a, b. Horseshoe kidney
72
tumour, renovascular hypertension,
and adenocarcinoma in patients with
horseshoe kidney.
Double kidney or ureters
Ureters could be double - over all its
extent - 2 separate ostia in the uri­
nary bladder (ureter duplex) or dou­
ble over part of its extent (ureter fis­
sus) (Fig. 20, 21,22).
Cysts
Simple renal cyst
Simple cysts are the most
common renal mass. A simple renal
cyst is unilocular, solitary, and con­
tains a single layer of flattened epi­
Fig. 20 a, b. Ureter fissus thelium with a fibrous wall. There is
no communication between the cyst
cavity and the renal collecting system (Fig. 23).
Simple cysts have been detected more easily since the advent of ultrasound and CT and may be
found in more than 50% of patients over the age of 50 years.
The ultrasound criteria for a benign cyst include: the absence
of internal echoes, smooth, sharply defined walls and acous­
tic enhancement beyond the posterior wall proportional to the
fluid content. Refraction lines at the edges of the cyst are
typical, as is the absence of flow on color Doppler ultrasonog­
raphy.
The CT criteria for a benign cyst include homogenous at­
tenuation value near the density of water, imperceptible cyst wall,
smooth interface with renal parenchyma, and lack of enhance­
ment following intravenous contrast injection (Fig. 24). Fig. 22. Ectopic right and double
In those cases not meeting the strict criteria for ultrasound or left kidney and ureters
CT, needle aspiration or enhanced MRI should be considered
to establish the final diagnosis. MRI is extremely sensitive to
vascularity and has detected small occult tumours in the wall
of renal cysts.
Polycystic kidney disease
Infantile p o lycystic kidney disease is a spectrum of
abnormalities that includes both microcystic and macrocystic
renal disease with variable degrees
of hepatic fibrosis. It is inherited as
an autosomal recessived. Patients
present in the first several months Fig. 2 3 .Urography-simple renal
of life with palpable kidneys and cyst
variable degrees of renal failure.
There is renal enlargement with
diffuse increased echogenicity of
the kidneys by US.
Juvenile polycystic disease
of kidney and liver (renal tubular
ectasia with congenital hepatic fi­
brosis) is also inherited as an auto­
somal recessived; patients usually
develop symptoms after 10 years of
Fig. 21. Double kidney and age. There is hepatosplenomegaly
ureter in the right side and portal hypertension. Fig. 24. CT- Simple cyst
73
Adult polycystic kidney disease is an autosomal dominant with variable penetrance. It is
a separate entity from infantile polycystic kidney disease. The cysts are of variable size and involve
both renal cortex and medulla; hepatic cysts occur in approximately 1/3 of patients, but there is usu­
ally no periportal fibrosis. Adult polycystic kidney disease usually presents in early adulthood with
hypertension, hematuria or renal failure.
Cysts are easily detected by ultrasonography, CT and MRI using the criteria for cysts
(Fig. 25). Intravenous urography demonstrates enlarged kid­
neys with smooth or irregular contours. The pyelocalyceal sys­
tem is usually splayed and defoformed by the multiple cysts.
Bleeding into cysts occurs very often and is best diagnosed by MRI
demonstrating cysts containing hemorrhagic fluid with mixed sig­
nal intensity and a fluid-level on both ^-weighted and T2-weighted
sequence.
Fine calcifications - probably a residual of intracystic bleeding
can be diagnosed at CT (sometimes on KUB).The frequency and
number of calcifications increases with age. As many as 40-80%
of all patients with adult polycystic kidney disease have hepatic
Fig. 25. MRT - coronal slice-poly­ cysts. In many cases the liver cysts may be larger and more nu­
cystic kidney merous than the renal cysts.
After the start of replacement therapy (dialysis or transplantation)
the size of the polycystic kidneys decreases.
Medullary sponge kidney
Medullary sponge kidney (“tubular ectasia”) is a sporadic disorder of developmental origin.
The collecting ducts in the distal renal pyramids and papillae become dilated; small cysts which usu­
ally communicate with the collecting ducts are found in which calculi frequently are formed. They are
occasionally seen in the medulla in the more severe cases.
Medullary sponge kidney is usually bilateral but may be unilateral. It is often an incidental finding in
intravenous urography.
Intravenous urography is diagnostic and shows linear dilated collecting tubules (“streaks” or “brush”
appearances), some of which contain calculi (Fig. 26).
Inflammatory disorders
Inflammation (specific or non-specific) leads to changes in
the form, dimensions and location of calyces (convex calyces);
there is no typical radiological appearance.
Chronic pyelonephritis is an interstitial, nonsuppurative nephri­
tis. The inflammatory process originates in the medulla or in the
cortex and involves the pyramids, the cortex or both, producing
cortical scars and calyceal deformities.
It rarely occurs in patients with a normal urinary tract. It may be
due to vesico-ureteral reflux, obstruction, sickle cell disease and
analgesics.
Urographic findings include unilateral or bilateral small kidneys.
Ultrasonography shows focal parenchymal atrophy and areas of Fig. 26. Medullary spongy kid­
fibrosis. CT demonstrates scarring with irregular renal margins ney (tubular ectasia)
(Fig. 27).
Renal tuberculosis is a specific inflammation and is usually
secondary to hematogenous spread from a pulmonary focus. Al­
though big morphologic changes are typically more severe in one
kidney, microscopic lesions are present in both. Progressive dis­
ease is associated with destruction of the medulla, pyramids, and
papillae with cavities.
Healing of these lesions is accompanied by interstitial fibrosis, pa­
renchymal calcification, cortical scarring, stricturing of infundibula
and calyces, and hydronephrosis. Extrarenal extension (e.g. peri­ Fig. 27. CT - enlarged right kid­
nephric or psoas abscess and fistulas to small intestine or colon) ney; oedema of parenchyma
74
is not uncommon.
The findings on plain films, intravenous urography and py­
elography reflect the bilateral, but asymmetric distribution of ac­
tive renal infection. These include:
- absent, decreased or delayed excretion of contrast material;
- localized caliectasies with irregularity of the calyces;
- papillary necrosis with irregular or moth eaten calyces and occa­
sional filling of adjacent medullary parenchymal abscesses;
- amputation of the tips of calyces and infundibula;
- hydronephrosis;
- a parenchymal mass or abscess that does not communicate with
pyelocalyceal system;
- calical scarring, linear, ring and/or amorphous parenchymal cal­
cifications.
Imaging modalities other than intravenous urography and retro­
grade pyelography are non-specific in renal tuberculosis (Fig. 28). Fig. 28. Urography-changes of
Involvement of the ureter, bladder and/or internal genitalia is quite upper calicies in: papilla, bot­
common in patients with renal tuberculosis. Alternating strictures tom of the calyces; dilatation of
and dilatation may give the ureter a “corkscrew” or “beaded” ap­ calicies (caliectasies), irregular­
pearance. ity of calices, papillary necrosis
Papillary necrosis with irregular calyces, stricture
Papillary necrosis is believed to be due to localized isch­ because of fibrosis
emia. It is especially frequent in diabetes mellitus and analgesic
abusers. Less common reasons include hypotension, renal vein
thrombosis, obstruction, sickle cell disease.
Intravenous urography remains the best imaging modality for
demonstrating the various stages of papillary necrosis. The find­
ings include:
- .decreased opacification of the affected calyces, contrast
material surrounding the separated necrotic papilla - central
separation produces a ring sign while marginal separation
produces a claw sign - a single contrast-filled cavity within a
papilla, a convex irregular calyx which becomes a “blunt” ca­
lyx with healing;
- hydronephrosis due to obstruction of the ureter by necrotic tis­
sue or a calculus;
- punctate or ring-shaped papillary calcification due to calcification
of one or more necrotic papillae (Fig. 29).
Pyonephrosis (purulent material in the obstructed pyelocalyceal Fig. 29. Changes in the form,
system) is usually secondary due to congenital anomaly, stricture dimentions and location of cali­
or calculus, which leads to hydronephrosis, urine stasis and infec­ cies (convex calyces)
tion.
Plain films may show an enlarged renal outline or an opaque calculus.
Retrograde pyelography shows blunted irregular calyces sometimes with evidence of papillary ne­
crosis. Filling defects representing necrotic tissue or purulent material can sometimes be seen in the
pyelocalyceal system and ureter.
Ultrasonography typically shows a dilated pyelocalyceal system containing echogemc fluid and or a
shifting fluid-debris level. Radiopaque and non-radiopaque calculi can often be identified. Failure to
visualize the proximal ureter suggests that there is an obstruction of the ureteropelvic junction.
CT shows multiple with low-attenuation, urine filled spaces. CT can detect even minimally opaque
calculi. Perinephric extension of the inflammatory process is more reliably detected by CT than by
other imaging modalities.
MRI does not seem to add anything.
N ephrocalcinosis
Nephrocalcinosis is usually a form of dystrophic calcification in the renal parenc y
75
ma. It can be secondary to
hypercalcemic and hypercal-
curic states, hyperoxaluria,
medullary sponge kidney,
cortical necrosis, adult poly­
cystic kidney disease, chronic
nephrosclerosis and chronic
glomerulonephritis. CT is the
best modality to diagnose tiny
calcifications, whereas more
big calcifications may be seen
on plain films (Fig. 30).
C a lcu li
It is estimated that 2-
3 % of the population develop
Fig. 30. Plain X-ray - nephrocal- Fig. 31. Plain X-ray - radiopaque urinary calculi. Men are affect­
cinosis homogenious stone in the left ed twice as often as women.
kidney Approximately 10% of stones
are caused by metabolic ab­
normality such as hyperparathyroidism, but most are idiopathic. Chronic infections and/or
foreign bodies (metal sutures which are not covered with mucosa may act as a nidus around
which calculi can be formed) can also cause stones. The clin­
ical significance of urinary calculi lies in the accompanying
symptoms.
There are two types of stones: ra­
diopaque (Ro-positive) and non­
opaque (Ro-negative). Approxi­
mately 90% of upper urinary tract
calculi are radiopaque and there­
fore potentially visible on plain
films. They could be:
Fig. 32. Plain X-ray - casting - homogeneous;
stones in the kidneys - non homogeneous, layered;
- casting (coral-like) - in the renal
pelvis (Fig. 31, 32).
When situated in the right
side (Fig. 33) differential diagnosis
with biliar stones could be made.
A lateral projection of abdomen is
necessary - if the radiopacity is Fig. 34. Urography-non
near the vertebral column - stones opaque stone in the left
are in the right kidney. kidney
The factors that determine
whether or not calculi will be
detected are respiratory mo­
tion, overlying gas and feac-
es, size and position of the
calculus and technical quality
of the film.
Fig. 33. Plain X-ray - radiopacity On intravenous urography,
of the right side near the pro­ an opaque calculus may be
cessus transversus of L3 more, less or equally opaque
as the surrounding opacified
urine. Non opaque stones are seen as a filling defect in the Fig. 35. Ultrasonography of kid­
contrast medium in the pyelocalyceal system (Fig. 34). ney
76
The combination of KUB and ultrasonography works very well
when dilatation is present, but the middle third of the ureter
can be a problem.
A renal calculus appears sonographically as an echogenic fo­
cus with sharp acoustical shadowing (Fig. 35).
CT is extremely sensitive in detecting calculi. On CT calculi
usually exhibit very high attenuation values (Fig. 36).
The complications of calculus disease such as hydronephro­
sis and retroperitoneal pathology are clearly depicted by CT.
MRI does not gjve further infomation.
O bstruction Fig* 36. CT - calculus in the left
Obstruction may occur at any level from the renal col- kidney
lecting tubules to the distal urethra. The urographic manifestations of acute obstruction are
normal or enlarged kidneys, mild to moderate dilatation of the pyelocalyceal system which
may be visualized best on delayed films. The classic urographic sign of long-standing obstruc­
tive hydronephrosis is a dilated collecting system (Fig. 37, 38).
Hydronephrosis and hydroureter are characterized with widened calyces, pelvis and ureter. It
could be:
- congenital;
- acquired;
- due to mechanical reasons;
- due to functional disturbances.
Intravenous urograpby is also excellent for evaluating the results of corrective surgery for py-
eloureteral obstruction.
Because ultrasonographic visualization of the collecting structures is independent of renal
function hydronephrosis is well demonstrated by ultrasonography even when there is no visu­
alization on intravenous urography. It should be known that ultrasonography can be normal in
patients with acute obstruction in whom dilatation of the collecting has not yet occurred.
While CT well demonstrates hydronephrosis, it is usually obtained to determine the etiology
and extent of pathology rather than as a screening examination. CT clearly depicts retroperi­
toneal lesions, a frequent cause of ureteral obstruction.
Hydronephrosis is also well demonstrated on both T1 and T0-weighted MRI. The dilated col­
lecting system appears as a cluster of communicating low-intensity structures within the renal
parenchyma, which has a more intense signal on T 1 -weighted images and the ureter is seen
as a dilated, elongated, low signal intensity column.
While intravenous urography provides more precise morphologic information, nuclear med­
icine has a number of important advantages in the management of the patient with urinary
obstruction. It can give information about whether the hydronephrosis is obstructive or non-ob­
structive. It is especially useful in pa­
tients with possible stenosis of the
ureteropelvic junction.
Trauma
The kidney is the most frequent­
ly injured organ in abdominal trauma.
The choice of imaging depends on the
patient’s clinical condition and the se­
verity of trauma.
In a patient who presents with hema­
turia following relatively minor trauma
it is appropriate to begin with an intra­
venous urography.
In a moderately or severely
injured patient - whenever possible
I i
- contrast enhanced CT should be Fig. 37. Hydronephrosis in Fig. 38. Hydronephrosis and
the initial imaging procedure, since it the right kidney hydroureter in the right
77
depicts the extent of renal and perinephric injury and may

? demonstrate injuries of other abdominal viscera. Ultrasonog­

raphy is not helpful in the acute situation.
Intravenous urography will demonstrate whether there are
one or two functioning kidneys. A renal contusion or intrare-
nal hemorrhage appears as a localized decrease in intensi­
ty of the nephrogram or as an intrarenal mass. Intravenous
urogram may require further evaluation by means of CT. In­
trarenal and extrarenal hematomas, disruption of the renal
parenchyma, perfusion defect and extravasation are well
Fig. 39. Urography - changes in demonstrated by CT.
the location of calyces of the Concerning trauma of the lower urinary tract lesions may in­
right kidney volve the bladder and the male urethra. Rupture of bladder
and the urethra in a patient who is not severely injured is prop­
erly diagnosed by cystography and urethrography, respective­
ly, showing contrast outside the natural lumen. In cases of a
multitraumatized patient CT should be performed as primary
examination since it gives information about the surroundings
and the relations to bones.
G enitourinary tum ours
Kidney tumours are approximately 1-2% of all tumours. They
could be:
- benign;
- malignant- up to 80%.
Fig. 40. CT - carcinoma of right Descendent urography shows irregular filling defect in the re­
kidney nal pelvis often associated with obstructive hydronephrosis
or mucosal irregularity for malignant tumours. We can find
changes in the location of calyces and pelvis too - they are displaced, deformed or curved.
Descendent urography shows irregular filling defect in the renal pelvis often associated with
obstructive hydronephrosis or mucosal irregularity (Fig. 39).
Renal cell carcinom a
Renal cell carcinomas occur most commonly in the sixth decade and are often de­
tected incidentally. Symptoms are usually non specific; e.g. hematuria, pain and a palpable
tumour may occur in adult; polycystic kidney disease a well as in renal cell carcinoma. Intra­
venous urography typically show renal enlargement with a well-circumscribed or occasionally
irregular mass filling defect often accompanied by hydronephrosis.
CT, MRI and ultrasonography can all be used in establishing the nature of a renal tu­
mour more precisely. Demonstration of a solid mass is indicative of a renal cell carcinoma until
another diagnosis has been proven.
CT is excellent for both diagnosis and staging (Fig.40). The CT criteria for renal malignancy
include heterogeneous tissue with an attenuation value near to that of renal parenchyma,
contrast enhancement, irregular interface with surrounding
parenchyma and areas of calcification.
Ultrasonography can also be used for the diagnosis of a solid
mass (i .e. sound absorption) and to exclude the presence of
a cyst.
MRI demonstrates an inhomogenous, enhancing mass. The
^-w eighted and T2-weighted signals vary with the composi­
tion of the tumour. MRI appears to be the most sensitive and
most accurate method for diagnosis in renal cell carcinoma
and detecting venous extension.
Wilms tum our
Wilms tumour is the most common renal malignant Fig. 41. MRI-coronal image-Wilms
tumour of childhood. Wilms tumour (nephroblastoma) is an tumour and tumour extensions
embryonic neoplasm that contains epithelial, blastemal, and into vena cava
78
stromal elements. It is similar in incidence to neuroblastoma
and accounts for approximately 8 % of all pediatric malignant
tumours.
The most common clinical presentation is that of an asymp­
tomatic abdominal mass. Other infrequent clinical presenta­
tions include abdominal pain, fever, anorexia, hematuria, and
hypertension. The tumour is usually solid with a prominent
pseudocapsule that separates it from normal renal parenchy­
ma. Wilms tumour may infiltrate the capsule or invade the re­
nal vein and inferior vena cava; there are frequently local me-
tastases to retroperitoneal lymph nodes (Fig. 41).
The screening modality of choice in pediatric patients with a
palpable abdominal mass is US. Wilms tumour is an intrare-
nal, echogenic mass; tumour echogenicity is usually equal to
or slightly greater than that of adjacent liver and more homo­
Fig. 42. Plain X-ray - radiopaque geneous than the echogenicity of neuroblastoma.
stones in the bladder There may be hypoechoic areas within the tumour that repre­
sent hemorrhage, necrosis, or dilated calyces.
CT confirms the presence of an intrarenal mass, determines
local extent of Wilms tumour, visualizes vascular structures,
identifies nodal involvement, evaluates presence or absence
of liver metastases.
MRI accurately assesses the renal origin of Wilms tumour as
well as its margins and local extension.
Metastases
Metastases to the kidney are usually associated with
primary neoplasms of the lung, breast, stomach, cervix, co­
lon, and pancreas. Differentiation from a primary renal malig­
nancy is the infiltrative, poorly defined pattern of metastases.
Needle biopsy is required for diagnosis.
Fig. 43. CT - stones in the bladder Pathology of the urinary bladder
Calculi in the bladder
Bladder stones like the kidney stones could be radiopaque or not. Calcium containing
stones could be seen at conventional roentgenography (Fig. 42).
They can be seen at ultrasonography and CT too (Fig. 43).
Summerizing the information about radiopaque findings in the abdominal area we can make a
differential diagnosis of urinary radiopaque calculi with:
- calcified hydatid cyst of kidney;
- renal tuberculosis calcifications;
- right site - biliar calculi (lateral projection - near the verte­
brae);
- in the pelvic area - phlebolites.
Diverticula of the bladder
Diverticula are acquired (usually) or congenital (rarely)
outpoutchings of the bladder wall. They may range from very
small to so large that they press on other pelvic organs. The
wall of a diverticulum is often smooth in contrast to the irreg­
ular trabeculated bladder wall. Approximately onefourth of all
diverticula contains calculi. In approximately 3 % malignant
tumour may be present.
Two important investigations for the diagnosis of diver­
ticula are ultrasonography which demonstrates an echopoor
outpoutchirtg and cystography, which depicts diverticula as
an additional shadow of the bladder wall. Fig. 44. Inflammation of the
With unenhanced CT and MRI it is important to demonstrate bladder - cystitis chronica
79
the neck of the diverticulum with mucosal relief in order to
avoid wrong diagnosis. At intravenous urogoraphy, enhanced
CT and enhanced MRI, contrast medium confirm the pres­
ence of a diverticulum.
Infection
In simple cystitis no changes are found with the various
imaging modalities, but in severe cystitis one can find a lightly
diminished bladder capacity with a thick bladder wall and mu­
cosal edema at ultrasonography, CT and MRI.
On intravenous urography in chronic cystitis the bladder
shrinks and the wall thickens (Fig. 44).
Fig. 45. Cystography - filling de­ Tumours
fect with irregular borders 90% of all urinary bladder tumours arise in transitional ep­
ithelium. Cystoscopy with biopsy is the most sensitive method of
detecting bladder tumours, but another imaging must be done for staging. Ultrasonography, CT and
MRI each have their advantages.
Ultrasonography can recognize some bladder tumours, but it often overlooks low grade papil­
lomatosis,very small tumours (< 10 mm), and tumours in trabecular bladders.
At abdominal or transrectal ultrasonography localized thickening and/or protrusion in the bladder lumen is
found. The echogenicity of bladder tumours is moderate. It is very important that before an ultrasonographic
examination the bladder must be well filled, because a folding of the wall should not be interpreted as a tu­
mour. It is often difficult to differentiate between small to moderate sized bladder tumours and trabeculation
of the wall. Ultrasonography of bladder tumours should always include examination of the kidneys.
Urography gives information about bigger size of a tumour and is seen as a feeling defect with
irregular borders (Fig. 45).
The main indication for CT is not only the diagnosis of bladder tumour or degree of bladder
wall invasion, but diagnosis of exhavesical spread e.g. iliac
nodes and extension outside the bladder wall (Fig. 46).
MRI is excellent for evaluation of the rare urethral tumours.
MRI and clinical staging are additional for staging urinary
bladder cancer.
For superficial tumours clinical staging, including deep trans­
urethral biopsy, is the best technique.
For invasive tumours, MRI is the best technique in the de­
termination of local tumour growth and the detection of bone
marrow infiltration.

A bbreviations:
KUB - kidney-ureter-bladder survey Fig. 46. CT of urinary bladder -
IVU - intravenous urography tumour of urinary bladder and
thicken wall
B ibliography
1. Рентгенология и радиология, учебно помагало за студенти по стоматология, 1995,
Пигмалион
2. Хаджидеков Г. Магнитнорезонансна урография в детската възраст, дис, 2011
3. Baxter G, Р. Sidhu. Ultrasound of the urogenital system, 2006, 2006, Thieme
4. Direct diagnosis in radiology, Urogenital imaging, 2008, Thieme
5. Moeller M, R.Reif. Pocket Atlas of Sectional Anatomy, Vol. 2, Computed Tomography and
Magnetic Resonance Imaging - Thorax, Abdomen and Pelvis, 2001, Thieme
6. Palma Dalla. What is left of i.v. urography?, Eur. Radiol, 2001,11, 931 -939
7. Rummeny Е., P. Reimer, W. Heinel. MR imaging of the body, Thieme
8. Schmidt. Ultrasound, 2007, Thieme
9. Ultrasound clinics, 2, 2007, Elsevier Saunders
10. Ultrasonography in urology - a clinical approach to clinical problems, 2008, Thieme
80
MUSCULOSKELETAL SYSTEM
Until approximately 30 years ago, radiologic examination of
the musculoskeletal system was limited to plain film radiography,
and this method still provides highly important information. How­
ever, during the last two decades, musculoskeletal radiology has
undergone a revolution as a result of the introduction of diagnostic
imaging methods such as ultrasonography, scintigraphy, comput­
ed tomography and magnetic resonance imaging.
BONES
Imaging modalities
X-ray methods
Plain radiography
The initial assessment of a bone lesion begins with plain
film radiography using speciphic views - two projections of bone Fig. 1a. Frontal and lateral view
- en face and en profile (for the third dimention) (Fig. 1 a) or of knee
comparative radiograph of bones in frontal and lateral projec­
tions (Fig. 1 b). They are indicated for diagnosis of fractures and
dislocations. Radiographs are sufficient for diagnosis of bone tu­
mours and other focal lesions. CT and MRT are used for staging
but add little to the diagnostic specifity of radiographs.
The major limitation of radiography is insensitivity for early bone
changes in conditions as osteo-
myelytis and stress fractures.
C T provides excellent visualiza­
tion in the transverse and tran-
saxial plane. CT is used as a
routine supplement to plain film Fig. 1b. Comparative radiograph
examination of injuries and le­ in frontal projection of knees
sions of the spine, pelvis, wrist
ankle and foot as well in the assessment of bone and soft tissue
tumours.
CT may be also used to diagnose complication of fractures like
nonunion.
CT may assist in staging bone tumours by demonstrating speci­
phic features like soft tissue extension and cortical destruction.
Arthrography today in most cases has been replaced by MRI, but
Fig. 2. Bone scintigraphy several major indications for arthrography still exist, including the
assessment of the shoulder, hip. knee, and wrist.
CT arthrography with double contrast technique (air and positive
water soluble contrast material) remains useful in the detection of
intraarticular bodies or labrum tears of the shoulder.
Bone scintigraphy using Technetium-99m-methylene diphos-
phonate plays an important role in the identification and localiza­
tion of bone lesions, particularly when the entire skeleton needs to
be surveyed. It is an investigation of choice for screeng for skeletal
metastases and other multifocal tumours (except multiple myelo­
ma - MRI of whole body is necessary) (Fig. 2).The major limitation
of bone scintigraphy is its non specifity. Areas of increased up­
take is seen commonly in benign conditions such as osteoarthritis.
Correlative radiographs are often required for definitive diagnosis.
Bone scintigraphy in combination with CT (SPECT-CT) reduces
the rate of false positive studies.
Fig. 3. MRI of ankle-Achilleas Bone scintigraphy is highly sensitive and able to demonstrate pa­
tendon thologies such as undisplaced fractures, stress fractures and os-
81
teomyelytis prior changes are
seen on radiographs.
Non X-ray methods
Ultrasonography typically is
used to evaluate the soft tissue
of musculoskeletal system. This
readily available, inexpensive
and rapidly performed study
also can be used in infants and
children. The indications for so­
nographic examination include
the following:
- assessment of joint instability
(developmental dysplasia of the
hip); joint effusion;
- injury to joints, tendons and
ligaments;
- detection of foreign bodies in the soft tissue, esp. pieces of glass or wood not detectable on the
plain radiography;
- guidance in fine needle aspiration and biopsy.
Limitation of ultrasonography is inability to visualize bone pathology and most internal joint desa-
rangements.
MRI - provides better definition of soft tissue and bone marrow than any other imaging techniques.
Muscule, fat, fluid, tendons or ligaments and cartilage can be distinguished from one another (Fig. 3).
Indications for MRI are: stress fractures, vertebral fractures, suspected spinal cord involvement,
posttraumatic osteonecroses, post-traumatic chronic osteomyelitis.
Indications for MRI is joint trauma - osteochondral fractures, intra-articular ligamentous lesions (cru­
ciate ligaments, collateral ligaments), meniscus injuries (especially in the knee).
Indications for MRI is trauma of the peripheral soft tissues, tendon and muscle injuries (hematoma,
rupture, ligamentous injury e.g., shoulder), tendosynovitis in chronic repetitive microtrauma.
Anatomy
Plain X ray should be technically good in order all details of a bone structure to be seen. That
means - appropriate centring, projection and exposure. Features for technically adequate X ray of
bone and joint means: fine bony detail, incl. sharp definition of bony surfaces and visibility of bony
trabeculae; visible soft tissues and sharp articular surfaces with minimal overlap of ajucent bone.
There is sequence for viewing X rays of bones - is there any changes in:
- shape;
- dimensions;
- borders - broken, unbroken;
- structure;
- soft tissue changes.
There are 3 groups of bones-long, short
and flat bones.
Long bone in adult consists of di-
aphysis, proximal and distal metaphysis
and epiphysis - the end of a bone. Di-
aphysis consists of dense compact bone
at the periphery and a medulary chan­
nel in the middle of the diaphysis and
cancellous (spongy) bone at the distal
and proximal metaphysis and epiphysis.
Cancellous bone consists of a spongy
like network of thin bony plates known
as treabeculae.Trabeculae in the bone
marrow are seen as a lattice work of fine Fig. 5 a, b. Scheme and X ray of long bones in child
82
white lines. Cortex covers the
proximal and distal parts (me­
taepiphysis) of the long bone.
The diaphysis and metaepiphy­
sis are covered by periosteum,
and the articular surface of the
epiphysis is covered by articular

l3 cartilage (Fig. 4 a, b).

In children between the
metaphyseal and epiphyseal
part of the long bone there is
<■ f hf4|* an epiphyseal growth cartilage Fig. 8. Scheme of joint
or physis. Bone is growing at
A JHI height by epiphyseal growth cartilage and at width - by the peri-
ost. Radiologically the growth plate is radiolucent and is visible
Fig. 6. Frontal projection of lum untill is closed (Fig. 5).
bal vertebrae - short bones An apophysis is a term that means a type of ossification centre that
forms a protrusion from the growing bone. Examples of apophyses
include the greater trochanter of the femur and the tibial tuberosity.
Short bones are vertabrae, tarsal and carpal bones. They
consist of a cancellous (spongy) bone, covered with thin cortex
(Fig. 6).
Flat bones are calvaria, sternum, scapulae, costae, pel­
vic bones. They consist of two cortical plates (lamina externa and
lamina interna) with spongy bone inbetween (diploe) (Fig. 7).
Anatomy of joints
A synovial joint consists of:
- epiphysis (articular end of the bone);
Fig. 7. Lateral projection of skull - articular cartilage;
- flat bone - joint capsule;
- joint fluid.
These entities together with muscles, tendons, and ligaments form an anatomic unit (Fig. 8).
There is a sequence for viewing X rays of joints:
- joint space width (4-6 mm width); when there is luxations and bone ankylosis there is missing joint
space;
- joint surfaces - they should be with smooth outlines;
- structure of the bones forming the joint (if there are basic pathological changes);
- anatomic relations between bones forming the joint (if there are normal);
- soft tissue appearance.
Cartilage is not visible on
plain radiographs and gives thin ra-
diolucency. Carilage disorders and
all soft tissue structures are best as­
sessed with MRT (Fig. 9 a, b).
PATHOLOGIC CONDITIONS OF
BONES
Change in the form of the bone
- it may affect the whole bone (rick­
ets, lues etc.);
- it may affect part of the bone (tu­
mours, cysts etc.).
Change in the dimensions of the
bone
- affecting the whole bone - acro­
megalia, chronical osteomyelitis etc.; Fig. 9 a, b. MRT of knee - coronal and sagittal slices
83
- affecting part of the bone - adamantinoma, exostosis cartilaginea
etc.
Change in the outlines of bone.They could be:
- broken - fracture;
- not rough, wavy (chronical osteomyelitis);
- not sharp - osteolytic process (inflammatory, tumours etc.).
Some times change in the shadow of the bone could be found.
The bone could be:
Change in the shadow of the bone
- more radiopaque - in cases of:
- qualitative changes - hypermineralization of a bone
- quantitative changes - extended bone
- abatement of the shadow of a bone:
- due to hypomineralization - in cases of:
- insufficiency of calcium in food; disturbances in resorption of Calcium in the intestines
- insufficiency of fixation of calcium in the bones
- excessive secretion of calcium from bones
- decreasing the whole amount of bone substance (hypoosteogenesis, atrophy)
Pathological changes in bones are due to: congenital ethiological reasons, neurotrophic or metab-
olitic reasons, blastoma processes - primary and secondary (metastases), infectious or parasite
reasons - hydatid disease etc., traumatic factors, incl. professional like vibration disease; physical,
chemical, electrical factors, radiation etc; dermatological factors - skin disease and bone changes -
psoriasis and not well clarified factors.
These factors lead to morphological and functional disturbances:
- Change in the normal osteoblast activity - more or less
- Change in the normal osteoclast activity - more or less
- Changed ostoblast and osteoclast activity lead to formation of pathological tissues (osteoid, calci­
fications, metaplasia, dysplasia etc.)
All these pathological processes in bones lead to qualitative and quantitative changes in ostoblast
and osteoclast processes:
- stop in osteogenese process in a phase of formation of osteoid tissue (Morbus Paget)
- loss of ability for fixation of calcium - Milckman syndrome etc.
- pathological overmineralization - Marble disease etc.
BASIC PATHOLOGICAL BONE CHANGES
There are two main groups of pathological bone changes:
- with decrease of bone substance (hypoosteogenesis) - they are: osteoporosis osteolysis and os­
teonecrosis
- with augmentation of bone substance (hyper­
osteogenesis) - osteosclerosis and periosteal
reaction
Osteoporosis
Osteoporosis is connected with hypomin­
eralization or demineralization and is visible
when loss of bone substance is more than 20-
30%.
There are three types of osteoporosis:
- local - in osteoarthritis (nonspeciphic, speci-
phic);
- spread - in limb (after immobilization);
- generalized - of the all skeleton.There are some
conditions connected with generalized osteopo­
rosis and they are:
- physiologycal (old people); Fig.11. Generalized; Fig.12. Hypertrophic os-
- congenital (osteogenesis imperfecta); homogenious osteo- teoporosis
- hypo, lack of vit. D (rickets); porosis - rickets
84
- endocrinological:
- hyperparathyreoidism;
- hypothyreoidism;
- Morbus Cushing;
- climacteric (postmenopausal).
Patoanatomically osteoporosis is expressed by thin, rarefied or
disappeared spongy spaces; thin compact substance and en­
largement of bone channel.
Depending on the X ray morphology osteoporosis could be:
- spotty osteoporosis-small, spotty shadows through spongy bone
(2-3 mm ) - X-ray symptom followed trauma or is due to neurotroph­
ical reasons (Fig. 10);
- homogenious osteoporosis - in the long bone: diaphysisis with
thin compact bone and wide medullar channel and metaphysis
consists of effaced spongy bone with cortical plate - as thin as
Fig.13. Osteogenesis imperfecta “drawn by pencil” (Fig. 11);
- multiple fractures and healing - hypertrophic osteoporosis - very rare - thickened bone following
fractures (xeroradiography) force lines (Fig.12).
Osteogenesis imperfecta is inherited as autosomal dominant dis­
ease expressed with generalized osteoporosis and have some
forms. There are very thin, osteoporotic bones, which are bowed
or broken. At birth fresh fractures may or may not be present but
healing fractures may be evident in the long bones or ribs. Prog­
nosis in the neonatal form depends on the number of fractures
(Fig. 13). Blue sclera are seen in many forms - Eddoves syn­
drome and when bone breaking, blue sclera and deafness are
presented - van der Floeve syndrome.
Osteolysis - means lysis of bone tissue
Fig. 14. Marginal osteolysis Patophysiologically is expressed as an increased ac­
tivity of osteoclasts or decreased activity of osteoblasts. Os-
teolysed bone is replaced by pus, granulations etc. According
to the size osteolytic changes
are small, middle or large. Os­
teolysis could be localized or
widespread. Depending on the
location osteolysis is marginal
and central. Marginal osteol­
ysis is at the periphery of the
bone (caries or usura costae,
superficial - sarcoma, gingival
carcinoma spread in the bone)
(Fig. 14). Fig. 16 a. Spongy sequester in
Centric osteolysis is inside the left limbus acetabuli
bone (cyst, central osteolytic
Fig. 15. Centric osteolysis process etc.) (Fig. 15).
Radiologically - osteolysis is ra-
diolucency, homogenious, without bone structure. It is a reversible
process.
Osteolysis could be found in cases of:
- iflammatory diseases (speciphic, nonspeciphic);
- cysts;
- tumours - primary and secondary (osteolytic metastases);
- acroosteolysis-accompanying sclerodermia, psoriasis etc.
Osteonecrosis Fig. 16 b. Compact sequester in the
Dead bone tissue due to stop in the arterial blood supply. diaphysis of a right hand's finger
85
X-ray symptom is sequestrum which could be two types accord­
ing to the place of formation- spongy and compact sequestrum
(Fig. 16 a, b).
Osteonecrosis could be found in cases of:
- inflammatory diseases (speciphic, nonspeciphic);
- aseptic necrosis;
- in patients undergone radiotherapy - radiation necrosis;
Osteonecrosis never accompany tumours. It is irreversible pro­
cess.
Osteosclerosis
Fig. 17. Local osteosclerosis Osteosclerosis is a process opposite to osteoporosis - it
enostosis means overmineralization of bone tissue. Patophysiologically it
is connected with hyperosteogenesis - intense osteoblastic ac­
tivity or decreased osteoclast activity. It could be in a compact
substance or in spongy substance. In cases when spongy bone
resembles compacta it is called eburnation of bone.
If it is in spongy bone, the bone is thickened and marrow spaces
are diminished and hence anemia and leucopenia is possible. If
osteosclerosis is in the diaphysis - enlarged compacta and ember-
rassed medulary channel are noticed.
Osteosclerosis is an irreversible process and it affects haemopo-
etic function.
There are three types of osteosclerosis:
1. Local - typical for:
Fig. 18. Spread osteosclerosis - inflammatory diseases (osteomyelitis, lues etc.)
osteopoikilia - tumours - benign (Fig. 17) and malignant:
- primary (ostosclerotic form of osteogenic sarcoma)
- secondary (osteosclerotic metastasis)
2. Spread
Osteopoikilia (osteosclerosis familiaris generalisata) is a hereditary disease expressed with forma­
tion of small areas of osteosclerosis in the bones (Fig. 18).
3. Generalized osteosclerosis is typical for:
- osteopetrosis;
- Morbus Cammurati-Engelman (diaphyseal hyperostosis);
- poisoning with phosphorus, tin etc.
Osteopetrosis (Morbus Albers-Schonberg, marble disease) is generalized osteosclerosis in the me­
taepiphyses of the bones. It is a condition of increased bone density which has been seen in infants,
children, and adults. In infants the bone may be very dense and the marrow space very small re­
sulting in lack of bone marrow and hence anaemia and leucopenia. The
bones are often brittle and fractures are not uncommon.
Periosteal reaction
Patophysiologically periosteal reaction is due to the intense activi­
ty of osteoblasts of the periost which leads to intense production of oste­
oid tissue which is mineralized. Periosteal reaction leads to enlargement
of bone and formation of osteophytes over the joint edges.
Types of periosteal reaction according to location:
- local (trauma, inflammatory process, initial sarcoma etc.)
- generalized (congenital lues, leukosis in childhood etc.)
Periosteal reaction could be everywhere except pelvis, scapulae, clavic-
ulae. It is an irreversible process.
Forms of periosteal reaction
1. periostitis
- accompanying trauma (Fig. 19)
- accompanying inflammatory diseases (osteomyelitis, lues etc.) Fig. 19. Periostitis of the
2. periostosis:
tibial bone
86
- accompanying circulator disturbanc­
es
- accompanying arthrosis (localised
periostosis);
- accompanying tumours
- onion peal pattern
- perpendicular-spiculated (sar­
coma)
X-ray image of periosteal reaction could be:
- Ro negative at the beginning (osteoid tis­
sue is not mineralized) - periostitis simplex;
- Radiopaque - single layer parallel to the
external outline of bone - periostitis ossif­
icans;
- Irregular periosteal reaction with wavy
Fig. 20. Irregular Fig. 21. Needle-like - perioste­ outlines, smooth and sharp (Fig. 20);
periosteal reaction al reaction in Ewing sarcoma of - Well expressed periosteal reaction - like
with wavy outlines the femur a muff (sclerosing osteomyelitis of Garre,
of fibular bone lues, Ewing sarcoma etc.);
- Spiculated - needle-like - periosteal reac­
tion - calcified thin streaks, orientated perpendicular to the bone. This kind of periosteal reaction is
typical for malignant process (Fig. 21).
Periostosis-osteophytes over the margin of a joint. It could be:
- primary - typical for degenerative disorders - arthrosis (osteoarthrosis) (Fig. 22);
- secondary - after inflammation.
Pathological bone reorganization (osteodistrophy)
This is a condition where the normal bone is replaced by new formed bone tissue - osteoid
tissue. It could be in sponge bone, in compact bone or both. It could develop in 1-2 bones (localized)
or could be generalized.
Morbus Paget is characterized with frayed, stratificated compact bone from osteoid tissue - so called
“Paget structure” (Fig. 23).
SKELETAL TRAUMA
Fractures and luxations
Bone fractures
A fracture is a break in the continuity of bone, cartilage, or both with associated soft tissue
injury. Where the bone is not completely separated, a break is called a fissure.
Etiologically, fractures can be classi­
fied as direct fractures (a fracture at the
site of the causative force) or indirect
fractures (a fracture at a site remote
from the causative force). The degree
and extent of the injury differentiate
complete from incomplete fractures.
A complete fracture occurs when the
entire circumference (tubular bone) or
both cortical surfaces (flat bone) have
been disrupted. Incomplete fractures
occur in the elastic bones of children
and young adults; typical incomplete
fractures are greenstick fractures and
fissures.
A complete fracture may consist of two
Fig. 23. "Paget struc­
fragments; if more than two fragments Fig. 22. Osteophyts (spurs) on
ture" of tibia (xeroradi­
are present, the fracture is termed a the anterior surface of the cer­
vical vertebra ography)
comminuted.
87
A closed fracture indicates that the skin is intact. An open fracture
is characterized by disruption of the skin, which allows communi­
cation between the fracture and the outside enviroument.
A transchondral fracture represents an injury to the joint. The frag­
ments may consist of cartilage alone or both of cartilage and bone
and are termed chondral and osteochondral fractures respectively.
Osteochondritis dissecans may be the result of such a lesion. The
most typical location is in the medial or lateral femoral condyles.
Osteocartilaginous fragments
may be partially or complete­
Fig. 24. MRT-condylar fracture ly detached but often they are
and bone bruise covered with cartilage and may
be visualised by sonography or
MRI.
Bone scintigraphy is an import­
ant examination for detection
these lesions, and CT and MRI
are needed to visualize their
full extent. Osteochondral frac­
tures are seen most commonly
in connection with ligamentous
lesions of joints (e.g. injury of
the femoral condyls in anterior
cruciate ligament tears of the
knee). Fig. 26. Fracture of tibial bone
Bone bruise of the bone mar­ with dislocation
row is a term that has been
introduced as a result of MRI
findings in patients who have
Fig. 25. MRT compression frac­ had an injury. It is considered
ture of L due to osteoporosis to represent edema or bleeding
secondary to traumatic trabecu-
lar lesions. A bone bruise is seen most commonly in cases of bone
contusion and in early stages of stress fractures (Fig. 24).
An impaction fracture results when one fragment of bone is driv­
en into an opposite fragment. Two speciphic types of impaction
fractures are recognized. A compression fracture most commonly Fig. 27. Longitudinal fissure of tibia
involves the vertebral bodies (Fig. 25).
A depression fracture results when impacted forces occur be­
tween one hard bone surface and an opposite softer surface, typ­
ically represented by a fracture of the lateral tibial condyle after a
valgus force is applied to the knee.
An avulsion fracture occurs when an osseous fragment is pulled
from the bone by a tendon or a ligament. On the radiographs this
type of fracture appears as a small thin cortical fragment close to
the joint.
Imaging modalities
The initial radiographic examination should include well-
known standard views, which are used because they have been
found to demonstrate most abnormalities. Under no circumstanc­
es should radiographs in a single plane only be considered ade­
quate.
Radiographs in two planes at right angles to each other are the
minimum, although additional oblique views often are necessary. Fig. 28. Depression fracture of
The imaging assessment of the injury may require information calvaria
88
obtained from methods other than
conventional radiographs, such as
sonography, CT, MRI, or bone scin­
tigraphy, which commonly demon­
strate the extent of the injury within
the soft tissue or bone marrow.
Successful treatment starts with
accurate diagnosis. The physician
should be familiar with the common
pathogeneses of injury. Insufficient
knowledge of the mechanism and
circumstances of injury is the most
common reason for misinterpreta­
tion of radiographs after trauma.
Radiological features of frac-
Fig. 29. Transverse Fig. 30. Oblique Fig. 31. Spiral frac- ture:
fracture line fracture line ture line - break in the outlines of bone;
- fracture line - radiolucent line
to the opposite outline of the bone;
- dislocation of the bone fragments (Fig. 26).
Fissure -means break in the outlines of bone and radiolucent line not reaching the opposite outline
of the bone (Fig. 27).
Sometimes fracture line is radiopaque - in cases of overlying and impact-
ed fracture or in flat bones (calvaria) -
depression fracture (Fig. 28).
According to the direction of the frac­
ture line fractures are:
- transverse fracture (Fig. 29);
- longitudinal ftacture line;
- oblique fracture line (Fig. 30);
- spiral fracture line (Fig. 31);
- fracture line forming triangle fragment
(Fig. 32);
- fragmented (Fig. 33). Fig. 33. Multiple fracture lines
Displacement of bone fragments is
also called dislocation of bone frag­
ments. They could be:
Fig. 32. Fracture line - at width (ad latus);
forming multiple frag­ - at lenght (ad longitodinem)
ments with two types - with elongation (cum
distractione) and with shortening (cum
contractione);
- at impaction (cum implantatione)-when fracture
line is radiopaque;
- at angle (ad axin);
- rotation - internal or external along the long axis of the
bone (ad peripheriam) (Fig. 34).
Fracture of radius in loco typico (so called Colles fracture) is a
fracture of distal metaphysis of radius.
The fracture often is comminuted, with articular involvement. In 60
Fig. 34. Fracture of the right
% of the cases there is an associated fracture of the styloid pro­
femur with dislocation of the
cess of the ulna (Fig. 35).
fragments (ad latus, ad longito­
Bennett fracture
dinem cum contractione and ad
The Bennett fracture is an oblique fracture of the base of
the first metacarpal bone. The metacarpal bone is pulled dorsally angle)
89
and radially by tbe abductor pollicis longus tendon. The fracture
extends into the first carpometacarpal joint, isolating a fragment
consisting of the volar edge of the base of the first metacarpal
bone. This volar fragment remains in place. The Bennett fracture
requires surgical reduction with pin fixation (Fig. 36).
Sress fractures
They happen when there is chronical loading of bones
without single trauma (soldiers, minors, sportsmen etc.). When it
is in metatarsal bones it is so called “march fracture”. In the long
Fig. 35. Intraarticular fracture bones periosteal reaction is observed and some times horizontally
of radius and styloid process orientated linear radiolucency (Fig. 37).
of the ulna with dislocation of Stress fractures are caused by fatigue failure of otherwise normal bone
fragments induced by repeated or cyclical stresses. Insufficiency fractures are
___ caused by normal forces or microtrauma and
occur in bones of reduced internal strength,
such those bones weakened by osteoporosis.
Sclopetarium (arm) fractures
They are usually fragmented, multiple
and frequently complicated with osteomy­
elitis. Some times small shots or bullet can
be seen (radiopaque shadows) (Fig. 38).
Greenstick fracture in children
This is a subperiostal fracture because
the periost and the bone are not accreted.
Flere there is a fracture of only one cortex
and bending or buckling of the cortex on the
opposite side of the bone (Fig. 39).
Epiphysiolysis
Epiphysiolysis is sliding and displace­
Fig. 36. "Bennett"frac- Fig. 37. Stress fracture of ment of the epiphysis towards the epiphy­
ture tibia seal cartilage (Fig. 40).
Pathological fractures
Pathological fractures occurrs in preliminary damaged bone (from cysts, tumours, metastasis
etc.) (Fig. 41).
These fractures occur in bone weakened by a preexisting condition and are caused by a force that
would not break normal bone. They can be considered a local manifestation of an insufficiency fracture.
The most common preexisting conditions are bone cysts, osteolytic metastases, and plasmocytoma.
Differential diagnosis of radiolucent fracture line:
- with growth plate in children - make comparable bilateral radiograms;
- with canales nutricii;
- with sutures of calvaria;
- with patella bipartita etc.
Healing of bone fractures passes through two stages:
- fibrotic calus - which is Ro negative;
- bone calus - which is
Ro positive - seen as a radi-
opacity around the broken ends
of the bone.
In children it can be seen after
10-20 days following fracture
and in adults - 20-30 days after
the fracrure (Fig. 42). v
Radiographic signs of osseous Fig. 38. Panoramic tomography.
consolidation: Multiple fractures with disloca- Fig. 39. Greenstick fractures of
- the osseous bridging of the tios and projectiles the left forearm in a child
90
fracture line;
- the fracture callus is of homogeneous
density;
- the density of the fracture callus equals
the density of the cortex.
Underexposed films overestimate the de­
gree of osseous bridging.
Complications after trauma:
- Periostitis traumatica
- osteoid tissue - Ro (-) - periostitis simplex
- osteoid tissue with calcium - periostitis
ossificans
- Myositis ossificans
Fig. 40. Epiphysiolysis Fig. 41. Subtrochanteric
.1 в * ai _ . . Often in m. deltoideus in marksmen, in m.
pathological fracture of the biceps brachii jn gymnasts . ossiflcatlons
femur due to osteolysis outside the bone borders (Fig.
43 a, b).
- Infection - osteomyeli­
tis - Ro symptoms of a fracture
and osteomyelitis
- Pseudarthrosis
Non-union refers to absent
healing after about 6 to 8
weeks. Both primary and sec­
Fig. 43 a, b. Plain X-ray and CT - myositis
ondary fracture healing can
ossificans of humerus
develop into pseudarthroses.
Radiological signs are no evidence of osseous bridging and the fracture
fragments are widened.
Trauma of joints
Luxations
Radiological features of luxation:
Fig. 42. Fractures of - missing joint space;
radius and ulna; calus - dislocation of bones (Fig. 44).
of radius Type of luxations
- Fracture and luxation (Fig. 45);
- Pathologic luxation - luxation in a preliminarily injured joint
(tuberculosis, tumour etc.);
- Habitual luxation - non traumatic repeated luxation.
DISEASES OF BONES AND JOINTS
INFLAMMATORY DISEASES Fig. 44- Posterior luxation of the
A bacterial infection of bone is called osteomyelitis or os- elbow
teitis and that of joint-septic arthritis. Both may be caused by
bacterial spread via the blood stream (e.g. haematogenous
spread) or by direct implantation of bacteria, such as in open
fractures or at surgery.
Non-speciphic inflammatory diseases
Osteomyelitis
The infection often is caused by staphylococcus,
but sometimes also by streptococcus (including Strep­
tococcus pneumoniae), E. coli, Klebsiella, Haemophilus
influenza etc.
Osteomyelytis could develope as a separate entity - pri­
mary osteomyelitis, or could be secondary - as a com­ Fig. 45. 3D reconstruction: Condy­
plication after infectious diseases - sepsis, pneumonia, lar fracture and luxation of tempo-
scarlet fever, abdominal typhus etc. Post traumatical os­ ro-mandibular joint
91
teomyelitis is a special kind of os­
teomyelitis when inflammation de-
velopes after fracture of a bone.
On the basis of the course of the
disease, osteomyelitis may be sep­
arated into acute, subacute, and
chronic stages.
Imaging modalities for diagnostic of
osteomyelitis are:
- radiography - should be the first
Fig. 46 b. MRT -axial slice- acute study;
osteomyelitis - decreased sig­ - CT - best method for bone changes;
nal on the images - MRT - study of choice for the eval­
uation of bone marrow (oedema, ne­
crosis etc.) and adjacent soft tissue changes;
Fig. 46 a. Acute osteomy­ - Nuclear medicine (radionuclide) studies.
Basic bone changes visible on different kinds of imaging are: oste­
elitis - soft tissue edema,
oporosis (usually spotty), periosteal reaction, osteolysis, osteoscle­
localized osteoporosis,
rosis and osteonecrosis (sequester could be peripheric, central or
medullary and cortical lu-
cencies and periostitis total)
Acute osteomyelitis often is seen in children, localized in the metaphy-
ses.
Patoanatomically at the beginning oedema of bone marrow
continues as a diffuse purulent inflammation reaching the periost.
Thrombosis of vessels lead to necrotizing of bone areas. According
to this the radiological changes in bone are osteolysis, peroistitis
and osteonecrosis.
The clinical symptoms and signs are pain, swelling, tenderness,
fever, elevated sedimentation rate, and leukocytosis. Conventional
radiographic examination initially may be negative, but after 1 to 2
weeks radiological symptoms are: localized osteoporosis in meta­
physic, irregular osteolytic regions are seen, together with a peri­
Fig. 47. Chronical osteomy­ osteal reaction parallel to diaphysis (Fig. 46 a). In the early stages
elitis - periosteal reaction, of osteomyelitis, diagnosis is better accomplished with scintigraphy
osteolysis, osteosclerosis and and MRI (Fig. 46 b).
sequester If nflammation reaches epiphysis septic osteoarthri­
tis develops. In children lysis of epiphyseal nucleus
is possible. If acute osteomyelitis is not treated the inflammation reaches the diaph­
ysis of a bone and chronical osteomyelitis develops.
Chronical osteomyelytis is localized in dyaphysis and is characterised with the fol­
lowing radiologycal symptoms: periosteal reaction, osteolytic areas, usually multiple,
osteosclerosis, sequester - from compact bone - needle like, and reactive osteoscle­
rosis around sequester (Fig. 47).
CT is the best imaging method for detecting or excluding a sequester (Fig. 48).
MRI is the best imaging method for the preoperative assessment of the extent of
chronic osteomyelitis.
Interpreting WBC scintigraphy and MRI in conjunction with the radiographic findings
is the most dependable method of determining reactivation of a chronic post trau­
matic osteomyelitis.
The radiographic features of chronical osteomyelitis depend on the time from
the appearance of the clinical findings to the radiographic examination. If the interval Fig. 48. CT
is short (less than 3 weeks) or the lesion has induced no symptoms, the dominat­ chronical os-
ing finding is osteolytic destruction similar to acute osteomyelitis. The radiographic t e o m y e l i -
findings vary if the clinical findings have been present for a longer time; osteolytic t i s - c o mp a c t
lesions with sclerotic rims, mixed osteolytic and osteoblastic lesions, and purely os- sequester
92
teosclerotic processes can be found. The radiographic evolution
of the lesion, even without therapy, ranges from progressive scle­
rosis to complete restoration of
the normal osseous structures
over several years.
The most typical signs of chron­
ical osteomyelitis is sequestra,
formation of involucra (new
bone formed around the se­
questrum) and sinus/fistlae -
tracts from the bone to the skin
surface.
Differential diagnosis of osteo­
myelitis is made with:
1. Periostitis traumatica (perios­
Fig. 49. Periostitis traumatica teal reaction and no other bone
changes) (Fig. 49).
2. Dyaphyseal form of tubercu­
losis (spina ventosa)-only clini­ Fig. 52. Ewing sarcoma
cally (Fig. 50).
3. Lues - alike bone changes;
osteosclerosis, periostosis,
osteolysis; lack of sequestrum.
Changes are in many bones;
Wassermann positive reaction
(Fig. 51).
4. Ewing sarcoma - very difficult
differential diagnosis because
they have similar clinical symp­
toms. Periostosis (onion peel
pattern or perpendicular peri­
osteal reaction - spiculae) and
lack of sequestrum are typical
for Ewing sarcoma (Fig. 52).
There are non typical forms of
osteomyelitis according to the Fig. 53 - Plain X ray - Brodie ab­
anatomical localization, accord­ scess in the distal metaphysis of
ing to the clinical and radiologi­ humerus
cal symptoms:
Brodie abscess
It is localized in the spongy bone, usu­
ally in metaphysis of a bone and is due
to embolization of small metaphyseal
artery. Radiologically is expressed as a
Fig. 51. Periostitis luetica radiolucent area with smooth borders
surrounded by osteosclerosis; lack of
sequestrum (Fig. 53).
Panaricium ossale
It is localized in the distal phalangs. Basic bone change is only
osteolysis of the distal part of the phalang (up to the lysis of the whole
phalang) (Fig. 54).
Sclerosing osteomyelitis of Garre
It is localized in the diaphysis without acute beginning.
Radiologically - well-expressed periosteal reaction and osteosclerosis (medul­ Fig. 54. Panaricium os-
lar channel is not visible); no sequestrum and osteolysis is found (Fig. 55). sale
93
Garre osteomyelitis is difficult to
treat and sometimes is difficult
to differentiate from malignancy.
Extensive periosteal new bone
formation with cortical thickening
have to be differentiated with oste­
oid osteoma, healing fracture and
Ewing sarcoma.
Complications of osteomyelytis:
- infection of adjacent joint (osteo­
arthritis);
- pathological fractures and luxa­
tions (Fig. 56);
- osteolysis of epiphyseal center
(Fig. 57).
Fig. 55. Garre Fig. 56. Os- Fig. 57. Osteolysis of epiphyseal Speciphic inflammatory diseas­
osteom yeli­ t eomyel yt i s center of right femur es of bones and joints
tis of tibia and patho­ Tuberculosis of bones and joints
logical frac­ Tuberculosis is a speciphic inflammatory diseases caused
ture of femur by mycobacterium tuberculousae.
It is due to haematogenious dissemination (secondary) - from tuber­
culous focus (most frequently-from primary lung tuberculosis) which
is at about 30-35% from cases with extrapulmonary localization.
Most often it is developed in the joints - tuberculous osteoarthritis
and rarely only in the bones - tuberculous osteitis. Most frequently
it is found in vertebra, hips, knees etc.
Pathoanatomically - speciphic granulations which are formed and
obliteration of vessels lead to bone changes.
Osteoarthritis tuberculousae - development of tuberculosis in
bones and joints
Fig. 58. Tuberculosis of the left According to the way of infection it could be:
hip joint - primary ossal - more often in children
- primary synovial - in adults
Ossal infection developes when necrotic tuberculous lymph node opens in a vessel and embols in
the metaphysis lead to osteitis and later to osteoarthritis.
Synovial infection develops when from necrotic tuberculous lymph node infection goes to synovia;
exudative synoviitis develops. Arthritis and infection of epiphysis leads to osteoarthritis.
Radiological symptoms of tuberculous osteoarthritis
1. Tuberculous osteoarthritis with ossal (haematogenious) way of infection:
- osteoporosis in metaphysis;
- osteolytic changes with irregular borders;
- sequestrum in spongy bone - small, oval or square;
- narrowed joint space (destroyed cartilage) - constant symptom for tuberculous osteoarthritis
(Fig. 58).
2. Tuberculous osteoarthritis with synovial way of infection:
- hydrops - widen soft tissues around the joint;
- narrowed joint space;
- osteoporosis in the metaphysis;
- osteolysis in the joint margins (Fig. 59).
In advanced cases - Ro symptoms of ossal and synovial forms are
one and the same.
Spondylitis tuberculosae (Malum Potti)
It is a tuberculosis of the vertebrae. According to the way
of developing, the infection could be spread by: central way - in Fig. 59. Tuberculosis of the left
the center of the vertebral body (usually in children) or by margin- knee joint
94
al way near the discal margins
- (usually in adults because of
slow vascularization)
Ro symptoms of spondylitis
tuberculosae are:
- narrowed discal space;
- osteolysis of the bodies;
- cuneiform fracture of vertebra
in the anterior part of the body;
- angular kyphosis (gibbus de­
formity);
- cold abscess - spindle shaped
radiopaque shadows around
the spine (one or two-sided,
with or without calcifications)
Fig. 60 a, b. Frontal and lateral projection of thoracic vertebra- narrowed (Fig. 60 a, b, c).
discal space; angular kyphosis, cuneiform smashed vertebra in the an- Differential diagnose is made
terior part of the body (fracture). Accidental finding-liver calcifications with osteolytic metastasis in the
vertebra (normal discal space,
smashed vertebral bodies)
Ro symptoms of tuberculous ostitis (extraarticular form of
tuberculosis)
Superficial tuberculous ostitis
- next to a process in soft tissues (lymph nodes, pleura etc.) - os­
teolysis with unequal, unsharp borders; lack of osteoporosis and
periosteal reaction
- by haematogenious way:
- diaphyseal form - periosteal reaction, medullar osteolysis
- tuberculous trochan-
teritis - osteolysis
- tuberculous of flat
bones (calvaria, ribs etc.)
Diaphyseal form of tubercu­
losis
Fig. 60 c - MRT - cold abscess
Spina ventosa
in tuberculous spondylitis
Spina ventosa deve-
lopes usually in children - in proximal phalangs.
Radiological symptoms: periosteal reaction (spindle - form of the
phalang), osteolysis, osteosclerosis, compact sequester (Fig. 61).
DD of diaphyseal form of tuberculosis:
- chronical osteomyelitis and Ewing sarcoma - hystologically
- actinomycosis - both with periosteal reaction - microscopically
- lues - osteochondritis luetica; serological diagnose
- sclerosing osteomyelitis of Garre Fig. 61. Spina ventosa
Caries sicca Volkmani
This is a special form of tuberculosis. It developes in caput
humeri, where is found: osteoporosis and osteolysis of caput hu­
meri and cavitas glenoidalis scapulae (Fig. 62).
Syphilis (lues, Morbus Hofmanni)
It is a speciphic pathological process due to Spirochaeta (Trepo­
nema) pallida. There are two types of lues - congenital and acquired.
Osteoarticular manifestations of syphilis can be seen with con­
genital, secondary, and tertiary syphilis.
I. Congenital lues
Depending on the time for appearing of clinical features congenital Fig. 62. Caries sicca Volkmani
95
lues is devided into:
1. Early congeni­
tal lues which is two
types: fetal lues and
lues of infants and
early childhood.
- ™ , I .. 2- Lues con9enital tar-
k da‘

I
IB M | IH H I Congenital lues
For fetal lues
and lues of infants
changes in the bones
are multiple and are
................... in the areas of pro-
Fig. 64 b. Osteoperiostitis lueti- visiona| ca|cification
Fig. 63. Congenital Fig. 64 a. Peri- ca (xeroradiogrphy) and the periost. Ra-
lues - intrametaphyse- ostitis luetica diological symptoms are: periostitis, osteolysis and
al fractures osteosclerosis.
Radiological forms of early congenital lues:
1. osteochondritis luetica;
2. osteoperiostitis luetica;
3. phalangitis luetica.
Two forms of lues have common radiological symptoms:
1. periostitis;
2. osteoperiostitis (periosteal reaction and osteosclerosis);
3. osteosclerosis;
4. osteolytic areas.
Osteochondritis luetica
Spirochaetas are in the metaphysis (zone of provisional calcification)
and subperiostally.
Pathoanatomically - in the mineralized zone of provisional calcifica­
tion osteosclerosis developes and osteolysis below it. X-ray symptoms
found are subchondral osteosclerosis and osteolytic areas. That’s the
Fig. 65. Lues congenital reason for intrametaphyseal fractures (Fig. 63).
tarda - tibia like a sword Osteoperiostitis luetica is expressed with periosteal reaction and osteo­
sclerosis (Fig. 64 a, b).
Ro symptoms of lues congenital tarda
Pathoanatomically hypermineralization and periosteal reaction develops.
Radiologycally there are three symp­
toms:
- periostitis
- osteperiostitis
- osteolysis
Most commonly they occur in the dyaphi-
sis, cranium pallatum dururm (Fig. 65).
The characteristic stigmata of late con­
genital syphilis are: interstitial keratitis,
saber shin deformity and Hutchinson’s
teeth (concave incisal edges, notched,
and hypoplastic teeth).
II. Acquired lues (lues acquisita)
Depending on the clinical course ac­
quired lues could be primary, second­
Fig. 67. Tertial lues - multiple
ary and tertiary. Changes in bones are
Fig. 66. Tertial lues - sub­ joint fractures and luxations
typical for tertial lues.
periosteal osteolysis (Charcot joint) of knee
96
Tertial lues
Neuropathic arthropathy (Charcot
joint), gummatous and nongummatous
syphilitic periostitis, and osteitis represent
musculoskeletal manifestations of tertiary
syphilis.
Radiologycal symptoms
In bones: subperiostally - osteolytic ar­
eas; osteitis and periostitis are seen
(Fig. 66).
In joints: neuropathic arthropathy (multiple
intrajoint fractures and luxations) is ob­
served (Fig. 67).
LACK OF VITAMIN D
RICKETS
Rickets has a very characteristic
radiographic appearance which is seen
when the growth plates are open. After closure of growth plates the disease is called osteo­
malacia.
In rickets, there is widening of the growth plates with irregularity and fraying of their metaph­
yseal boarders because of the osteoporosis.The bones may have a very thin compact bone
and wide medullary channel. Intracortical striations may be seen (Fig. 68).
The changes in the rickets are most severe where bone growth is the greatest. Therefore the
knees, ankles, and wrist are the best sites for evaluating possible rickets. The changes also
are most marked when growth is rapid. Various bone deformities are variably present, and
skeletal growth is delayed.
In some forms of rickets there may be associated secondary hyperparathyroidism. This is
particularly common in vitamin D dependent rickets, a familial condition due to lack of the
second hydroxylation of vitamin D in the kidney. It is never seen in vitamin D resistant rickets.
The bones affected by rickets may be bowed (Fig. 69 a). During healing of rickets the zone
of provisional calcification often calcifies first and there may be lucent bands in the metaphy-
ses - Looser zones. They are a characteristic feature of osteomalacia; represent incomplete
fractures, which appear radiographically as radiolucent lines.They often are symmetric and
perpendicular to the cortex and characteristically only affect a part of the bone circumference
(the continuity of bone is broken and the radiolucent line doesn’t reach the opposite side of the
bone). They differ from stress fractures because of their frequent bilateral location (Fig. 69 b).
Radiologycal symptoms of rickets are:
- generalized osteoporosis;
- zone of provisional calcification disappears - the growth plates
are widened and frayed;
- change in the form of metaphysis - cup-shaped;
- lucent bends in the metaphyses-symmetrically.
There are many conditions that mimic rickets. These include cop­
per deficiency in infancy, hypophosphatasia, hyperparathyroidism
both primary and secondary, several forms of metaphyseal chon­
drodysplasia as well as other disorders. In many of these disor­
ders the appearance of the metaphyses although similar to rick­
ets, usually can be distinguished from it on radiographs.
Renal osteodystrophy
This may be difficult to separate radiologically from rick­
ets unless the hyperparathyroidism is severe, which is uncommon
in ordinary rickets. The best sign of hyperparathyroidism in older
children as well as in adults is subperiosteal resorption along the Fig. 69 b. Rickets - symmetric
radial side of the middle phalanges of hands. Brown tumours may radiolucent bends in the me­
be seen and fractures are common. taphysis
97
JOINT DISEASES
There are two main groups of diseases affecting the joints: inflam­
matory diseases of joints (arthritis) and degenerative diseases of
joints (arthrosis).
Inflammatory diseases of joints
Inflammatory diseases of joints (arthritis, polyarthritis) ac­
cording to the clinical course could be acute and chronic arthritis.
Inflammatory diseases of joints (arthritis) could be classified as:
1. Infectious arthritis and spondylitis (diskitis).
The inflammation is caused by organisms (usually bacte­
Fig. 70. MRT of sacroiliac
ria) that enter the joint from perforation of the skin, from direct
joints-arthritis
spread from soft-tissue infection, or from the blood.
2. Rheumatoid arthritis.
This is a systemic inflammatory disease of the connective tis­
sue consisting primarily of a polyarthritis, but also has extra-articular
manifestations such as inflammations of the bursae, tendon sheaths,
vessels, and internal organs. In more than 70% - 80% of cases the se­
rum rheumatoid factor is present (“seropositive rheumatoid arthritis”).
3. Seronegative spondyloarthropathy
This is an inflammatory condition with characteristic in­
volvement of the skeleton, peripheral arthritis, and various extra
- articular manifestations. The rheumatoid factor is not present, but
there is a strong association with the HLA-B27 antigen. The group
of seronegative spondyloarthropathies includes:
- ankylosing spondylitis (Bekhterev disease);
- reactive arthritis (special type: Reiter syndrome);
Fig. 71 a. Plain radiography of - psoriatic arthropathy.
left hip-arthritis 4. Inflammatory systemic connective tissue diseases
This is a group of diseases associated with noninfectious
inflammation of the connective tissues. Articular involvement is one of many clinical symptoms and
often is a minor feature. This group of diseases includes:
- systemic lupus erythematosus;
- progressive systemic sclerosis (sclerodermia);
- polymyositis and dermatomyositis;
- vasculitis (polyarteriitis nodosa).
Imaging modalities
Conventional radiography still plays a central role in diagnosing and monitoring joint dis­
orders and in planning therapy. The routine examination consists of at
least two views obtained in different projections, frequently with com­
parison views of the contralateral side. Digital radiography has the ad­
vantage over conventional film-screen systems of displaying the find­
ings of interest at a brightness that is optimal for interpretation.
Computed tomography is indicated for evaluating the sacroili­
ac, sternoclavicular, and temporomandibular joints and the atlanto-oc-
cipital transition, and for assessing speciphic problems related to de­
generative changes of the spine.
For the large joints, computed tomography can delineate the radio-
graphic features without superimposition of other structures.
Descrete changes are seen better on MRI studies. MRI may be
useful to detect early signs of joint inflammation where radiographs
are normal (Fig. 70). MRI is able to detect synovial inflammation, as
well as bone changes such as marrow oedema and small erosions.
The best method for evaluating synovitis is with MRI and enhance­
ment following intravenous injection of gadolinium. In this way one can Fig. 71 b. CT of left hip ar-
separate fluid from synovitis. thritis
98
Pathogenesis of arthritis and its radiographic appearance
Arthritis has a vast number of causes.They all have in
common that they induce an inflammation of the synovial lining
that is responsible for the disease process. This explains the
similarity of the morphologic articular changes, regardless of
the cause.
Synovitis with thickening of the synovial lining and hyperemia ini­
tially causes joint effusion and periarticular edema that are clini­
cally and radiographically apparent as soft-tissue swelling.
Arising from the synovial lining as well as in the subchondral re­
Fig. 72. Rheumatoid arthritis of gion, vessels and soft tissues proliferate and form granulation tis­
small joints sue (“pannus”). The pannus and inflammatory effusion erode joint
cartilage and also bone not covered by the protecting cartilage
layer (“bare area”) adjacent to the capsular insertion. This leads to the for­
mation of erosions.
In the course of the disease, cartilage destruction progresses, and pannus
extends from the peripheral and subchondral sites towards the joint, initially
leading to the destruction of the subchondral bone plate and eventually to
erosions and osteolytic defects.
With progression of the disease process, cartilage and bone are further de­
stroyed (resulting in joint space narrowing), eventually leading to complete
destruction and forming initially fibrous and later osseous bridging of the
joint resulting in ankylosis.
Septic arthritis
Haematogenous infection may lead to septic arthritis in any joint, but it

S
Щ is most common in the hip and in the sacroiliac joints. In any joint, s
arthritis may be caused by trauma from an open wound, surgery, or adja
* cent osteomyelitis. Septic arthritis should be considered w
Fig. 73. Arthritis of arthritis.
the knee Septic arthritis occurring in superficial joints generally is easy to diagnose
because of joint swelling due to intraarticular pus or synovitis or both. Septic
arthritis in deep joints, such as the hip and sacroiliac joints, and in the spine is more difficult to diag­
nose.
In the acute stage of septic arthritis of the hip the conventional radiographic examination may be
normal. After one week the joint cartilage is reduced and broad erosions in the femoral head may be
observed (Fig. 71 a, b). Subsequently, the hip joint may be totally destroyed.
Radiological symptoms of septic artritis are:
- soft tissue swelling;
- osteoporosis;
- joint space loss;
- marginal and central osseous erosions;
- bony ankylosis.
Rheumatoid arthritis
Rheumatoid arthritis is clinically and histologically an in­
flammatory systemic connective tissue disease of undetermined
etiology, with chronic joint involvement (synovitis), systemic
symptoms and frequent involvement of tendon sheaths, bursae,
vessels, serous membranes, eyes and internal organs.
Rheumatoid arthritis is autoimmunologic disease and could be:
1. primary chronic - affecting small joints (Fig. 72) and secondary
chronic - affecting large joints (Fig. 73).
Autoantibodies, so called rheumatoid factor can be found in 75%
of patients with rheumatoid arthritis. Fig. 74. Subluxations of meta­
Pannus is formed which causes: narrowing of joint space; ero­ carpophalangeal joints causing
sions and lysis of cartilage and bone. Inflammatory process ends ulnar deviation of fingers
99
with fibrous and osseus ankylosis.
Radiologycal symptoms of rheumatoid arthritis
- narrowed joint space;
- osteoporosis;
- osteolysis of joint surfaces;
- subchondral osteosclerosis;
- pseudocyst;
- bone ankylosis.
Deformations (ulnar deviation) and subluxations occurs. Second­
ary degenerative changes - osteophytes develop (Fig. 74).
HLA - B27 rheumatoid diseases
The seronegative spondyloarthropathies are asymmet­
rical polyarthropathies, usually involving only a few joints. They
have a predilection for the spine and sacroiliac joints.
This is a group of diseases, connected with B27 antigen tissue
Fig. 75. Ankylosing spondylitis - compatibility and include:
- ankylosing spondylitis (M. Bekhterev);
"bamboo stick"
- Reiter’s syndrome;
- psoriatic arthritis.
Ankylosing spondylitis (Morbus Bekhterev) - (spondylitis ankylopoetica)
This is a chronical inflammation of the joints and ligaments of the vertebral column and sacro
iliac joint which become ankylosed.
There are two forms of disease:
- descending form - downwards the cervical vertebra - Morbus Bekhterev;
- ascending form - from sacro iliac joint upwards - Morbus Pier-Marie-Schtrumpfel.
They are expressed with:
- ankylosis of intervertebral joints (between proc. art. superiores et inferiores);
- ankylosis of sacro-iliac joint;
- sclerosing of lig. supraspinatum, lig. flavum et lig. laterali.
Radiological symptoms of ankylosing spondylitis are:
- ankylosis of intervertebral joints;
- bilateral sacro ileitis with osteosclerosis and/or ankylosis;
- syndesmophyts - vertically orientated bony spurs arising from vertebral bodies.
Symptoms of “bamboo stick” and “railing”are found due to calcifications in ligaments.
“Bamboo stick” - ossification of the anterior and posterior longitudinal ligaments is the hallmark of
ankylosing spondylitis and occurs only in the late stages of the disease.
“Railing” symptoms means three vertical radiopaque lines corresponding to the ossified supra - and
interspinal ligaments and the osseous ankylosis of the costovertebral and costotransversal joints
(Fig. 75).
Reiter’s syndrome
Inflammatory disease of the joints, usually of the lower limb
accompanying by urethritis and conjuctivitis. It follows either a sex­
ually transmitted infection, presumably caused by chlamydiae, or
an intestinal infection with Yersinieae, shigellae, or salmonellae.
The foot (metatarsophalangeal joints, calcaneus) is preferential­
ly involved. Erosive changes predominate over osteoproliferative
changes.
Radiological symptoms:
- soft tissue swelling;
- narrowed joint space;
- erosions;
- osteophytes (Fig. 76).
Psoriatic arthritis
In patients with psoriasis joints are involved: nonsymmetri-
caly - arthritis of a large joints (similar to Reiter’s syndrom); sym- Fig.76. Reiter's syndrome
100
metrically - arthritis of small joints (similar to rheumatoid arthritis
- distal interphalangeal joints are involved) and spondylarthritis
(similar to spondylarthritis ankylopoetica). Radiographic changes
of psoriatic arthropathy include periarticular erosions and perios­
teal new bone formation in peripheral joints (Fig. 77).
Inflammatory systemic connective - tissue diseases
This is a group of diseases characterized by abbacterial
inflammation of the connective tissue with swelling of the intracel­
lular substance. They present as a monoarthritis, oligoarthritis, or
polyarthritis primarily involving the wrist. In contrast to rheumatoid
arthritis and seronegative arthritis, they are frequently associated
with soft tissue calcifications, skin changes, and neurologic symp­
toms.
These inflammatory systemic connective-tissue disorders are au­
toimmune diseases whose pathogenesis is still not fully under­
Fig. 77. Psoriatic arthritis stood. They develop in patients with a genetic predisposition.
Systemic lupus erythematosus
The articular involve­
ment of systemic lupus ery­
thematosus is symmetric, pri­
marily affecting the joints of
the hand and wrist, the knee,
and the shoulder.
In most cases, the radio-
graphic findings are limited to
soft-tissue swelling and juxta
Fig. 78. Ulnar deviation of pha- Fig. 79. Osteoporosis; acro-oste- articular osteoporosis. De­
langs olysis of distal phalangs; calcifi­ structions of the cartilage and
cations around the joints bones are rare. Longstanding
disease with recurrent arthritic
attacks can lead to deforming nonerosive arthropathy (Fig. 78).
Progressive systemic scleroderma
CREST syndrome is a special manifestation of the disease: acral type, associated with cal­
cinosis, Raynaud symptoms,oesophageal dysfunction, sclerodactyly, and teleangiectases. Progres­
sive systemic scleroderma usually begins with Raynaud syndrome, edematous swelling of the distal
extremities including skin thickening and polyarthralgias.
There are soft tissues cahnges - initially thickening, later thinning of the soft-tis­
sue around the distal phalanges and extensive subcutaneous extra-articular and
sometimes also intra-articular calcifications. In the bones - osteolysis involving
the distal phalanges (acro-osteolysis syndrome); erosions of the first carpometa­
carpal articulation, with radial subluxation of the first metacarpal bone (Fig. 79).
Degenerative disease of joints - arthrosis
A universally accepted terminology for degenerative changes in joints
does not exist. The most frequently used terms are degenerative joint disease,
(degenerative) osteoarthritis, (osteo) arthrosis, and arthrosis deformans. The
latter is the preferred term in the European literature and osteoarthritis is a term
which is widely accepted in the USA.
Degenerative joint diseases include many different conditions and often un­
known ethiologies. They all have in common that they occur at an older age (in
the fifth decade of life or later - primary osteoarthritis) or as secondary osteoar­
thritis following a pre-existing joint disorder. Secondary osteoarthritis can also
occur early in life. . .
Primary osteoarthritic changes are found mainly in the spine and in the hip, Fig.^ 80. Arthrosis
knee, first metacarpophalangeal articulation and interphalangeal articulations of interphalange-
(Fig. 80). al j ° ints
101
The shoulder, elbow, foot and ankle are infrequently involved. Os-
teoarthritic changes found in these joints should always be con­
sidered secondary in nature.
Secondary osteoarthritic changes have preferred sites determined
by the underlying joint disorder (Fig. 81).
Changes in the joint:
- damage to the hyaline articular cartilage and synovial lining;
- subchondral damage;
- osteophyte formation;
- meniscus and disk damage.
Pathogenesis of osteoarthritis and its radiographic features
The cause of osteoarthritis is defective cartilage, damaged
by mechanical or metabolic processes. In many cases, however,
the etiology remains unclear.
In the course of degenerative alterations, cartilage destruction
Fig. 81. Secondary arthrosis af­ leads to narrowing of the load-bearing zone of the joint space. The
ter rheumatoid arthritis-oste­ lack of the cartilage increases the impact load of the subchondral
oporosis and narrowed joint bone which becomes hypervascular toward the marrow space.
space; subchondral osteosclero­ The hypervascularity leads to increased osteoblastic activity and
sis and osteophytes trabecular thickening with sclerosis. Since the bone cannot with­
stand the continued overload, the trabecular structures collapse.
This leads to the formation of so-called “detritic cysts”. On conventional radiography, the subchondral
cysts appear as localized osteolytic lesions (oval radiolucencies) that are more or less surrounded
by a pronounced sclerotic rim (Fig. 82 a, b).
Due to regional growth factors, enchondral bone formation produces osteophytes (spurs). This may
as an attempt by the bone to broaden the load-bearing area of the joint (Fig. 83).
So radiologic symptoms of osteoarthritis are:
- irregularly narrowed joint space;
- subchondral osteosclerosis;
- subchondral cysts;
- osteophytes.
Degenerative changes of the spine
Degenerative disease of the spine is one of the most common clinical entities and affects
the intervertebral disks, including apposing vertebral end plates, intervertebral (facet) articulations,
and atlanto-axial articulation. Intervertebral and atlanto-axial articulations are genuine synovial ar­
ticulations and consequently show the same basic abnormalities seen with degenerative disease of
synovial articulations found at other sites in the body. The most severe primary spinal degenerative
changes are found in the lower cervical and
lumbar spine regions.
Degenerative intervertebral joint
disease can occur both separate from and
together with degenerative disk chang­
es. Secondary degenerative changes
may result from abnormal distribution of
load-bearing following trauma, inflamma­
tions, congenital dysplasias or develop­
mental malformations, metabolic and hae-
matologic conditions, or osteonecroses.
Manifestations of spinal degenerative
changes are:
- changes of the intervertebral disk (chon-
drosis);
- changes of the vertebral end plates; Fig 82 a P|ajn radjogra. Fig. 82 b. MRT of a knee -
- changes of the intervertebral articulations; phy-Subthondral cysts of subchondral cysts
- ligamentous calcifications and ossifications; |<nee
102
- stenosis of the spinal canal.
The basic findings of disk degeneration are:
- disk-space narrowing (= chondrosis);
- subchondral sclerosis;
- Schmorl's nodes;
- spondylophytes;
- vacuum phenomenon;
- calcifications in the disk (nucleus pulposus) (Fig. 84 a, b).
Radiologic symptoms of spondylosis are: normal width of the
discal spaces; reel-shaped vertebra; subchondral osteosclerosis
and marginal osteophytes (Fig. 85).
Radiologic symptoms of spondylarthrosis are: the combina­
tion of altered vertebral end plates (band-like sclerosis, contour
irregularities) and narrowed disk + narrowed intervertebral joints
and sharp proc. intervertebrales (Fig. 86).
Imaging modalities
Fig. 83. CT of knee - osteophytes MRI
By taking advantage of multiplanar display (axial and sag­
ittal) and by applying high-resolution coils and sequences that
distinguish disk material from
osseous structures, MRI can
generally answer most ques­
tions concerning degenerative
disk disease. It can also differ­
entiate between scar tissue and
recurrent prolapse. Therefore,
this modality has become the
primary diagnostic method to­
day (Fig. 87).
Fig. 84 a. MRT-normal disk Myelography
Myelography combined
with CT is comparable to MRI
for diagnostic assessment of
findings causing neurologic
symptoms. Speciphic advan­ Fig. 85. Plain X-ray - cervical
tages are the direct visualiza­ spondylosis
tion of spinal stenosis, nerve
root compression, or indenta­
tion of the cord by osseous pro­
jections and soft-tissue masses.
Nowadays it has been replaced
by CT and MRI.
CT
CT is good for the mor­
phologic evaluation of the spine
and spinal canal even without
Fig. 84 b. MRT-disk degenera­ intrathecal administration of
tion contrast medium (Fig. 88).
However, artefacts can interfere
with the clinical application of CT at the cervicothoracic junction.
DISC HERNIATION
Disc herniation means localized displacement of nucleus,
or fragmented annular tissue beyond the intervertebral disc space. Fig. 86. Plain X-ray - cervical
The inner content of the disc protuberates through the fibrous ring spondylartrosis and osteochon-
and compresses nerves or/and medulla spinalis. drosis of C45
103
CT and MRI can be
used for the diagnosis of a disc
herniation.
There are different types
of disk herniation:
- bulging disk;
- focal bulge or protrusion - the
nucleus material remains with­
in the outermost fibres of annu­
lus fibrosus;
- prolapse or extrusion - the
nucleus material has pene­
trated the annulus fibrosus
Fig. 87. MRI - spinal degenera­ Fig. 88. CT - lumbal vertebra but is contained in front of
tive changes - disk space narrowing and os- the posterior longitudinal lig­
teophytes-spondylarthrosis ament;
- sequester or free fragment.
A bu lging disc is a common finding and is often seen in combina­
tion with reduction of the height of a
disc. In bulging discs there is a gen­
eral expansion of the disc beyond the
margins of the adjacent vertebral end
plates (Fig. 89).
In disk herniations there is a focal ex­
tension of different size of the disk outside
the vertebral body (Fig. 90 a, b).
In international literature this is called
"focal disc bulge" or "protrusion"
(Fig. 91 a, b).
These terms are used interchangeably
and usually represent different degrees of
the same condition, protrusion being the
Fig. 89. MRI - multiple larger disc herniation. Common to both is
disk bulgings that the nucleus material remains within Fig. 90 a. MRI-sagittal im
the confines of the outermost fibres of the age-posterior herniation of L
4-5
anulus fibrosus which is focally weakened.
In "prolapse" or "extruded disk" the nucleus material has
penetrated the annulus fibrosus but is contained in front of the
posterior longitudinal ligament (Fig. 92). With the present imag­
ing modalities it is often impossible to differentiate between these
types of disc herniation.
In sequestration or free fragment the disc material is no
longer contiguous with the intervertebral disk and usually it has
penetrated the posterior longitudinal ligament.
Disk herniations are divided into central, posterolateral, lateral (fo-
raminal) and lateral (extraforaminal).
In the radiological report it is important not only to de­
scribe the disc herniation but also its influence on nerve roots
and the dural sac. The general rule is that the common pos­
terolateral disc herniation compresses the nerve-root which
exits in the neural foramen below the intervertbral disc, i.e. a
L4- L5 disc herniation will compress the Lr root. In lateral disc Fig. 90 b. MRT - transverse im­
herniation, the root in the rootcanal will be compressed and in age - herniation into the right
this situation a L4 - L5 disc herniation will compress the L4 root. side of the spinal canal; normal
In the cervical spine isolated disc herniations which left L5 nerve root
104
are seen in young and mid­
dle aged adults are relative­
ly uncommon. However, the
majority of disc herniations
are found in combination
with degenerative osteo-
phytic spurs with narrow­
ing of the spinal canal as
well as the root canals. As
in the lumbar spine the disc
herniations are usually pos­
terolateral raising the possi­
bility of nerve-root compres­
sion. Large posteroateral
and central disk herniations
Fig. 91 a. MRI - sagittal image - Fig. 91 b. MRI - transverse im­ sometimes cause compres­
central protrusion age - central protrusion sion of the medulla.
Bony spurs (os-
teiphytes) causing narrowing of the spinal canal
and root-canals are very common in the mid­
dle-aged and in the elderly. There is often a poor
correlation between these degenerative chang­
es and clinical symptoms, except in the most
advanced cases. The most frequent location of
advanced degenerative disease is seen at the
C5 - C6 and C6 - C7 levels, where mobility is most
expressed. Osteophytic spurs from the vertebral
bodies enter the central spinal canal and osteo­
phytes from the uncovertebral joints and interver­
tebral joints enter the root canals. MRI and CT can
be used for diagnosis.
The clinical information needed is knowledge of the
presence of a medulla or nerve-root compression,
Fig. 92. Extrusion Fig. 93 a. Gout. at what level it is found, and whether there are sin­
and nerve root gle or multiple affected levels. All of this information
compression is important for the choice of surgical procedure, i.e. laminectomy, facetectomy,
anterior approach etc.
Metabolic arthropathies
Gout (osteoarthrosis urica)
Gout is caused by uric acid crystal deposition in soft tissues
and articular structures. Acute gout refers to soft tissue swelling
with no visible bony changes. Chronic gouty arthropathy occurs
with recurrent acute gout. Gouty arthropathy is usually asymmet­
ric in distribution and often monoarticular. Gouty arthropathy in­
volves the first metatarsophalangeal joint in 70% of cases. Other
commonly affected joints include ankles, knees and intertarsal
joints.
Radiographic features of gouty arthropathy:
- irregularly narrowed joint space;
- unequal joint surfaces;
- subchondral osteosclerosis;
- osteolytic areas;
- osteophytes;
- tophus: soft tissue mass in the synovium of joints, the subcuta- Fig. 93^b. Bone changes and so
neous tissues of the lower leg, Achilleas tendon, olecranon bursa tissue "tophies
105
at the elbow, helix of the ear. Sometimes calcification of tophi can
occur (Fig. 93 a, b).
Osteoarthritis is a destructive joint disease, caused by
damaged cartilage regardless of the nature of the cartilage dam­
age. Arthritis is a destructive joint disease primarily caused by
synovitis regardless of the nature of the synovitis. The cartilage
damage of “primary” arthritis causes a secondary osteoarthritis.
These mechanisms explain why radiographically visual­
ized joint changes represent a summation effect of the result of
both disease processes.
Conclusion: differentiating the signs of degenerative joint disease
from those of arthritis is often difficult and sometimes impossi­
ble. However the different therapeutic approaches demands that a
Fig. 94 a. Plain radiogra­
differentiation should always be attempted, whether a disease is
phy-multiple exostoses
caused by synovitis or by damaged cartilage.
TUMOURS ANDTUMOUR-LIKE DISEASES OFTHE BONES
Tumours are devided into primary and secondary (metastases). Primary tumours are devided
into benign and malignant.
Tumour like lesions are distinctly different from primary bone tumours. They can spontaneously re­
gress or cease to grow and never metastasize. They are relatively common and only a few of them
require therapy.
Bone tumours
Bone tumours may cause nonspeciphic changes, but an analysis of these changes is very
important for the further assessment of the patient. Basic bone changes that develop in response
to benign and malignant tumours may be similar, and these may simulate those of other conditions,
such as inflammation, metabolic diseases, and trauma.
Osteolysis - bone destruction can occur as a localized osteolytic region which is seen not only
in benign or malignant tumours, but also with metastatic disease or can appear as numerous small
cavities, 1 to 5 mm as in more aggressive tumours.
Periosteal bone reaction may be localized about the periphery of a tumour, or may be as
diffuse sclerosis throughout the bone. Neoplastic bone (i.e. bone produced by the tumour itself) of­
ten has an irregular appearance e.g. osteosarcoma often forms neoplastic bone, which is seen as
irregular, dense areas within the bone or amorphous dense masses in the soft tissues. In chondro-
matous tumours (enchondroma and chondrosarcoma), calcifications often are seen as punctate
formations.
With slowly growing tumour, a periosteal reaction may be seen as a thin calcified layer. If the tumour
grows more rapidly and with varying speeds, several layers are superimposed on each other in an
onion-peel pattern. In rapidly growing aggressive tumours, a perpendicular periosteal reaction may
be seen with calcified thin streaks, which may be orientated per­
pendicular to the surface of the bone (so called spiculae).
Osteosclerosis is ofen met usually in the cases of benign
tumours and cysts.
A newly recognized tumour may be solitary or multiple. Multiple
lesions may indicate the presence of a multicentric tumour, such
as histiocytosis X, or a primary malignant tumour that already has
metastasized.
In order to make diagnose bone tumour it is necessary to analize
several things:
- localization of the tumour;
Tumours can occur anywhere in the skeleton, but many tumours
predominate in speciphic locations. Most primary bone tumours
occur in the long bones, but certain types prefer flat bones, small
bones, or vertebrae. Osteomas often are seen in the skull; haeman­
giomas - in the skull and vertebral bodies; chordomas - at the base Fig. 94 b. Knee MRI. Coronal
of the skull and sacrum and enchondromas in the tubular bones slice presenting an exostosis
106
of the hand. Location of tumour within the bone is important. In
the long tubular bones, most tumours are seen at sites where the
growth is most extensive (i.e. in the proximal portion of the humer­
us, the distal end of the femur, and the proximal end of tibia). Sev­
eral exceptions exist - chondroblastoma often occur in the epiph­
ysis before the growth plate is closed; giant cell tumour originate
in the metaphyses and quickly extend into the epiphysis.Usually
in diaphysis develops Ewing sarcoma; in metaphysis - osteogenic
sarcoma; in epiphysis - chondroblastoma and giant cell tumour.
It is very important to know if the tumour is within or outside the
bone and is it located centrically or eccentrically within the bone.
- type of destruction - bone destruction pattern (geographical,
moth-eaten, permeative etc.);
Fig. 95. Compact osteoma in the - margin of the lesion - with thin, sclerotic rim is more likely benign;
left frontal sinus with wide and irregular - more likely malignant;
- cortical changes - effect on surrounding bone is important: ex­
pansion and thinning of cortex - it is more likely benign tumour; if penetration of cortex exist - more
likely to be malignant tumour;
- periosteal reaction (multiple lamellated, spiculated) and new bone formation: osteogenic sarcoma,
Ewing sarcoma;
- soft-tissue infiltration.
This analysis generally determines the biologic activity (inactive, active, aggressive) of the
tumour. This information can provide a definitive diagnosis.
In some cases, it may be impossible to differentate radiologically different kinds of tumours, so biop­
sy often is required to reach diagnosis.
Imaging modalities
Radiography - is an initial imaging technique for evaluation of suspected bone tumours. It is most
reliable imaging method for detection and diagnosis of bone tumours and tumour-like lesions and
remains the initial imaging method despite advent of modern techniques e.g. CT, MRI. Its limitations
are lack of diagnostic value for soft tissue and bone marrow lesions and subtle cortical and perios­
teal lesions.
CT
Although the role of CT for staging malignant tumours has decreased with the growth of MRI,
it remains the standard method of evaluating uncertain radiographic and scintigraphic findings in
the spine and pelvis and for optimal assessment of pulmonary metastases. Some comparison stud­
ies could demonstrate that CT has the same accuracy as MRI for staging lesions. Because of its
sensitivity in detecting calcifications and ossifications, CT is superior to conventional radiography in
determining the tumour matrix and can add to the differential diagnostic assessment. It may be used
in speciphic instances where accurate characterization of the tumour matrix may be diagnostic, such
as suspected cartilage tumour.
Bones scintigraphy
Bone scintigraphy provides overview of entire skeleton; it is
necessary for the routine staging of bone tumours; screening for
metastases and lesion multiplicity and to monitor osseous lesions
following therapy.
Only a few entities such as Paget disease and osteoid osteoma,
exhibit a diagnostic pattern of bone uptake. The intensity of uptake
within a lesion is not a reliable differentiating imaging finding.
Angiography
Diagnostic role of angiography has largely been replaced
by contrast CT and MRI. Nowadays it may have a selective role in
defining vascular relationship; pre-operative embolisation of me­
tastases or embolization of soft-tissue haemangiomas.
MRI imaging
MRI is considered the gold standard for staging malignant Fig. 96. CT - osteid-osteoma
107
and benign tumours and treatment planning.
This applies to the entire skeleton, but above
all to the extremities. Furthermore MRI can
provide a variety of differential diagnostic cri­
teria by means of the different signal intensi­
ties and contrast enhancement. MRI is used
to assess tumour extent within the marrow
cavity of the bone and associated soft tissue
mass. Its advantages are - multiplanar imag­
ing capability; it is sensitive for medullary le­
sions; it has superior soft tissue contrast and
extent - neurovascular bundles, muscle, fas­
cia could be seen. With MRI the tumour lo­
cation in bone and tumour extension into soft
tissues or joints can be diagnosed. Concern­
Fig. 97. Enchondroma of Fig. 98. Osteochondro- ing soft tissue tumours, MRI can determine
V metacarpal bone ma the position of a tumour, the structure from
which it emanates, and the involvement of
surrounding structures.
In modern practice, bone tumours are commonly treated with chemotherapy or radiotherapy prior to
surgery. MRI and/or PET CT may be used to assess response to therapy.
All imaging methods play a role in diagnosing and staging primary and secondary bone tu­
mours (metastases).
Primary tumours
Primary tumours are divided into benign and malignant.They are classified according to the
dominant matrix produced by the primary tumour.
- Bone-producing tumours - osteoma; malignant form - osteosarcoma
- Cartilage-producing tumours- chondroma; maligant form - chondrosarcoma
- Tumours arising from the bone marrow - Ewing sarcoma, Haematologic tumours (lymphoma, plas-
mocytoma)
- Vascular tumours - haemangioma; malignant form - haemangiosarcoma
- Connective tissue tumours - fibroma, malignan form - fibrosarcoma
- Fat tissue - lipoma; malignant form - liposarcoma
Benign tumours of bone tissue
Benign bone tumours have some common features:
- they have low growth;
- they are capsulated (smooth borders);
- structure close to initial
tissue;

p
- they don’t give recidives;
- they don’t give metasta­
ses.
Plere are some of the most fre­
quent tumours:
Bone-producing tumours
Osteoma
Osteomas and bone is­
lands are benign bone forming
lesions; they can be monostotic
or polyostotic. They are frequent­
ly incidental radiographic find­
ings that must be distinguished
from osteoblastic metastases. Fig. 99 a. Plain X-ray-
Osteoma is divided into: non ossifying fibroma Fig. 99 b. CT - non ossifying fibroma
Bone exostosis could be single of tibia in child of tibia
108
or multiple (Fig. 94 a, b).
Differential diagnosis is made with cartilagineous exostosis where
the clinical finding is bigger than radiological and formation has
acute angle with diaphysis.
Compact osteoma - from compact bone; most frequently in the
skull - in the sinus area (Fig. 95).
Osteid osteoma
This is a benign, painful osseous lesion that is characterized
by small size (less than 2 cm) and sharp demarcation. It is charac­
terized clinically by night pain, affected by salycilates.The tumour
causes focal bone destruction (nidus) that is surrounded by varying
degrees of sclerosis (Fig. 96).
Cartilage-producing benign tumours
Chondromas
They develop usually in the metacarpal bones. In the
Fig. 100. Haemangioma in bone spongy bone is called enchondroma and radiologically is round or
and phlebolits in soft tissues ovoid radiolucencies, often with a scalloped borders, or a lesion
with a matrix of mixed coarse, ringlike, or confluent calcifications.
The lesion may thin and scallop the cortex because of endosteal erosion (Fig. 97).
Osteochondroma
This is a very common benign osseous neoplasm that extends from the underlying bone.
The osteochondroma can be pedunculated or sessile, with its broad base incorporated in the bone
and associated with loss of a cortex. Calcifications (linear, geographic, irregular) are always detect­
able, unless the osseous chondroma has matured and is completely incorporated into the osseous
structures (Fig. 98).
Connective-tissue benign tumours
Fibroma
In children and adolescents it developes in the metaphysis of long bones, jaws, sinus etc.
There are two types of fibromas: ossifying and non-ossifying.
Non-ossifying fibroma radiologically is a well-demarcated, solitary ovoid radiolucency, with its
long axis orientated along the cortex of the tubular bone. It is separated from the normal bone
by a thin sclerotic rim and generally demarcated from the adjacent soft tissues by neocortex
(Fig. 99 a, b).
Vascular tumours
Haemangioma
The haemangioma is the most frequent osseous tumour and represents a benign tumourlike
lesion consisting of capillary and cavernous blood vessels.
It is found primarily in the spine and is al­
most always asymptomatic.
Haemangiomas in flat bones appear radio­
graphically as round, sharply demarcated, os­
teolytic lesions surrounded by a thin sclerotic
rim (Fig. 100). They can develop in bones, in
soft tissue or in bones and soft tissues.
Primary malignant bone tumours
They have some common features:
- infiltrative, quick and destructive
growth;
- give metastases;
- give recidives;
- radiologically - have irregular bor­
ders.
They can arise from: skeletal tissues - p jg io i a. Plain X-ray Fig. 101 b. MRT - osteolytic form
bone, chondral, muscle, connective tissue _ osteolytic form of of osteosarcoma of fibular head
and vascular tissue (osteosarcoma, chon- osteosarcoma of tibia
109
drosarcoma, haemangiosarcoma) or from bloodcell tissue (cells
from bone marrow and reticulo-endothelial cells - myeloma, Ewing
sarcoma).
Osteogenic sarcoma (Osteosarcoma)
Osteosarcoma is the most common malignant primary
bone tumour, most frequently occurring in children and adoles­
cents. It has some characteristic:
- it is monoosal; more often in childhood;
- its location is in metaepiphysis of a long bone; grows across the
bone and spreads to the chondros and doesn’t involve it;
- doesn’t infiltrate soft tissues;
Fig. 102 a. Plain X-ray of a
- gives metastases by blood and doesn’t give bone metastases.
knee-osteosclerotic osteosarco­
Types of osteogenic sarcoma
ma in right femur
- primary bone - 95%:
- outside the bone (extracorti-
cal) - parosal and periosal form
The radiographic findings are vari­
able.
Osteolytic osteosarcoma
(about 10% of cases): cause osteoly­
sis or moth-eaten pattern of destruc­
tion, almost always with periosteal
reaction (Fig. 101 a, b).
O steoblastic (oste oscle­
Fig. 102 b. CT - osteosclerotic os­
rotic) osteosarcom a (about 10%
teosarcoma
of cases) is characterized by dense
sclerotic tumour mass. The tumour can be confined to the outline
of the affected bone and sharply demarcated from the surrounding
spongy bone. Any extension of the tumour into the soft tissues in­ Fig. 103. Mixed form of os­
duces a periosteal reaction (Fig. 102 a, b). teosarcoma
Mixed o ste o lytic/o ste o b la stic osteosarcom a: this
is the most frequent manifestation. Radiographically osteolytic and osteoblastic changes are
found together, with the osteoblastic changes corresponding to mineralized osteoid. The de­
gree of osteolytic and osteoblastic changes varies from case to case. The tumour margins are
indistinct and periosteal new bone formation, characteristically spiculated. Lamellated, inter­
mittently disrupted periosteal bone formation is also observed (Fig. 103).
Diaphyseal location of osteosarcoma is very rare. The differential diagnosis with Ewing
sarcoma is very difficult (Fig. 104 a, b).
Parosteal osteosarcom a (from parosteal or
periosteal connective tissue)
Parosteal osteosarcom a (juxtaco rtica l
osteosarcom a, parosseous osteosarcom a):
This well-differentiated osteosarcoma has its epi­
center adjacent to the bone. Parosteal osteosar­
coma appears as a lobulated density along the
surface of the metaphyseal cortex of the tubular
bone and leads to thickening and deformity of the
cortex. Only 10% of the tumours extend into the
bone marrow (Fig. 105 a, b).
Periosteal osteosarcoma: Like the paroste­
al osteosarcoma, this is a surface lesion, preferen­
tially involving the tibial and femoral diaphyses. It
is dominated by a soft-tissue mass with a tumour Fig. 104 a. Diaphyse­
Fig. 104 b. MRT - di­
matrix that is less mineralized than the parosteal
al location of osteo­ aphyseal location of
osteosarcoma.
sarcoma osteosarcoma
110
Chondrosarcoma
This lesion is a malignant
cartilage-forming tumour of adult­
hood. It may be primary or may occur
secondarily to a pre-existing lesion.
It may also arise from soft tissues.
Radiologically: localized radiolucen-
cy, which often demonstrates a per­
meative pattern. The tumour margins
may be variably well delineated or
indistinctly outlined. Periosteal reac­
Fig. 105 a. Plain Fig. 105 b. MRT - parosteal os- tion and osseous extension are of­
X-ray - parosteal os- teosarcoma of the femur ten present. The tumours can calcify
teosarcoma of the (like enchondromas) or can be pure­
femur ly lytic (Fig. 106 a, b).
Malignant tum ours from bone marrow
Ewing Sarcoma
This is a highly aggressive malignant tumour of childhood and adolescence.
In contrast to patients with bone tumours, patients with Ewing sarcoma have symptoms of
inflammation and resembles osteomyelytis - fever, temperature, soft-tissue swelling (very typ­
ical), local pain, and erythema.
According to the location:
- in long bone (70 %) - in diaphysis (grows longitudinally); 30% developes in metaphysis;
- in flat bones - 25% and 5% in vertebra.
Tumour gives close methastasis by lymph, distant - by blood and in bones.
Radiological symptoms:
- in tubular bones: osteolytic areas in the medullar channel
(“moth-eaten”); several periosteal layers (“onion peel pattern”) or
perpendicular periosteal reaction (spiculae) and enlarged soft tis­
sues (Fig. 107 a, b);
- in flat bones: there is generally irregular and indistinctly demarcat­
ed osseous destruction or the lesion may be strictly permeative with
patchy sclerotic zones diffusely interposed. Osteolytic lesions rarely
occur.
Biological behaviour of the tumour - it is sensitive to radiation - ra­
diotherapy is extremely helpful.
Differential diagnosis with osteogenic sarcoma when developed in
the metaphysis is made.
Myeloma (plasm ocytoma, Morbus Rusticki-Kahler)
Myeloma is a common malignancy of plasma cells character­
ized by diffuse bone marrow infiltration or multiple nodules in bone. Fig. 106 a. Chondrosarco­
It occurs in elderly patients and is rare below the age of 40. There ma of the right femur
are two forms of myeloma: single which is rare and multiple
that developes - in places of haemopoesis - flat bones (crani­
um, ribs, pelvis, sternum).
Multiple myeloma may present clinically in a number of
non-speciphic ways including bone pain, anaemia, hypercal-
caemia or renal failure. In urine - Bence-Jones protein is a
very common sign.
Radiologically changes include single or multiple osteolyt­
ic areas; there is no osteosclerosis and periosteal reaction
(Fig. 108).
Bone scintigraphy is relatively insensitive in the detection of
multiple myeloma. Radiography is the investigation of choice Fig. 106 b. CT - Chondrosarcoma
in the detection and staging of multiple myeloma. Alternatively, of illium
111
whole-body MRI may be used. MRI has equal
sensitivity to radiography in the detection of
multiple myeloma.
Skeletal m etastases
Metastases are the most frequent tumours
of bone. In patients over 40 years old, they are
take first place in the differential diagnosis of
osteolytic or osteoblastic lesions.
Almost any primary carcinomas may me­
tastasize to bone. The most common primary
sites associated with skeletal metastases are:
breast, prostate, kidney, lung, gastrointestinal
tract, thyroid, melanoma.
Bone metastases are often clinically occult, or
they may present with bone pain, pathological
Fig. 107 a. Ewing sarcoma Fig. 107 b. MRT- Ew­ fracture or hypercalcaemia.
of the femur ing sarcoma of the Radiographically, skeletal metastases are
left humerus three types: osteolytic, osteoblastic or mixed.
Most commonly they are lytic. Osteolytic le­
sions with a pattern of destruction range from complete bone
destruction to a moth-eaten infiltra­
tive permeative destruction. There is
generally an indistinct rim, but a scle­
rotic rim can be observed rarely. The
periosteal reaction is variable. This
pattern is principally found in metas­
tases from bronchial, renal, breast,
and thyroid carcinomas. Osteolytic
malignant lymphomas and plasmocy-
tomas can not be differentiated from
osteolytic metastases (Fig. 109).
Fig. 108. Multiple lucent
Sclerotic metastases occur with
"punched-out" defects through­
prostate, stomach carcinomas and
out the skull
carcinoid tumour. Osteoblastic le­
sions are of various sizes. The in­
creased density ranges from small
patchy areas to diffuse involvement Fig. 110 a. Lateral pro­
of the bone (Fig. 110 a, b). This type jection of lumbal spine
of metastases is primarily seen with osteosclerotic metas-
carcinomas of the prostate and less tasis from prostatic can­
frequently (about 20%) with breast cer - "black vertebrae'
and gastrointestinal tumours (e.g.
colon, gastric, pancreatic car­
cinomas). Solitary osteomas
Fig. 109. Lateral projection of and bone islands may not be
skull - multiple osteolytic me­ easily distinguished radio­
tastases graphically from osteoblastic
metastases. However, meta­
static lesions generally show intense uptake on the bone scan,
whereas bone islands and osteomas show no or weak uptake.
Mixed osteolytic-blastic lesions contain both osteolytic and
osteoblastic foci. Differential diagnosis is made with malignant
lymphoma. Fig. 110 b. CT - osteosclerotic
Skeletal metastases most commonly involve spine, pel- metastases in prostatic carcino-
vis, ribs, proximal femur and proximal humerus and are un- ma
112
common distal to the knee and elbow.
Scintigraphy with 99mTc-MDP (bone
scan) is used in staging those tumours
that are known to metastasize common­
ly to bone, e.g. prostate or breast.
Skeletal metastases usually show
on bone scan as multiple areas of in­
creased tracer uptake (Fig. 111).
Tumour-like diseases of bones
Paget's disease (osteitis deformans)
Paget’s disease is a common bone
structure" disorder, occurring in elderly patients
and characterized by increased bone
resorption followed by new bone forma­
tion. The new bone thus formed (osteoid bone) has thick trabeculae, and
Fig. 111. Scintigra­ is softer and more vascular than normal bone. Common sites include
phy-multiple metas- the pelvis and upper femur, spine, skull, upper tibia and proximal hu­
tases merus. Paget’s disease is often asymptomatic and seen as an incidental
finding on radiographs performed for other reasons. There are three
forms of Paget’s disease: osteolytic, osteosclerotic and mixed. Strictly lytic or sclerotic stages
of Paget disease are rarely observed. Lytic and sclerotic changes are seen in the mixed stage
that enables the diagnosis of Paget disease.
Radiographic changes of Paget’s disease are variable depending on the phase of the disease
process and the location. If it is in the upper part of the femur the compact bone is frayed,
stratificated from osteoid tissue (shepherd's crook deformity). If it is in the skull the changes
resemble “nigro head” (Fig. 112).
Fibrous dysplasia
Fibrous dysplasia is a fibroosseous lesion of the bone and bone marrow. It is due to
mutation in the production of proosteoblasts. It is 2,5% from all bone tumours and 7,5% from
the benign bone tumours. It is a common condition where the bone tissue and bone marrow
are replaced by fibrous connective tissue. It is characterized by single or multiple benign bone
lesions composed of islands of osteoid and woven bone in a fibrous stroma. It most commonly
involves the spongy bone of lower extremity or skull and presents with local swelling, pain or
pathological fracture.There are two forms of fibrous dysplasia:
single (monoosal) - in one bone and multiple (polyosal) - in
a few bones of the facial skeleton and other bones. Fibrous
dysplasia could be classified as:
- cranio-facial form: fibro-osseous lesions in the skull (sphe­
noid, frontal bone etc.); in the facial bones; in the jaws or in the
facial and skull bones; Fig. 113. CBCT - panoramic recon­
- Jaffe-Lichtenstein syndrome: polyossal changes and skin hy­ struction - ground glass density
perpigmentations („cafe au lait”); in the left side of the mandible
- Me Cune-Albright syndrome: polyossal changes (onesided),
skin hyperpigmentations („cafe au lait”) and endocrinopathy.
Radiologically there are three forms of fibrous dysplasia:
- osteolytic;
- osteosclerotic;
- mixed, so called „ground glass” .
Areas of homogeneous grey hazy density, usually described as
„ground glass”; a characteristic radiographic feature that differ­
entiates fibrous dysplasia from other pathologies (Fig. 113).
Langerhans cell histiocytosis (H istiocytosis X )
Langerhans cell histiocytosis includes three entities Fig. 114. Lateral projection of
with unknown ethiology, which have common histological fea­ skull-multiple osteolytic chang­
tures where the affected tissues are infiltrated with Langer- es in the cranium
113
I
hans cells.
Langerhans cell histiocytosis (previously known as Histiocy­
tosis X) comprises rare diseases: Eosinophilic granuloma,
Hand-Schuller-Christian syndrome, Letterer-Siwe syndrome,
Hashimoto-Pritzke syndrome etc. where the accumulation of
pathological Langerhans cells lead to destruction of tissues.
Another classification of histiocytosis distinguishes a chronic
localized type from an acute disseminated type.
Fig. 115. Eosinophilic granulo­
ma - "geographic map" osteo­ Therefore the clinical manifestation of Langerhans cell his­
lytic changes in the cranium tiocytosis varies - from monoosal or polyosal disorders with
without osteosclerosis unifocal or multifocal bone alterations to dessiminative forms
affecting many organs and systems.
Hand-Schuller-Christian disease includes: bone changes, diabetes incipidus and ex-
ophtalm (Fig. 114).
Letterer-Siwe disease usually developes in children and consists of: bone changes,
anaemia, skin changes, haemorrhagic diathesis, lyphadenomegalia, hepatosplenomegalia.
Eosinophilic granuloma - the localized form of Langerhans cell histiocytosis may be ex­
pressed with single or multiple changes in the skeleton, without involving the internal organs.
The eosinophilic granuloma often is an incidental radiologic finding, especially in the calvaria.
Clinically, however, patients can present with soft-tissue swelling and localized bone pain.
It most often occurs in the first and second decades of life, but can be detected in infancy and
even up to the fifth decade of life.
It has the tendency to involve the calvaria, ribs, spine, pelvis, and femur, but other skeletal
sites can be involved. The disorder is usually monostotic, but multiple foci are observed in
about 20% of cases.
The radiographic findings depend largely on the stage of the eosinophilic granuloma at the
time of detection. The calvaria generally shows this lesion to be a round to ovoid lytic area
measuring up to 3 cm in diameter. Despite its sharp margin, a sclerotic rim is usually absent in
the early stages. Sometimes a geographic pattern of destruction can be observed (Fig. 115).

A bbreviations:
WBC - scintigraphywhite-blood cell scintigraphy
OM - osteomyelitis

B ibliography
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лицевочелюстната област, Медикарт, 2012, 2, 38-39.
2. Йовчев Д. фиброзна дисплазия, ’’Проблеми на стоматологията”, 2007, (XXXIII- II), 9-13
3. Aguri A, A.Dailey. Grant’s atlas of anatomy, 2009, Lippicott Williams and Wilkins
4. Balcheva M., M. Abadjiev, D. lovchev, A. Kisselova. Osseous and dental problems in patients
with renal failure A case report. Journal of IMAB - Annual Proceeding (Scientific Papers), 2010,
vol. 16, book 4, 2010; DOI: 10.5272/jimab.1642010_43-44 (abstract book vol. 16, book 2, 7)
5. Burgener F, M. Kormano, T.Pudas. Bone and joint disorders-differential diagnosis in conven­
tional radiology, 2006, Thieme
6. Direct diagnosis in radiology; musculoskeletal imaging, 2008, Thieme
7. Moeller M, R. Reif. Pocket Atlas of Radiographic Anatomy, 2000, Thieme
8. Munk P, A. Ryan. Teaching atlas of musculoskeletal imaging, 2008, Thieme
9. Muskuloskeletal imaging, 2001,Thieme
10. Practical differential diagnosis for CT and MRT, 2008, Thieme
11. Wegener O. Whole body computed tomography, 1994, Blackwell scientific publications
114
CENTRAL NERVOUS SYSTEM
With the appearance of CT, nuclear medicine techniques
and magnetic resonance imaging neuroradiological diagnosis
underwent rapid change. The sensitivity and specificity of imag­
ing modalities and their ability to localise disease have all im­
proved a lot. Modern neuroradiological diagnosis of disorders of
the brain is dominated by CT and MRI.
Modalities for examination of the cranium and the brain
Skull radiography
Radiographic examination of the skull has significantly
Fig. 1. Lateral projection of skull diminished after the introduction and spreading of CT and MRI.
- osteolytic metastases There are, however, many conditions that can be diagnosed by
skull radiography directly or indirectly. Calcifications are visible on
the plain X-ray of skull, for example in falx cerebri. Intracerebral calcifications can be normal as in
the pineal gland and in the choroid plexus. They can be pathologic as in infectious diseases, e.g.
toxoplasmosis, cytomegalic inclusion disease and cysticercosis. Tumour calcifications are most fre­
quently identified in oligodendrogliomas, meningiomas and craniopharyngeomas. Lateral displace­
ment of the calcified pineal gland has been used as a sign of intracranial mass effect. Destruction of
sella turcica can be a general sign of increased intracranial pressure. Enlargement of sella turcica
indicates a pituitary adenoma.
Osteolytic lesions of the skull can be seen in many diseases, both benign and malignant for
example eosinophilic granuloma, multiple myeloma, osteolytic metastases etc. (Fig. 1).
Osteoclerotic lesions can represent meningiomas, osteomas, fibrous dysplasia, Paget's dis­
ease or sclerotic metastases from prostatic carcinoma etc.
Skull fractures are usually of linear type. In depressed skull fractures tangential films are es­
sential for determination of the degree of depression.
Computed tomography
Nowadays, modern spiral CT acquires serial images of the whole head in less than one
minute. Three dimensional reconstuctions (3D) may be obtained routinely (Fig. 2).
CT angiography (intravenous injection of contrast) has almost replaced angiography.
In the MRI era, CT remains essential in the neuroradiological assessment of almost all disease en­
tities mainly because of its speed and accessibility. In trauma cases, in all patients with sudden, se­
vere neurological deficit a CT scan is the first modality. MRI follows only if a more detailed evaluation
of parenchymal abnormalities, a better topographical definition, or further attempts for pathological
tissue characterization are required.
Magnetic resonance imaging
The value of magnetic resonance imaging in diagnostic neuroradiology is significant. MRI is
superior to CT in the assessment of lesions in the white substance of the brain (Fig. 3).
In addition, it is the examination of choice in posterior fossa lesions, as well as in the examination of
those lesions situated near the midline or the base of the skull. The main disadvantage of the method
is the difficulty in visualizing fresh blood and calcifications. For diagnostic neuroradiology access to
both CT and MRI is essential.
Advantages of MRI include high tissue contrast without the use of additional contrast media and also
the absence of artefacts caused by bone and air. If the patient is unable to lie still, serious movement
artefacts result. Aneurysm clips made of magnetic material repre­
sent an absolute contraindication to examination by MRI.
The grey matter of the brain contains 10-15% more water than
the white matter while the white matter contains relatively
more lipids. This difference in content contributes to the high
contrast difference demonstrated by MRI between grey and
white matter. Because pathological processes in the central
nervous system in the main exhibit increased water content
(oedema) and because MRI is more sensitive than CT in the
demonstration of water content increase, MRI has high sen­
sitivity. Fig. 2. 3D CT of the orbital region
115
Angiography
The basic principle of angiography has not changed since
1927 when Egas Moniz, a Portuguese neurosurgeon, first pre­
sented it by performing direct puncture of the carotid artery in the
neck. Angiography is nowadays performed almost universally via
the femoral artery and the selective catheterization and injection
of the arteries of interest. The images are electronically acquired
with digital systems and subsequently photographed onto x-ray
film (digital subtraction angiography) (Fig. 4).
The technique of femoral puncture was first described by Selding-
er in the 1950s; an introducer is nowadays usually placed in the
right femoral artery and a catheter is directed under fluoroscopic
control in the supraaortic vessels.
Angiography remains necessary in many conditions but it is usu­
Fig. 3. MRI of the brain-axial
ally preceded by CT and/or MR.
slice
Angiography must always be performed in the case of subarachnoid
haemorrhage, or when an arterio-venous malformation must be defined in all its aspects (feeding arter­
ies, nidus, draining veins) before surgery or interventional procedures can be performed. Angiography is
frequently needed in the preoperative evaluation of tumours, particularly meningiomas, in case of arteriitis
or when the vessels in the neck must be seen before surgery or angioplasty for atherosclerotic disease.
Magnetic resonance angiography will probably reduce the need for catheter angiography.
Nuclear medicine methods
Nuclear medicine techniques using isotopes give primarily functional information and be­
cause spatial resolution is not nearly as good as with CT and MRI, morphological information is
limited. Isotope techniques are becoming increasingly important as a result of the development of
tracing molecules and other technical advances.
SPECT (single photon emission computed tomography) examinations are performed with a
gamma camera. The radiopharmaceuticals are lipophilic and because of this pass the intact blood-
brain barrier, and are extracted from the blood into the brain substance in proportion to blood flow in
the region. Blood flow is considered to be related to metabolic activity. Both hypo-and hyperperfusion
can be demonstrated. Clinically SPECT is used in the localization of epileptic foci, in the assessment
of ischaemic conditions and in the investigation of dementia.
PET (positron emission tomography) is a complex form and extension of the classical tracing molecule
technique. The technique depends on special synthesis techniques in which different substances are la­
belled with short lived positron-emitting radionuclides, which are produced in a cyclotron. After injection of
the preparation into the patient, its distribution in time and space is examined with the help of the positron
camera. The method gives regional quantitative functional and biochemical information. This information
can be difficult or impossible to obtain in any other way. Blood volume, blood flow, metabolism, receptor
and enzyme kinetics and pH can all be studied with PET. The technique improves the diagnosis and
monitoring of treatment in a number of large groups of illness, for example tumours, infarctions, epilepsy,
skull injuries, psychiatric, metabolic disorders etc.
Pathology
Trauma
The importance of plain X-rays of the skull is in the assess­
ment of fractures of calvaria. There are fractures with fracture line
and depression fractures (Fig. 5 a, b).
CT is the most important radiological examination technique in
the emergency management of head injuries. The equipment is
widely available and the examination is quick, has high sensitivity
for fresh bleeding and can reveal oedema. It can also indicate the
presence of increased intracranial pressure which manifests itself
in the form of compressed cisterns, sulci and ventricles. CT is well
suited to the diagnosis of certain fractures especially depressed
fractures and fractures of the skull base. It is also useful in the Fig. 4. Angiography of vertebral
examination of multiple injuries. arteries
116
During examination of the skull and brain,
an examination of the cervical spine can
be performed and this is important in un­
conscious patients.
At MRI there are difficulties in detecting
fresh bleeding and a traumatic subarach­
noid haemorrhage can go undetected. MRI
has certain advantages in the examination
of patients in the subacute stage and at
later follow-up because of its greater sen­
sitivity in the detection of old bleeding, oe­
dema and other fluid collections.
Hence MRI has a limited role in the emer­
gency examination of head injury patients
and CT is the method of choice.
Fig. 5 a. Vertical fracture Fig. 5 b. Depression fracture Contusion injuries
line of skull of left parietal bone Focal traumatic intracerebral lesions
are contusion with oedema, with or with­
out a bleeding component, and a pure haematoma. The injuries are often multiple and the sites of
predilection are the anterior parts of the frontal and temporal lobes. The oedema is sometimes dif­
fuse (Fig. 6).
Traumatic haematomas can generally be distinguished from spontaneous haematomas by the fact
that they are usually more irregular in outline and in addition that they involve the cortex.
At CT, oedema displays low attenuation and at MRI with ^-weighted image slow signal and with
T,-weighted images high signal.
Fresh bleeding displays high attenuation at CT, up to between 50-80 HU, and this decreases post-hae-
morrhagely by 2-3 HU per day.
At MRI fresh bleeding is difficult to detect. With T2-weighted images, contusion bleeding is demon­
strated as an area of low signal within the high signal area of oedema. When the bleeding reaches
the subacute stage with formation of methaemoglobin, the lesion can be demonstrated well at MRI
because of its high signal intensity.
A haematoma can occur some days after trauma and explain sudden worsening of the clinical pic­
ture. This is an indication to repeat CT exmamination.
Subdural haematoma
Acute subdural haematomas arise through venous bleed­
ing and there is often a co-existing contusion injury. The haemato­
ma is seen between the skull and the surface of the brain (Fig. 7).
As usual, the collection of blood is hyperdense at CT and the at­
tenuation of the lesion decreases with time. In the subacute stage
(after 1-3 weeks) the haematoma is more or less isodense and
can therefore give diagnostic difficulties. Visualization of the le­
sion can be facilitated by injection of contrast medium because
a thin membrane takes up contrast to a greater or lesser degree
which forms between the haematoma and the surface of the brain.
Assessment of the configuration of the ventricular system is es­
pecially important in bilateral isodense subdural haematomas be­
cause displacement of the midline structures may not occur.
After approximately 3 weeks the haematoma becomes hypodense
and the condition is then called chronic subdural haematoma. The
haematoma at this stage has varying density because of rebleeding
on one or several occasions, but the hypodensity always dominates.
MRI has higher sensitivity for small subdudral haematomas than Fig. 6. Multiple contusion haema­
does CT when the acute stage has passed. tomas with surrounding oedema.
Extradural haematoma Compression and displacement
Extradural haematomas usually arise through rupture of of the lateral ventricles
117
meningeal arteries, usually the middle meningeal artery, but can arise
C from venous bleeding. Usually a co-existing fracture of the skull is
^ j present. The haematoma has a convex shape (Fig. 8) and usually con-
I I fines the sutures because the dura in these areas is especially well
i attached to the skull. However, the haematoma can detach venous
> sinuses. The haematoma's density at CT and signal intensity at MRI
are similar to those seen with acute subdural haematoma.
r Cerebrovascular lesions
CT, MRI and angiogrpahy are the three main methods used
in the diagnosis of ischaemic and haemorrhagic lesions of vas­
cular origin. CT is the most important method because it is ca-
_ pable of distinguishing between infarction and fresh intracerebral
L h a e m o r r h a g e . Clinically these conditions are collectively referred
to as stroke. It is difficult to distinguish between infarction and fresh
bleeding using MRI. Angiography gives specific information about
Fig. 7. Subdural haematoma the anatomy of the vessels prior to surgical procedures for aneu­
rysm or stenosis.
Infarction
Infarction can be classified as large infarction, lacunar infarction and subcortical atheroscler-
tic encephalopathy (Binswanger's disease).
CT can demonstrate an infarct after approximately six hours but
some infarcts are not visible on CT for one or sometimes two days.
Occasionally, as a very early sign of infarction, the thromboem-
bolus itself can be seen in the vessel as a hyperdense structure.
Areas of infarction can be seen earlier with MRI than with CT.
The larger infarcts are confined to specific vessel areas
and of these infarction confined to the area supplied by middle
cerebral artery is the most common (Fig. 9). This type of infarction
involves both white and grey matter.
Lacunar infarctions are small (less than 15 mm) and usual­
ly situated in the area of the internal capsule. It can, however, take
more than a week before they are detected.
In Binswanger's syndrome a diffuse hypodensity is seen
in the white matter within the centrum semiovale, mainly periven-
tricularly. This hypodensity can be accompanied by lacunar infarc­
tions. The changes are usually bilateral but can be asymmetrical
Fig. 8. Extradural haematoma
and are best shown with MRI using T2-weighted images.
Intracerebral haematoma on the left side
Spontaneous intracerebral haematoma can occur in hy­
pertension or at rupture of arterial or arteriovenous aneurysms.
Haemorrhage can also occur in infarction and in tumours or me-
tastases.
A fresh haemorrhage is hyperdense and well-defined at CT (Fig. 10).
During the first days a hypodense zone of oedema appears around
the haematoma. Large haemorrhages can also affect the ventric­
ular system. Haematomas as small as a few mm in diameter can
be demonstrated.
The density of the haematoma decreases gradually from the
periphery to the centre. Depending on its size it takes from 2-4
weeks before the hyperdense component has disappeared. After
two months the haematoma is hypodense and resembles, as far
as density of an old infarct.
Haematoma following rupture of an arterio-venous malformation
is usually confined to the lobe in which the malformation is situ­ Fig. 9. MRT - large cerebral in­
ated. At MRI, vessel malformations display low intensity because farct
118
of the blood flow within. For more detailed information of arterial
supply and venous drainage of malformations angiography must
be performed. This information can also be obtained with MR an­
giography.
The commonest locations for aneurysms are the anterior
communicating artery and the middle cerebral artery. In 20% of
cases more than one aneurysm is evident. The accuracy of CT
in cases of subarachonoid haemorrhage depends on the size of
the haemorrhage and the time of onset. MRI is a poor method
for detecting blood in the subarachnoid space. Larger aneurysms
can be demonstrated with CT after injection of contrast (Fig. 11)
or with MRI which displays low signal, or varying signal intensity if
the aneurysm is partly thrombosed. Further information about the
relevant anatomy can be obtained at angiography (Fig. 12) and
in general all intracerebral vessel areas need to be examined in
Fig. 10. CT scan of a haemor­ order to detect the presence or another additional aneurysms.
rhage in the left putamen The investigation should be performed immediately after the
bleeding because vessel spasm can occur after 2-3 days and this
can last for approximately one week. If surgery is delayed the risk
of a further episode of bleeding is increased.
Tumours
The term "brain tumour" usually includes all neoplastic
growths originating from the skull, the meninges, cranial nerves,
pituitary, brain parenchyma, embryological remnants, metastases
and lymphomas. They could be divided into primary and second­
ary tumours.
Primary tumours
Symptoms caused by brain tumours are quite variable as
follows: increased intracranial pressure caused by the tumour itself
Fig. 11. CT angiogram - 3D an or hydrocephalus - headache, nausea and vomiting; acute pre­
eurism sentation (may be due to haemorrhage into the tumour) - sudden
severe headache, stroke, seizure; focal neurological disturbance;
cranial nerve palsy, hormonal effects etc.
Many classifications have been proposed mainly based on histological criteria, taking into consider­
ation the cell of origin and the degree of malignancy.
We present a main basic topographical subdivision within which the histological subtypes are divid­
ed into: supratentorial tumours and infratentorial tumours. And both are subdivided into extraaxial
and intraaxial tumours.
Different histological subtypes occur more frequently in the pe­
diatric age (infratentorial tumours, medulloblastomas, ependymo­
mas), while others are more frequent in adults and in the supra­
tentorial compartament (meningiomas, gliomas).
The main aim of the neuroradiological diagnosis is first
to identify and recognize the tumour, then to locate it precisely,
define its macroscopic structure (solid, cystic, necrotic, calcified
etc.) and recognize its relationships with the surrounding struc­
tures (mass effect, hydrocephalus). To achieve this task the three
main diagnostic modalities, CT, MRI and angiography may be nec­
essary.
MRI is the most informative modality due to its multiplanar capabil­
ities that provide topographic details; CT, however, better demon­
strates calcifications, providing relevant information on age and
main characteristics of the tumour. Fig. 12. Frontal angiogram-an­
Angiography is nowadays very rarely necessary for diagnostic eurism of right posterior cere­
purposes; it is performed only when knowledge of the type and bral artery
119
degree of vascularization is rel­
evant for planning surgery or
when a preoperative embolisa­
tion may be used, for example
meningiomas.
Supratentorial, extraaxial tu­
mours
They are mainly represented
by meningiomas, craniophar­
yngiomas, epidermoids, chor­
domas, and neurinomas.
Meningiomas
Meningiomas are the
most common, non glial, intra­
cranial tumours; their preva-
Fig. 13 a. CT-non contrast scan - Fig. 13 b. CT- enhancement af- lence among operated tumours
large occipital hyperdence mass ter contrast administration is about 13-19%. They may oc­
cur at any age but have a peak
incidence around 45 years of age. The most common locations are: falx and parasagittal (25%),
convexity (20%), sphenoid (20%) etc.
Meningiomas may present with seizures, progressive focal neurological signs in relation to the loca­
tion of the tumour and signs of raised intracranial pressure.
Imaging modalities
Plain films of the skull may be diagnostic when they show focal hyperostotic changes of the skull or
calcifications, associated or not with signs of raised intracranial pressure (erosion of the floor of the
sella turcica).
CT always demonstrates the presence of the meningioma if the examination is performed using in­
travenous contrast enhancement.
Meningiomas are usually isodense to the cerebral cortex. About 20% of meningiomas contain areas
of calcifications and may then range from slightly to markedly hyperdense.
Meningiomas enhance intensely and homogeneously following intravenous injection of iodinated
contrast (Fig. 13 a, b). Surrounding oedema may be absent or very marked, without definite relation­
ship to tumour size.
On MRI meningiomas tend to be isointense to cortex and hypointense to white matter in ^-weighted
images; in T?-weighted images meningiomas are again isointense
to slightly or markedly hyperintense.
Enhancement with Gadolinium is usually very marked and homo­
geneous (Fig.14).
MRI shows much better than CT the relationship of the tumour
with vascular structures, venous sinuses, their compression or
obstruction and all topographical relationships useful for surgical
planning. MRI is the modality of choice but CT is definitely diag­
nostic in the majority of cases.
Angiography is performed preoperatively not for diagnostic pur­
poses but to evaluate the type and degree of vascularization, and
with a view to possible preoperative embolisation.
Supratentorial intraaxial tumours
Gliomas
Primary cerebral gliomas represent about 50% of all intra­
cranial tumours. They include:
- astroglial tumours; the precursor cell type is the astrocyte; Fig. 14. Axial MRI - T^weighted
- oligodendroglial tumours, originating from the oligodendroglia; image, coronal slice with con­
- ependymomas, originating from the ependymal cells; trast - enhancement of the pa­
- glioblastoma multiforme, highly malignant glial tumour without a renchymatous part of the me­
clearly defined cell of origin. ningioma
12 0
From a clinical point of view the most common presentation is that
of progressive focal neurological deficits related to the localisation
of the tumour: motor, sensory, visual fields, language, memory,
behaviour etc. Signs of raised intracranial pressure or seizures are
not infrequently the presenting sign.
Astrocytoma
In adults they represent 25-35% of all supratentorial glio­
mas, they may arise anywhere in the cerebral hemispheres.
At CT they appear as homogenous areas of hypodensity with
relatively well defined margins, they rarely present with peri­
focal oedema. Contrast enhancement is rarely found (Fig. 15
a, b).
At MRI, the tumour tissue is usally slightly hypointense in T
and definitely hyperintense in T . (Fig. 16); the lesion usually ap­
pears homogeneous with well defined margins. Calcifications is
Fig. 15 a. CT without contrast present in about 20% of astrocytomas and is better recognized
with CT.
Differential diagnosis is relatively easy and includes other neo­
plastic lesions such as metastasis, other gliomas and lymphomas,
cerebral abscesses, cerebritis and ischemic lesions.
Angiography, when performed, usually only shows vessel dis­
placement due to mass effect and no tumour vascularization.
Extraaxial infratentorial tumuors
These are tumours located under the tentorium, outside
the brain stem and the cerebellum. Symptoms may be due to dys­
function of the nervous structures of the brain stem and cerebel­
lum and show signs of raised intracranial pressure due to hydro­
cephalus.
Imaging modalities
Plain radiographs are not now necessary although they
may show signs of raised intracranial pressure, rarely a direct sign
of calcifications within the tumour or focal bony changes in the
Fig. 15 b. CT with contrast injec­ posterior fossa may be found.
tion - the tumour is hypodense CT, without and with intravenous injection of contrast is
and shows no enhancement able to detect the majority of lesions except small intracanalicular
neurinomas.
MRI has the superiority of spatial resolutuion with multiplanar sections and better tissue dis­
crimination.
Angiography is rarely needed, mainly in vascular tumours
(haemangio-glioblastomas).
Meningiomas
The most frequent sites for infratentorial meningiomas are:
the petrous bone, clivus, foramen magnum, tentorium.
CT and MR appearance of posterior fossa meningiomas does not
differ from that of supratentorial lesions.
Neurinomas
They represent about 8% of intracranial tumours. The most
frequent infratentorial neurinoma is that of the 8th nerve; much more
rare are those of the 7th nerve.
The CT and MRI appearances are not different from those of the
supratentorial tumours.
They usually enhance markedly but may have intratumoural cystic
components. Fig. 16. MRT - T2 -weighted im­
Intraaxial infratentorial tumours age. The tumour is markedly
As for extraaxial tumours, intraaxial infratentorial tumours hyperintense
121
may present with focal signs due to impairment of nervous struc-
tures of the posterior fossa, brain stem and cerebellum, or with
signs of supratentorial hydrocephalus.
J J P ** As a 9eneral rule, POSterior fossa intraaxial tumours in chldren are
Г Ш *'Г У usually primary tumours (brain stem gliomas, cerebellar medullo-
b|astomas or astrocytomas) while in adults most commonly they
are secondary tumours (metastases mainly from lung tumours in
male, breast tumours in female).
Astrocytoma
Cerebellar astrocytoma accounts for 6-10% of all cerebral tu­
mours and is the most common infratentorial tumour in children.
It is a slow growing infiltrating tumour with significant cystic com­
ponents in about 60% of cases, mainly localized in the cerebellar
hemispheres in 75 % of cases. It is more common in the first de­
Fig. 17. MRI-cerebellar astro­ cade with a peak around the fourth year.
cytoma in left hemisphere; It usually appears as a well defined round lesion with regular mar­
^-weighted image with con­ gins.
trast On CT the solid components of the tumour are isodense and the
cystic parts are hypodense. Marked enhancement of the solid com­
ponent is usually observed, enhancement may occur at the level of the capsule of the cyst. Calcifica­
tion is found in about 10-20% of cases.
MRI clearly shows the nodular component, usually iso-hypointense in T1 and slightly hyperintense in
T . The cyst may be isointense in T1 due to the high protein content and hyperintense in T2. Marked
enhancement following Gadolinium injection is usually observed at the level of the parenchymal com­
ponent (Fig. 17). The tumour is inhmogenous, mainly cystic.
Medulloblastoma
Medulloblastoma is a highly malignant tumour, originating from primary, non differentiated neu-
roectodermic cells located at the level of the roof of the fourth ventricle. The most common location is
midline, within the cerebellar vermis, with anterior growth within the fourth ventricle.
On CT the tumour presents as a solid, homogenous mass, usually isodense or slightly hyperdense,
with marked enhancement following contrast injection. Calcification and cysts are rarely present.
On MRI the tumour is most commonly isointense both in T1and T0 and enhances markedly following
Gadolinium injection.
Pathology in the region of the sella
In general, sellar lesions present with endocrinological
or neurological symptoms. Approximately 60% of the patients
display the symptoms and signs of pituitary malfunction. Su­
prasellar involvement often gives rise to visual field defects
through pressure on the optic chiasm but can also cause
symptoms due to hypothalamus dysfunction. The commonest
lesions in the sellar region are pituitary adenoma, craniophar­
yngioma, suprasellar meningioma and empty sella. Less com­
mon lesions are: optic glioma, hypothalamus glioma, large an­
eurysms, metasases, cancer of the sphenoid sinus, arachnoid
cysts, chordoma, sarcoidosis and lymphoma.
Pituitary adenomas are found in the anterior lobe of the pituitary
gland and can be expanding or invasive. Small adenomas, less than
10 mm (often referred to as microadenomas) do not affect the sur­
rounding structures. Those adenomas which do not produce hor­
mones are often those which reach the largest size and their pres­
ence is usually first detected when their continued expansion gives Fig. 18. CT with contrast-large
rise to symptoms of compression on surrounding structures. 60 % pituitary tumour - round mass
of pituitary adenomas are prolactin-producing tumours, so called projected over the basal cis­
prolactinomas which cause amenorrhoea, galactorrhoea and impo­ terns enhanced intensively af­
tence. More uncommon are those which produce ACTH and cause ter contrast injection
122
Cushing's syndrome, and are in general small and those which
produce growth hormone, cause acromegaly and the majority are
small too.
Large adenomas are well shown both at CT and MRI and display
both an intra- and suprasellar component (Fig. 18). The mass ef­
fect on suprasellar structures, such as the optic chiasm is demon­
strated better with MRI than with CT.
Small adenomas are seen on CT as small focal hypodensities and
by MRI as low signal lesions, in both cases soon after intravenous
injection of contrast medium.
Craniopharyngiomas originate from the remnants of Rathke's
cleft. They are usually situated superior to the sella but 20% of
them have an intrasellar component. The cystic and solid propor­
tions of these tumours are variable and calcification within the tu­
mour is common (Fig.19). Calcium-containing tumours allow easy
Fig. 19. CT - craniopharyngioma diagnosis with CT while diagnosis with this method can be difficult
if the tumour is more or less cystic.
Suprasellar meningiomas are in general easy to diagnose at CT because of their marked contrast
uptake and commonly demonstrable hyperostosis. On MRI meningiomas generally have a signal
which is similar to that of grey matter which means that they are difficult to differentiate from their
surroundings. Introducing contrast medium Gadolinium signal intensity on ^-weighted images is
raised and facilitates diagnosis.
Secondary tumours - metastases
A variety of tumours can metastasize to the brain. The primary tumour can not be identified
based on the morphologic features of its intracranial metastases.
The most common tumors that metastasize to the brain are bronchial and breast carcinoma.
Intratumoral hemorrhage is relatively common in metastatic melanoma.
The clinical presentation is highly variable. It is common for patients with multiple brain metastases
to have minimal clinical symptoms. This is particularly characteristic of metastatic breast cancer (Fig.
20 ).
Large supratentorial metastases or smaller supratentorial metastases with mass effect and perifocal
edema may present with seizures (Fig. 21).
With infratentorial metastases, the clinical presentation is often dominated by symptoms due to hy­
drocephalus.
Imaging criterion for brain metastasis is variable:
- a relatively large solitary mass with circular or scalloped rim enhancement;
- further investigation of a relatively large, solitary cerebral mass reveals one or more additional
lesions;
- multiple small enhancing lesions with a large amount of sur­
rounding edema;
- multiple small, nodular-enhancing lesions with no significant
mass effect and no significant edema;
- single large infratentorial mass that compresses the fourth ven­
tricle and has led to hydrocephalus.
Demyelinating diseases
Demyelination is produced by many different agents from
infection to radiation therapy, toxic effect of drugs, autoimmune
processes, ischaemia, etc. The term demyelination is used to in­
dicate a condition in which normally formed myelin is later de­
stroyed.
With CT the brain parenchyma is directly imaged: white matter is
slightly hypodense with respect to the slightly hyperdense gray mat­
ter. Foci of demyelination may be recognized as hypodense areas
against the already hypodense background of the white matter. Fig. 20. Multiple supratentorial
MRI has proven to be far superior to CT in the diagnosis of white metastases
123
matter lesions, due to its sensitivity to white matter changes that ap­
pear as hyperintense areas against the relatively isointense back­
ground of the white matter on T2-weighted images.
Gadolinium injection shows the disruption of the blood-brain
barrier when present and has proven to be of great value in
better diagnosing MS and understanding its clinical evolution.
Multiple sclerosis
Multiple sclerosis (MS) is a chronic disease of young adults
characterized by the presence in the brain and spinal cord of focal
lesions of demyelination, known as plaques. In the brain MS has
a fairly characteristic distribution, with plaques tending to occur
along the walls of the cerebral ventricles, as well as the corpus cal­
losum and posterior fossa. Plaques may also be seen in the spinal
cord. Clinical presentation is extremely variable and may include
Fig. 21. CT - right frontal cere­
double or impaired vision due to optic neuritis, weakness, numb­
bral metastasis - a typical dig­
ness and tingling in the limbs, and gait disturbance. As well, the
itate pattern of white matter
time course and nature of disease progression are quite variable.
oedema
CT is usually positive in about 50% of MS patients non dependent on
the type or phase of the disease. Plaques are visible as foci of hypodensity, mainly in the supratentorial
periventricular white matter. Small plaques, particularly in the corpus callosum, in the subcortical areas, in
the brain stem and posterior fossa are in general not easily recognized.
There is no way to distinguish recent from old plaques when they
coexist in the same patient.
MRI is definitely superior to CT: much smaller plaques can be
detected and critical areas such as the corpus callosum and the
brain stem are easily investigated employing sagittal or coronal
sections (Fig. 22).
The positivity of MRI is around 90% in patients nondependent on
the type or phase of the disease; the positivity rises up to 100% in
cases of definite MS.
The most common locations are in the deep white matter of the
cerebral hemispheres. The cerebral or cerebellar peduncles,
brain stem, medial longitudinal fasciculus and corpus callosum
are also frequently involved. Gadolinium injection provides the
only way to differentiate recent from old plaques; recent plaques Fig. 22. MRI - multiple high sig­
show a focal hyperintensity on Tr
nal white matter lesions
Abbreviations:
MS - multiple sclerosis
HU - Hounsfield units
ACTH - adenocorticotropc hormone
3D - three dimensional reconstruction

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