Approach to Diagnosis: Diagnostic Imaging Other Invasive

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					Approach to
Diagnosis:
Diagnostic Imaging
Other Invasive Procedures
       Imaging Modalities
   Digital Radiography     (Computed radiography)
    Picture Archiving and Communication Systems (PACS)-
    Filmless ; best suited for Computed Tomography/ MRI/
    PET scanning




                                                       2
Imaging Modalities
   Ultra Sound
   Safe/Low cost technologoy
   Uses cross sectional imaging
   Non invasive.
   Detects tissue/water interfaces and causes
    echoes.
   Displayed as static gray scale images or moving
    in real time images.
   Doppler imaging with color (intensity) coding
    helps to measure direction, velocity, and
    magnitude of flow.
   Recommended for children and women during
    pregnancy
   Limitations- ‘acoustic barriers’-
    air/bone/barium/obese/chest and operator
    expertise


                                                      3
Imaging Modalities
   Computed Tomography- measures relative
    linear attenuation coefficients for radiation
    absorption. Uses linear beam slice imaging
    and produces cross sectional images
   Used with iv or oral contrast get high
    contrast imagery
   MDCT – multi detector CT for 3-D imaging
    (allows faster san time and reduces
    radiation) most useful in angiographic
    vascular studies
   Concerns about radiation makes it not the
    first choice. US/MRI are preferred choices



                                                    4
Imaging Modalities
   MRI   super conducting magnets measure H+
    energy transfers and calculates the image display
   T1 weighted- ‘bright’ signal by high intensity
    tissues- fat, sub acute hemorrhage, mucus. ‘dark’
    signal by low intensity- CSF, fluid cysts. Soft
    tissues are in between.
   T2 weighted- Water is ‘high’ (bright) signal
    intensity, whereas muscles/soft tissues/fat tned
    to have lower intensity and appear dark. Bone
    and air will appear very dark.
   Safe –no radiation/ images multiple planes
   Has increased sensitivity but less specificity



                                                     5
MRI…
   In the cranium cannot distinguish between
    infarction/edema/tumor/infection/demyelin
    ation
   High cost
   Contraindicated in patients with metallic
    parts- pacemakers/internal clips/
    claustrophobic
   MR Angiography- with contrast




                                            6
MRI the choice technology for
   Nervous system- brain and
    spinal cord
   Musculoskeletal system
   Pelvis and retroperitoneal/
    mediastinal/ large vessel
    imaging
   Liver, spleen, pancreas and
    kidney
   Difficult fetal problems

                                  7
Contrast Media in imaging
   Oral and IV
   Increase contrast between
    tissues
   Useful in hollow viscera imaging
   Vascular studies
   Kidney/ Gall Bladder functions
   Barium Sulfate-GI tract imaging.
    ‘Double’ contrast with
    barium/air interface

                                   8
Magnetic Resonance Spectroscopic
Imaging (MRSI)

   Measures choline/citrate ratio
    in cancer prostate.
   Post treatment assessment of
    brain tumors
   Useful in Breast cancer
    assessment




                                     9
Water soluble iodinated contrast

   Vascular imaging
   Renal
   Low osmolar contrast reduce
    the risk severe reactions.
   For MRI gadolinium chelates are
    used and are safer




                                   10
Contrast Induced Nephropathy

   CRF cases-
   DM/ CHF/ Sepsis/
    Dehydration/70+yrs/
    Chemo/Tx Pts/
   Nephrotoxic drugs/
   HIV-AIDS




                               11
Single Photon Emission Tomography
(SPECT)
   Uses radioactive carbon or
    oxygen
   Used in search of metastases
    not seen on CT or MRI
   Uses fluordexoyglucose (F-FDG)
   Used in detection of epilepsy
    foci, in Alzheimer’s
   High cost
   PET/CT

                                    12
Cost Comparison using CXR as
base (x)




                               13
  Imaging
Radiation!




        14
The Approach
   Neck and Face
   Chest
   Breast
   Cardiovascular
   Gastrointestinal
   Urinary
   Musculoskeletal
   Reproductive
   Obstetrics


                       15
US normal Crvical LN/ Metasttic LN




                                     16
   Post-contrast coronal T1-
    weighted MR image
    through the posterior neck
    demonstrating metastatic
    right-sided cervical
    adenopathy (white
    arrows), following
    the lymphatic drainage
    from a primary
    nasopharyngeal
    carcinoma.




                           17
   Post-contrast axial
    T1-weighted MR
    image that
    demonstrates an ill
    defined enhancing
    mass replacing the
    superficial and
    deep lobes of the
    left parotid gland
    (white arrow).
    Biopsy confirmed
    this to represent a
    mucoepidermoid
    carcinoma.




                      18
US: Fibroadenoma/ Ca Breast




                              19
NECK and FACE issues
    Thyroid Mass- Goiter/
     Hashimotos/ Cyst/ Cancer-
1.   ?I131 scan-’hot’ or ‘cold’
     nodule
2.   US – ?cyst/solid/
     ?single/multiple and FNAC
3.   MRI- extent of cancer
     Hypothyroidism (Myxedema): The diagnosis of
     hypothyroidism is made clinically by routine
     thyroid hormone determinations, and there usually
     is no need for routine imaging studies.
                                                         20
Other neck masses

    Congenital cysts
    Metastatic lymph nodes
    Infected lymph nodes/abscess
1.   Thin slice (<3mm) contrast CT
     is best
2.   MRI- best for cancer of aero-
     digestive tract


                                 21
Hypercalcemia issues
   Asymptomatic
   Constipation, anorexia, n/v, belly pain, absent
    bowel sounds
   Renal stones/thirst/renal failure
   Muscle weakness
   Confusion/psychosis/coma
   Hyperparathyorism
   CRF/vit D excess/ Sarcoidosis/
    Immobilization/ Drugs- thiazides, lithium,
    TUMS




                                                  22
    Imaging for hypercalcemia

   Clinical asssessment
   Radiology of hands (hyperparathyroid)/
    pelvis/spine (metastatic cancer/myeloma)




                                           23
    Cancer of the Larynx
   Presenting Signs and
                             1. Computed tomography
    Symptoms
                             ■ Thin-section CT is the best
   Neck mass (cervical
                                modality for
    adenopathy) in a
                                demonstrating the extent
    smoker older than age
                                of tumor and the
    40 (men more often
                                presence of cervical
    than women)
                                adenopathy
   Hoarseness
                             ■ 2. Magnetic resonance
   Stridor                     imaging- Preferred
   Common Sites - vocal        modality for evaluating
    cord Supraglottic soft      the mucosa andcartilage
    tissues                     involvement.
                             ■ Superior to CT


                                                       24
       Salivary Gland (Parotid) Neoplasm
   Palpable mass (slightly
    tender or non tender)             Computed tomography
   Facial palsy                       or
   benign tumor, slow-               magnetic resonance
    growing, painless, non             imaging
    tender, and mobile                CT is superior to MRI
   malignant tumor, tends to          for detecting an
    enlarge rapidly over several       underlying calcified
    weeks and be slightly              stone (calculus)
    painful and minimally             MRI is superior to CT
    tender,                            for sharply outlining the
    hard and fixed on palpation,       margins of the mass
    and often associated with         FNAC Bx
    facial nerve paralysis

                                                             25
       Occult Primary With Positive
       Lymphadenopathy
   Neck mass in a       1. Magnetic resonance
                            imaging
    smoker older than    ■ Preferred imaging
    age 40 (men more       modality for evaluating
    often than women)      the pharyngeal mucosa
                           and other sites where the
   Common Causes          occult malignancy may
                           reside
    Squamous             2. Computed tomography
    carcinoma of the     ■ High-speed studies may
    pharynx, tonsil,       detect the site of an occult
                           carcinoma in about 25% of
    pyriform sinus,        cases (thus permitting
                           directed biopsy by
    nasopharynx, or        endoscopy)
    base of the tongue

                                                      26
        Internal Disk Derangement of
        TM Joint
   Clicking or popping
    sound when opening the       1 Magnetic resonance
    mouth                           imaging
    (anterior subluxation with   ■ Preferred modality for
    reduction of the disk)          evaluating displacement
   Painful limitation of jaw       of the disk and whether
    movement (anterior              there is reduction during
    subluxation without             function
    reduction of the disk)
   Chronic spasm of the           Arthrography and CT
    lateral pterygoid muscle       are not as effective
   Trauma
   Arthritic changes in the
    TM joint



                                                           27
     Cranial Neuropathy
                                 1. Magnetic resonance imaging
1.   Brain Neoplasm (primary or ■ Study of choice for assessing cranial
     spread of existing tumor)      neuropathy of undetermined cause
2.   Infection (viral or         2. Computed tomography
     bacterial)                  ■ Less sensitive than MRI
3.   Radiation therapy           Facials Palsy
4.   TRIGEMINAL NEUROPATHY  Does not require imaging
     (NOT TIC DOULOUREUX) Most      confirmation unless facial function
     commonly due to a              is slow to return or there is some
     cerebellopontine angle         other complicating factor
     mass, schwannoma of the        (pain, dysfunction of other cranial
     trigeminal nerve, or           nerves, parotid mass)
     perineural spread of tumor    Rare-Must exclude parotid
     from the oral cavity or the    malignancy and temporal bone
     head and neck                  tumors (hemangioma,
5.   FACIAL PALSY- Most             cholesteatoma, neurinoma)
     common cause is Bell’s        skull base infections (diabetics),
     palsy (viral neuritis)
                                   Brainstem lesions in children, and
                                   Lyme disease in patients living in
                                    endemic regions.
                                   Trauma is a leading cause of facial
                                    palsy and requires CT

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                             Plain radiograph (sinus)
                             ■ Limited role in assessing
       Sinusitis             sinus disease


   Pain, tenderness,     1. Computed tomography
    and swelling over    ■ Procedure of choice for
    the involved sinus     exquisitely defining the
   Eye pain, fever,       sinonasal anatomy and
    chills (suggesting     infections of the paranasal
    extension of           sinuses and the soft
    infection beyond       tissues of the head and
    the sinuses)           neck
   Recent acute viral
    upper



                                                           29
      Respiratory system
   CXR-     If it will alter management, then it is justified
   The X-ray beam passes from posterior to anterior (PA).
   The X-ray beam passes from anterior to posterior (AP)
   Lateral

   US- Good for effusions
   CT- Two types
   Standard- stage lung tumors, investigate lung masses
    and to assess the mediastinum and pleura




                                                                 30
        Hemoptysis
    Coughing up blood             CXR- Initial imaging procedure
     (resulting from bleeding
     from the respiratory tract)   CT- Suspected malignancy
1.   Infection (pneumonia,         Fiberoptic bronchoscopy
     tuberculosis, fungal
     infection, lung abscess)
2.   Bronchogenic carcinoma
3.   Bronchiectasis
4.   Bronchitis
5.   Pulmonary infarction
     (secondary to embolism)
6.   Congestive heart failure
7.   Pulmonary hemorrhage
     syndromes




                                                                31
         Pleuritic Pain
   Pain that is aggravated by breathing      CXR
    or coughing (maybe of sudden
    onset, chronic, or recurring)             CT
   Rapid and shallow respiration
   Limited motion of the affected side
   Decreased breath sounds on the
    affected side
   Pleural friction rub
   Pneumonia/ Tuberculosis/
    Pulmonary embolism/
    Trauma/ Neoplasm/ Occult
    rib fracture/ Congestive
    heart failure/ Mixed
    connective tissue disease/
    Pancreatitis



                                                     32
    Wheezing
   obstruction to the flow of      CXR
    air at some level- (Most        CT- noninvasively
    commonly heard on
                                     evaluate the trachea
    expiration)
                                     and central airways
   Asthma                           for masses,
   Congestive heart failure         narrowing, or
   Pneumonia                        compression that is
   Bronchogenic tumor               not evident on plain
                                     chest radiographs.
   Pulmonary embolus
   Tracheobronchomalacia
   Foreign body


                                                            33
     Asbestosis
   Insidious onset of              CXR-   Preferred initial
    exertional dyspnea and           imaging (irregular or
    reduced exercise tolerance       linear small opacities
   Symptoms of airways              (usually most
    disease (cough, sputum,          prominent in the
    wheezing) occurring              lower zones) and
    primarily in heavy               characteristic diffuse
    smokers                          or localized pleural
   Occupational exposure            thickening
                                    HRCT- High resolution
                                     CT (eliminates CXR-
                                     false +)



                                                           34
        Asthma
   Episodic respiratory distress,      CXR
    often with tachypnea,
    tachycardia, and audible            Spirometry
    wheezes
                                        Skin Tests
   Anxiety and struggling for
    air
   Use of accessory muscles of
    respiration
   Hyperexpansion of the lung
    (due to air trapping)
   Prolonged expiratory phase




                                                      35
        Bronchitis (Chronic)
   Chronic productive cough        CXR
    (excessive tracheo-             Spirometry
    bronchial mucus secretion
    sufficient to cause cough
    with expectoration of
    sputum that occurs on
    most days for at least 3
    consecutive months in at
    least 2 consecutive years)
   Cigarette smoking
   Occupational exposure
   Air pollution and other
    types of bronchial
    irritation
   Chronic pneumonia
   Superimposed emphysema


                                                  36
      Pleural Effusion
   Pleuritic pain                              CXR
    Dyspnea
                                                 CT

                                             
   Often asymptomatic and discovered as
    incidental finding on chest radiograph      US
   Decreased or absent breath sounds,
    percussion dullness,
    and decreased motion of hemithorax
   Congestive heart failure (usually
    bilateral but larger on the right)
   Neoplasm (primary or metastatic
    lung cancer, lymphoma)
   Pneumonia/abscess
   Ascites
   Pancreatitis (usually left-sided)
   Tuberculosis
   Pulmonary embolism (small)
   Mixed connective tissue disease
    (lupus, rheumatoid arthritis)
   Trauma (hemothorax)




                                                       37
          Pneumonia
     Cough with sputum production                 CXR
     Fever and chills
     Chest pain and dyspnea
1.    Viral respiratory infection
2.    Cigarette smoking
3.    Chronic obstructive pulmonary disease
4.    Alcoholism
5.    Loss of consciousness
6.    Dysphagia with aspiration
7.    Hospitalization or institutionalization
8.    Surgery/trauma
9.    Heart failure
10.   Immunosuppressive disorders and
      therapy
11.   Central obstructing neoplasm (e.g.,
      bronchogenic carcinoma)




                                                          38
           Pneumothorax
    Sudden, sharp chest pain, severe dyspnea,
     shock, and life-threatening respiratory failure          CXR
    Pain may be referred to corresponding
     shoulder, across the chest, or over the
     abdomen (simulating acute coronary
     occlusion or acute abdomen)
    Markedly depressed or absent breath sounds
    Shift of mediastinum to opposite side and
     ipsilateral diaphragmatic depression (with
     large or tension pneumothorax)
1.   Spontaneous (rupture of small, usually apical bleb)
2.   Trauma (penetrating or blunt, rib fracture,
     tracheobronchial injury)
3.   Complication of mechanical ventilation
     (barotrauma)
4.   Chronic obstructive pulmonary disease
5.   Chronic pulmonary disease (e.g., sarcoidosis,
     Pneumocystis jiroveci pneumonia (formerly
     Pneumocystis carinii)



                                                                     39
      Pulmonary Embolism
                           CXR
   Nonspecific
                           CT- Has replaced V/Q lung scanning
    tachypnea,              in most institutions as the preferred
                            imaging and excluding PE (a filling
    dyspnea, and            defect within the pulmonary artery or

    hemoptysis              as an abrupt cutoff (complete
                            obstruction) of a pulmonary artery
                            branch)
   pleuritic chest        Radionuclide ventilation–
    pain in pulmonary       perfusion (V/Q) lung scan
    embolism with          Pulmonary arteriography-
    infarction              rarely used




                                                               40
    Tuberculosis
   Varies from
    asymptomatic            CXR
    exposure to fever,      Sputum tests
    productive cough,       Skin tests
    and night sweats




                                            41
        Lung Cancer
   Cough (with or without          CXR- inital
    hemoptysis)                    CT-
   Dyspnea, wheezing,             PET/CT- Definitive
    pneumonia                        noninvasive study
   Chest pain                    ■ Detects hilar and
   Weight loss                      mediastinal
   History of smoking               lymphadenopathy
   Pleural effusion                 and bronchial
   Recurrent Horner’s               narrowing
    syndrome                      ■ May show metastases
   Superior vena cava               in the liver and
    syndrome                         adrenal
   Symptoms relating to distal      glands
    metastases (e.g., occult
    fracture, seizure)


                                                          42
Palpable Breast Mass

   1. Mammography
   ■ Procedure of choice for
    determining whether a
    palpable mass is unequivocally
    benign (fibroadenoma)
In young women (under age 30) the initial
assessment of a palpable breast mass should
be done with ultrasound; if a cyst is detected,
no imaging with radiation exposure is needed

    All suspicious masses must be biopsied


                                                  43
    Palpable Breast Mass
2. Ultrasound
■ Indicated as a confirming procedure if
  physical examination or mammography
  suggests that the palpable mass may
  repre sent a simple cyst or intramammary
  lymph node.
 cannot provide a definitive diagnosis

  of other solid or complex masses.
               Routine Mammography
               American Cancer Society Guidelines
               For women age 40 and older, yearly
               mammograms are recommended
                                                    44
Nipple Discharge
   BENIGN (90%)             1. Galactography
   Normal (physiological)      (ductography)
   Papilloma                2. Ultrasound
    (intraductal)            ■ Directed sonography
   Mammary duct ectasia        may be helpful in
   Fibrocystic changes         imaging the lesion if
                                palpation of a single
   MALIGNANT (10%)             point in the breast
                                expresses a nipple
                                discharge




                                                        45
Screening Outcomes
   70–100 (7–10%) will be recalled for more
    studies (magnification or other special
    views; US)
   15–20 (1.5–2%) will require biopsy, with
    carcinoma detected
   in only 20–45% of recommended biopsies
    5–7 (0.5–0.7%) will have cancer detected
    (1–3/1,000 womenscreened)
   Recall rate, biopsy rate, and cancer
    detection rate will beapproximately 50%
    of subsequent screening examinations


                                           46
 High-Risk Screening
1.   Annual mammography before age 40,
     and/or additional annual screening with
     MRI (or US if MRI is not available).
2.   Family history of breast cancer in
     premenopausal women (especially first-
     degree relatives and bilateral cancers)
3.   Genetic risk for breast cancer
4.   BRCA-positive women
5.   Biopsy diagnosis of atypical or lobular
     carcinoma in situ
6.   Personal history of breast cancer
7.   Mantle radiation for Hodgkin’s disease



                                               47
48
49
 The lungs are a
  common site of
  haematogenous
  metastatic disease.
 Common primary
  sites include:
• Breast
• Kidney
• Head and neck
• Colorectal.


                    50
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       Angina Pectoris
                              1. Radionuclide myocardial
    Atherosclerotic             perfusion scan
     coronary artery          ■ SPECT scanning has a specificity
     disease                     and sensitivity
1.   Elevated serum              approaching 95% for detecting
     cholesterol                 areas of myocardial ischemia as
                                 perfusion defects on stress
2.   High cholesterol            testing that fill in during an
     intake                   ■ 2. Coronary arteriography
3.   Tobacco smoking          ■ Indicated when angioplasty or
     (primarily cigarettes)      bypass surgery isbeing
                                 considered
4.   Diabetes mellitus        ■ Evaluates the extent and severity
5.   Hypertension                of disease (percentage of
6.   Strong family history       stenosis involving one, two, or
                                 three vessels)
                              ■ Left ventricular angiogram can be
                                 obtained to evaluate wall
                                 motion


                                                              58
                         ■ 1. Ultrasound with color Doppler
       Claudication      ■ Preferred noninvasive imaging
                            technique to demonstrate the
   Deficient blood         presence of atherosclerotic
    supply to muscles       plaques and assess the degree
                            of luminal stenosis
    during exercise      ■ 3. Arteriography
    (initially           ■ Indicated if surgery or
    intermittent, may       angioplasty is contemplated
    proceed to              to more precisely define the
                            location and extent of a lesion
    continuous pain at      and assess the status of the
    rest)                   peripheral runoff vessels
   Atherosclerotic      ■ 4. MR or CT angiography
    vascular disease     5. Interventional radiology
                            (percutaneous transluminal
                            angioplasty)


                                                         59
    Congestive Heart Failure
Approach to Diagnostic Imaging
■ 1. Plain chest radiograph
■ 2. Echocardiography, magnetic resonance
  imaging, or cardiac computed tomography
■ Can evaluate the dimensions of the left
  ventricle and other cardiac chambers, ejection
  fraction, and wall-motion dysfunction
■ Echocardiography and MRI can be used to
  assess the presence and severity of
  incompetence or stenosis of heart valves


                                               60
          Cor Pulmonale
    Exertional dyspnea              ■ 1. Plain chest radiograph
    Angina pectoris                 ■ Usually shows a normal-sized
    Syncope                             heart or only mild
1.   Chronic obstructive pulmonary       cardiomegaly, but there may
     disease                             be enlargement of
2.   Pulmonary fibrosis                  the right ventricle and right
3.   Acute or chronic pulmonary          atrium
     embolism                        ■ 2. Echocardiography
4.   Primary pulmonary               ■ Indicated to evaluate the degree
     hypertension                        of function of the
5.   Pulmonary venoocclusive             left ventricle (as well as the
     disease                             degree of enlargement
6.   Extrapulmonary diseases             of the right atrium and right
     affecting pulmonary mechanics       ventricle)
     (morbid obesity, chest wall     ■ 3. Computed tomography
     deformities, neuromuscular      ■ Can be useful for diagnosing the
     disease)                            etiology of cor pulmonale




                                                                          61
       Myocardial Infarction
   Deep substernal chest pain          ■ 1. Plain chest radiograph-
    (described as an aching or
    pressure)                           ■ Useful as a baseline for
    that often radiates to the back,
                                           assessing pulmonary
    jaw, or left arm                       venous congestion
   Pain similar to that of angina      2  Usually evident from the
    pectoris but usually more severe,      patient’s history and
    long lasting, and relieved only a      confirmed by
    little or briefly by rest or           electrocardiogram and
    nitroglycerin                          enzyme studies.
   Symptoms of left ventricular
    failure, pulmonary edema, shock,    3  Advanced- Direct Infarct
    or significant arrhythmia may          Imaging
    dominate the clinical appearance    4  1. Radionuclide imaging-
   About 20% of acute myocardial          determine areas of
    infarctions are silent (or not         infarction, ?old or new,
    recognized as an illness by the        assess global function
    patient)
   Elevation of myocardial enzymes     5  2. MRI- areas of viable/non
    in the serum                           viable tissue
                                        6  3. Coronary CT=high
                                           negative predictive value




                                                                         62
        Valvular Heart Disease
   Murmur, clicks and     1. Plain chest radiograph
    clinical symptoms      ■ 2.EchocardiographyMore
    vary, depending on the    precisely demonstrates
                              size of the orifices of
    precise valve involved    affected valves
    and whether there is   ■ Doppler flow studies can
    predominant stenosis      assess the degree of
    or regurgitation          valvular movements




                                                        63
       Any patient with a pulsatile abdominal
       mass and hypotension should proceed directly to
       surgery without any intervening imaging study.

     Aneurysm Abdominal Aorta
    Most are asymptomatic and         ■ 1. Ultrasound
     discovered incidentally on
     routine physical examination or   ■ Most cost-effective    (dilatation
     plain abdominal radiograph           of the aorta to greater than 3
    Pulsatile mass                       cm and the presence of
                                          intraluminal clot)
    Severe abdominal pain and
     hypotension (if rupture)          ■ 2. CT angiography
1.   Atherosclerosis                   ■ 3. Magnetic resonance
2.   Trauma                               imaging
3.   Arteritis syndromes                 Alternative to CTA
4.   Connective tissue                 ■ Especially useful in patients with
                                          depressed renal function
     disorders (Marfan’s                  (because MR contrast is not
     syndrome, cystic medial              nephrotoxic)
     necrosis)
5.   Syphilis


                                                                         64
       Aneurysm (Peripheral)
   Limb ischemia      ■ 1. Ultrasound with
                          color Doppler
    (due to thrombus   ■ Preferred initial
    within the            imaging procedure
    aneurysm)          2. CT or MR
                          angiography
   Signs of distal    ■ Modalities of choice
    embolization          for evaluating the
                          location and size of
   Gangrene              aneurysms




                                                 65
         Deep Venous Thrombosis
1.   Asymptomatic (one-third of      ■ 1. Color Doppler
     patients with symptomatic          ultrasound
     pulmonary emboli but no
     clinical signs of DVT will      ■ Preferred initial imaging
     nevertheless have a lower          modality (>95%
     extremity venous thrombus)
                                        accuracy)
2.   Variable combination of pain,
     edema, warmth,                  ■ 2. Venography
     skindiscoloration, and          ■ Traditional “gold
     prominent superficial veins
     over the involved area             standard”
3.   Delayed complications of        ■ 3. Indirect CT venography
     dermatitis, ulceration, and
     varicosities
                                     D-Dimers?




                                                                   66
     Thoracic Outlet Syndrome
1. Numbness, paresthesias, pain,
   and sensory and motor deficits     ■ 1. Plain chest radiograph
   in the hand, neck, shoulder, or    ■ Imaging study of choice to
   arm (secondary to arterial,         demonstrate a cervical rib or
   venous, or nerve compression)       a tumor in the apex of the
2. Obliteration of the radial pulse    lung
   (if the artery is involved)
3. Intermittent cyanosis, edema,      ■ 2. Arteriography or
   and thrombotic symptoms             venography
   (if the vein is involved)          ■ Studies performed in both
  Congenital anatomic anomaly         the neutral position(arms at
   (cervical rib, abnormal             the sides) and in the
  insertion of the anterior           position thatreproduces the
   scalene muscle on the first rib)    patient’s symptoms may
  Aberrant healing of rib or          demonstrate kinking or
   clavicle fracture                   partial obstruction of the
  Neoplasm                            subclavian artery or vein
                                      ■ 3. MR or CT angiography


                                                                  67
       Ascites
    Small amounts may be
     asymptomatic                   ■ 1. Ultrasound
    Abdominal distension and
     discomfort                     ■ Mobile, echo-free fluid
    Anorexia, nausea, and early     regions shaped by
     satiety                         adjacent Structures
    Respiratory distress (due to   ■ 2. Computed tomography
     reduced lung volume)
    Bulging flanks, fluid wave,    ■ More expensive, but may
     shifting dullness               demonstrate the
1.   Cirrhosis                       underlying abdominal
2.   Neoplasm (hepatic cancer        disease process (if US
     or peritoneal                   fails to do so)
     carcinomatosis)
3.   Congestive heart failure        3. Plain AXR not useful
4.   Tuberculosis (and other         4. Laparoscopy
     infections)
5.   Hypoalbuminemia
     (nephrotic syndrome,
     protein-losing enteropathy,
     malnutrition)



                                                           68
     Constipation
    Decrease in frequency of         ■ 1. Plain abdominal
     stools or difficulty in
     defecation-
                                       radiograph
    Acute Bowel obstruction or       ■ Detects mechanical
     adynamic ileus                    bowel obstruction
     Chronic
                                      ■ 2. Computed

1.   Neurologic dysfunction-
     (diabetes, spinal cord            tomography
     disorder, parkinsonism,
     idiopathic megacolon)            ■ Better characterizes the
2.   Scleroderma                       site and cause of
3.   Drugs (anticholinergic agents,    narrowing or obstruction
     opiates, aluminum-based
     antacids)                         of the bowel
4.   Hypothyroidism                   ■ 3. Radiopaque marker
5.   Cushing’s syndrome                study
6.   Hypercalcemia
7.   Debilitating infection           ■ 4. CT colonography
8.   Anorectal pain (fissures,         (virtual CT colonoscopy)
     hemorrhoids, abscess,
     proctitis)                       Colonosocpy/ Stool
                                       analysis


                                                               69
      Dysphagia
      (Difficulty Swallowing)
    Difficulty initiating swallowing      ■ 1. Barium swallow
    Food sticking in the upper or         Endosocpy preferred choice
     middle esophageal region
    Odynophagia (pain on
     swallowing)
    Regurgitation
    Aspiration
1.   Carcinoma
2.   Peptic or lye stricture
3.   Achalasia
4.   Scleroderma
5.   Diffuse esophageal spasm
6.   Cervical esophageal web
7.   Neuromuscular disorder
8.   Dysmotility (abnormal
     propulsion)




                                                                    70
Gastrointestinal Bleeding
(Chronic, Obscure Origin)
   Presenting Signs and    ■ 1. CT enterography or
    Symptoms                   dedicated small bowel
   Anemia (iron               follow-through study
    deficiency)             2. Capsule video-
   Fecal occult               endoscopy
    blood/guaiac positive
    stools
   Common Causes
   Neoplasm (benign or
    malignant anywhere      initially undergo upper
    in the alimentary       gastrointestinal
   tube)                   endoscopy or optical
   Peptic ulcer            colonoscopy rather
                            than an imaging
                            procedure.

                                                      71
    Gastrointestinal Bleeding
    (Acute Lower)

   Diverticulosis      ■ 1. Radionuclide scan
   Angiodysplasia       and Colonoscopy
   Ischemic colitis    ■ Indicated to search
   Hemorrhoids           for underlying
    (diagnosed by         colonic pathology
    proctoscopy)          that may represent
   Polyps/carcinoma      the bleeding site
    (more frequently
    associated with
   chronic bleeding)


                                             72
Gastrointestinal Bleeding
(Acute Upper)
   Hematemesis,
                             ■ 1. Endoscopy
    melena, hematochezia
                             ■ Procedure of choice
   Peptic ulceration
    (duodenum, stomach,      2. Angiography to locate
    esophagus)                  bleeder
   Gastric mucosal lesion
    (superficial erosions,
    stress ulcers)
   Esophageal varices
   Neoplasm
   Mallory–Weiss tear



                                                    73
     Jaundice: Differentiation of
     Medical (Hepatocellular) from
     Surgical (Biliary Obstruction)
     Causes

                                      ■ 1. Ultrasound
   Yellowing of skin and
                                      ■ Preferred initial imaging
    sclera                              technique for
   Abnormal liver                      demonstrating
    enzymes                             dilated bile ducts
                                        (indicating biliary
   Dark urine and pale                 obstruction)
    stools                            2. Computed tomography
   Common duct stone                 ■ Highly accurate
   Pancreatic carcinoma              3. Magnetic resonance
                                        cholangiopancreatography
   Cholangiocarcinoma                  (MRCP)
   Primary hepatocellular            ■ Preferred diagnostic
    dysfunction                         approach if ERCP is likely
    (alcoholism, hepatitis)             to be unsuccessful


     Endoscopic retrograde cholangio- pancreatography
     (ERCP) Invasive procedure of choice
                                                                74
Biliary Obstruction
   Yellowing of skin and   ■ 1. Computed
    sclera (jaundice)          tomography or
   Abnormal liver             ultrasound (duct stone
    enzymes                    sensitivity less than
   Dark urine and pale,       80–85%),
    clay-colored stools     2. Magnetic resonance
   Common duct stone          cholangiopancreatogra
                               phy (MRCP)
   Pancreatic carcinoma
                            ■ 3. Endoscopic
   Cholangiocarcinoma         retrograde
   Obstructing                cholangiopancreatogra
    metastases                 phy(ERCP)


                                                   75
Cholecystitis (Acute)
   Acute colicky right upper      ■ 1. Ultrasound
    quadrant pain and              3. Magnetic resonance
    tenderness                      cholangiopancreatograp
   Fever                           hy (MRCP)
   Nausea and vomiting
   Mild jaundice
    (occasionally)
   Mild leukocytosis
   Mild elevation of serum
    bilirubin, alkaline
    phosphatase,
   and serum glutamic
    oxaloacetic
    transaminase
   (SGOT)


                                                         76
Liver Metastases
   Usually asymptomatic            1. Computed tomography
   May have nonspecific            2. Magnetic resonance
    weight loss, anorexia,           imaging
    fever,
   weakness
   Hepatomegaly (hard and
    often tender)
   Ascites
   Jaundice
   Gastrointestinal tract
    (colon, pancreas, stomach)
   Lung
   Breast
   Lymphoma
   Melanoma




                                                              77
    Pancreatitis (Acute)
   Steady, boring                    ■ 1. Computed tomography
    midepigastric pain radiating
    straight                          ■ 2. Magnetic resonance
                                       imaging (with MRCP)
    through to the back
                                      ■ 3. Ultrasound
   Elevated serum amylase
    and lipase
   Biliary tract disease (e.g.,
    stones)
   Alcoholism
   Drugs
   Infection (e.g., mumps)
   Hyperlipidemia
   ERCP
   Neoplasm
   Surgery or trauma




                                                             78
    Pancreatitis (Chronic)/
    Cancer of the Pancreas
   Midepigastric pain               ■ 1. Plain abdominal
   Weight loss, steatorrhea,         radiograph-pancreatic
    and other signs and              calcifications in 30–
    symptoms                          60% of patients
    of malabsorption                 2. Computed
   Alcoholism                        tomography or
   Hereditary pancreatitis           magnetic resonance
   Hyperparathyroidism              imaging (with MRCP)
   Obstruction of main              ■ 3. Endoscopic
    pancreatic duct (stricture,       retrograde
    stones,                           cholangiopancreatogra
                                      phy
   cancer)                          (ERCP)



                                                         79
Abdominal Mass in a Child
   Kidney                ■ 1. Plain abdominal
   Adrenal glands         radiograph
   Pelvic structure      ■ 2. Ultrasound
                           Best initial imaging
                           modality




                                               80
Epigastric Mass
   Liver         1. Computed
   Spleen           tomography
   Stomach       ■ Directly images the
   Duodenum         liver, spleen, gastric
                     wall, and Pancreas
   Pancreas
                  Magnetic resonance
                     imaging
                  ■ Indicated if the patient
                     cannot receive
                     iodinated
                  intravenous contrast
                     material



                                           81
     Right Upper Quadrant Mass
                          ■ 1. Ultrasound
   Right lobe of the     ■ High accuracy for detecting masses
    liver                     involving the gallbladder (acute
                              cholecystitis, carcinoma, and bile
   Gallbladder               ducts, as well as diffuse and focal
                              hepatic abnormalities
   Bile ducts            ■ Good imaging test for detecting renal
   Right kidney              lesions and differentiating renal
                              cysts from solid tumors or abscesses
   Right adrenal gland   ■ 2. Computed tomography
   Hepatic flexure of    ■ Indicated if there is bile duct dilatation
                              and US fails to show an obstructing
    the colon                 mass
   Duodenum              ■ Indicated for confirmation and staging
                              if US shows a solid renal mass
                          ■ Best modality for detecting adrenal
                              masses (metastases, adenoma,
                              carcinoma)
                          ■ 3. Magnetic resonance imaging
                          ■ Indicated if the patient cannot receive
                              iodinated intravenous contrast
                              material



                                                                    82
Left Upper Quadrant Mass
                             ■ 1. Computed tomography
   Spleen                   ■ Directly images the spleen,
   Left lobe of the liver      liver, gastric wall,
                                pancreas, left kidney, and
   Stomach (gastric            left adrenal gland
    outlet obstruction       ■ Adequate US examination is
    or tumor)                   often precluded by gas
                                contained within the
   Splenic flexure of          stomach, small bowel, and
    the colon                   colon
                             ■ 2. Endosocpy
   Pancreas                 ■ If there is evidence of
   Left kidney                 gastric outlet obstruction,
                                can evaluate for peptic
   Left adrenal gland          ulcer or gastric malignancy
                             ■ 3. Magnetic resonance
                                imaging
                             ■ Indicated if the patient
                                cannot receive iodinated
                                intravenous contrast
                                material

                                                          83
Hypogastric Mass
   Bladder        1. Ultrasound
   Colon          ■ Preferred initial imaging
   Uterus         2. Computed tomography
                   ■ Indicated to better define
   Ovary
                      the extent of a lesion if
                   a solid mass is detected by
                      US
                   3. Magnetic resonance
                      imaging- preferred for
                      soft tissue and pelvic
                      structures



                                             84
Left Lower Quadrant Mass
   Colon       1. Plain abdominal
                   radiograph
                ■ Can demonstrate large
                   bowel obstruction or
                   fecal
                   impaction
                ■ 2. Computed tomography
                ■ Preferred initial imaging
                   technique for detecting
                   and defining the origin
                   of a palpable mass or
                   the extent of
                   diverticulitis
                ■ 3. Magnetic resonance
                   imaging
                ■ Indicated if the patient
                   cannot receive contrast
                Colonoscopy choice


                                          85
    Esophageal Mucosal Laceration
    (Mallory–Weiss Syndrome)

   Repeated vomiting     1. Endoscopy
    followed by           ■ Required to
    hematemesis             demonstrate the
    (especially             superficial
    in men older than       lacerations or
    age 50 with history     fissures near the
    of alcohol abuse)       esophagogastric
                            junction




                                                86
Varices (Esophageal/Gastric)
   Upper gastrointestinal     ■ 1. Endoscopy
    bleeding                   ■ Procedure of choice for
   Cirrhosis                     acute bleeding
   Obstruction of the         ■ 2. Computed tomography
    splenic or portal vein     ■ Multi-detector study with
    (e.g., carcinoma              contrast enhancement
    of the pancreas)              can show the full extent
   Hepatic vein obstruction      of the varices and often
                                  demonstrate the cause
                               1. Transjugular intrahepatic
                                  portosystemic shunt
                                  (TIPS)




                                                         87
      Appendicitis
   Sudden onset of          2. Computed
    epigastric or              tomography
    periumbilical pain       ■ “Gold standard”
    that shifts to the       3. Ultrasound
    right lower quadrant
                             ■ Highly sensitive
   Rebound tenderness         and specific
   Low-grade fever
   Leukocytosis           Multi-detector CT imaging used as
                           an alternative to sonography in:
                           nonpregnant patients,
                           grossly obese or large body habitus
                           patients,
                           patients with severe abdominal pain,
                           and
                           when sonography is inconclusive.
                                                             88
        Cancer of the Colon
    Bright red rectal bleeding,      ■ 1. Colonoscopy
     altered bowel habits,            ■ More sensitive and specific ■
     abdominal or back pain              Provides excellent color
    Iron deficiency anemia,             images and an opportunity
     occult blood in the stool,          for biopsying lesions
     weight loss
1.   Diet (low in fiber, high in      ■ 2. CT colonoscopy (virtual
     animal fat)                         colonoscopy)
2.   Personal or family history of    3. Barium enema
     colorectal polyps                Staging- CT/ Transrectal
3.   Familial polyposis syndrome         ultrasound/ PET/CT
4.   Family history of colorectal
     cancer
                                     1. General population: after age 50,
5.   Chronic Ulcerative colitis         every 5 years by either
6.   Crohn’s colitis                    Colonoscopy/ FOB
7.   Hypercholesterolemia            2. Positive family history or genetic
                                        screening: after age 30, every 2
                                        years
                                     3. Ulcerative colitis and Crohn’s
                                        colitis: annually after 5–10 years
                                        of disease                       89
      Irritable Bowel Syndrome
   Symptoms triggered by               Colonoscopy is
    stress or ingestion of foods         frequently performed,
   Pasty, ribbon-like, or pencil-       generally showing
    thin stools                          normal findings
   Mucus (not blood) in the            Barium enema
    stools
   Onset often before age 30
    (especially in women)
   Variants-
   Spastic colon (chronic
    abdominal pain and
    constipation)
   Alternating constipation and
    diarrhea
   Chronic painless diarrhea



                                                                 90
Urinary Disorders- Flank Pain
   Trauma                  ■ 1. Computed
   Spontaneous renal          tomography-■ Most
    hemorrhage                 sensitive single
   Obstructing ureteral       examination
    calculus                2. Ultrasound
                            ■ Relatively efficient for
                               detecting renal
       Ultrasound is less      masses or ureteral
       sensitive than CT       obstruction
       for the detection    ■ Useful when there is a
       of renal masses.        need to avoid ionizing
                               radiation, such as in
                               examining pregnant
                               women and children


                                                     91
    Hematuria (Painless)/ Painful

   Neoplasm (kidney,           1. Computed
    ureter, bladder,             tomography
    urethra)                    ■ More sensitive than
   Glomerulonephritis           US for detecting renal
                                 masses
   Vascular abnormality
    (aneurysm,                  2. Ultrasound
    malformation, arterial      ■ Relatively efficient
   or venous occlusion)        3. Cystoscopy
   Papillary necrosis
   Urolithiasis



                                                      92
    Renal Failure (Chronic)
   Irreversible loss of renal function      ■ 1. Ultrasound-Imaging procedure
    (uremia)                                  of choice
   Neuromuscular (peripheral
    neuropathy, muscle cramps,
   convulsions, encephalopathy)
   Gastrointestinal (anorexia, nausea
    and vomiting, peptic
   ulcer, unpleasant taste in the
    mouth)
   Cardiopulmonary (congestive heart
    failure, hypertension,
   pericarditis, pleural effusion)
   Skin (uremic frost, pruritus)
   Secondary hyperparathyroidism
   Diabetic nephropathy
   Hypertension
   Glomerulonephritis
   Polycystic kidney disease
    (autosomal dominant)




                                                                              93
Renal Mass
   Flank pain            Ultrasound
   Hematuria             CT
   Palpable mass
   Fever (suggests
    renal abscess)
   Cyst
   Neoplasm (benign
    or malignant)
   Abscess

                                        94
Addison’s Disease
   Weakness, fatigue, orthostatic   ■ 1. Plain abdominal radiograph
    hypotension (early)              ■ May demonstrate adrenal
   Increased pigmentation               calcification
   Weight loss, dehydration,        2. Computed tomography
    hypotension (late)
   Small heart size
   Anorexia, nausea and vomiting,
    diarrhea
   Decreased cold tolerance
   Autoimmune process
    (idiopathic atrophy)
   Granulomatous process
    (tuberculosis, histoplasmosis)
   Neoplasm (lymphoma,
    metastases)
   Infarction
   Hemorrhage




                                                                       95
Primary Aldosteronism
(Conn’s Syndrome)
   Presenting Signs and    1. Computed tomography
    Symptoms                ■ Procedure of choice for
   Hypertension               detecting the adenoma,
   Hypokalemia             which is usually small (<2
   Increased serum and        cm)
    urine aldosterone       Also useful for Cushings
    (radioimmunoassay)
   Low plasma renin
    activity
   Common Causes
   Hyperfunctioning
    adrenal adenoma (80%)
   Bilateral adrenal
    hyperplasia (20%)



                                                     96
MUSCULOSKELETAL:
Acute Monoarticular Joint Pain
   Gout                              1. Plain skeletal radiograph
   Calcium pyrophosphate             ■ Preferred study for
    deposition disease (CPPD)          demonstrating soft-tissue
   Septic arthritis                  swelling and calcification,
   Bursitis/tendinitis                bone erosions, joint
   Trauma                            space narrowing, and any
   Hemarthrosis (bleeding             underlying fracture
    diathesis)
   Localized manifestation of
    inflammatory polyarthritis
   (rheumatoid arthritis,
    Reiter’s syndrome, psoriatic
   arthritis)




                                                                  97
Polyarticular Joint Pain
   Rheumatoid arthritis               ■ 1. Plain skeletal
   Ankylosing spondylitis              radiograph
   Reiter’s syndrome                  ■ Preferred study for
   Psoriatic arthritis                 detecting soft-tissue
                                        swelling,
   Osteoarthritis                     calcification, bone erosions,
   Systemic lupus                      joint space narrowing,
    erythematosus                      and osteophyte formation
   Hypertrophic
    osteoarthropathy
   Polymyalgia rheumatica
   Diffuse appearance of a
    usually monarticular
    condition
   (gout, CPPD, calcium
    hydroxyapatite deposition
   disease, bacterial arthritis)



                                                                   98
Osteoporosis
   Often asymptomatic           1. Plain radiograph (spine)
   Dull aching pain in the      ■ 2. Measurements of bone
    bones (particularly in the      mineral content-
    lower                           (quantitative CT, single-
   thoracic and lumbar area)       and dual-photon
   Tendency to develop             absorptiometry, dual-
    compression fractures of        energy x-ray
    the vertebrae                   Absorptiometry DEXA)
   with minimal or no trauma
   Kyphosis of the thoracic
    spine
   Fractures at other sites
    (hip, wrist) with less
    trauma
   than required in normal
    patients




                                                                99
Skeletal Metastases
   Most often              1. Radionuclide bone
    asymptomatic             scan-Preferred
    (discovered during       screening technique
    staging
   procedures)
   Back pain
   Lung
   Breast
   Prostate
   Thyroid
   Kidney
   Lymphoma
   Melanoma


                                                100
Scaphoid Fracture
   Pain in the region   1.   Plain skeletal
    of the anatomic           radiograph- fails to
    snuff-box                 detect up to 25% of
                              nondisplaced fractures)

   High incidence of    ■ 2. Magnetic
    complications           resonance
    (delayed union,         imaging- ■ High
    nonunion,               sensitivity
   avascular
    necrosis)


                                                        101
Meniscal Tear (Knee)
   Pain and swelling
   Click in movement of the joint
   Knee “giving way” or locking in a single position
   1. Magnetic resonance imaging
   ■ Imaging procedure of choice for detecting
    partial
   and complete meniscal tears, as well as
    associated
   abnormalities of the collateral and cruciate
   ligaments




                                                        102
    Rotator Cuff Tear
   Pain when the arm is    ■ 1. Magnetic resonance
    raised above the           imaging (shoulder)-
    shoulder or                procedure of choice
   adducted across the     for detecting partial and
    chest, but not when        complete rotator cuff
    the arm is
                             tears■ 2. Ultrasound
   held down by the side
                             ■ Sensitive for
   Weakness of shoulder       diagnosing rotator cuff
    abduction (due to          tear
    underuse atrophy
   of the deltoid)



                                                   103
    Carpal Tunnel Syndrome
   Pain, paresthesias, and sensory deficits in      ■ 1. Magnetic resonance imaging
    the distribution                                 ■ 2. Ultrasound
   of the median nerve                              ■ Suggested as a low-cost
   May be weakness or atrophy in the                 alternative
    muscles controlling
   abduction and apposition of the thumb
   Positive Tinel’s sign (paresthesias after
    percussion of
   the median nerve in the volar aspect of
    the wrist)
   Occupations requiring repetitive hand and
    wrist motion
   Gout
   Calcium pyrophosphate deposition disease
    (CPPD)
   Acromegaly
   Myxedema
   Pregnancy
   Oral contraceptives




                                                                                        104
Osgood-Schlatter Disease
   Pain, swelling, and     ■ 1. Plain radiograph
    tenderness over the        (knee)
    anterior tibial         ■ Demonstrates soft-
    tubercle (at the           tissue swelling
    patellar tendon            associated with
    insertion)              fragmentation of the
   Trauma from                anterior tibial tubercle
    excessive traction by   ■ 2. Magnetic resonance
    the patellar tendon        imaging
   on its immature         ■ Often reveals diffuse
    apophyseal insertion       thickening of the
                               patellar
                            tendon



                                                     105
Paget’s Disease
   Usually asymptomatic         ■ 1. Plain skeletal
    (discovered                   radiograph
    incidentally on
    radiographs or routine
    laboratory studies)
   Symptoms (typically
    insidious onset) may
    include pain,
    pathologic fracture of
    weakened bone,
    deformities, high-
    output cardiac failure,
    headaches, decreased
    hearing, and
    increasing skull size


                                                        106
NEUROLOGIC: Amaurosis Fugax
   Ipsilateral blindness that      1. Magnetic resonance imaging
    usually resolves fully within       (brain)
    2–30 min (sudden onset and      ■ Can evaluate for infarction
    brief duration)                 ■ 2. MR or CT angiography (neck
Plaques or atherosclerotic ulcers       and head)
    involving the carotid           Duplex, color-fl ow Doppler
artery in the neck                      ultrasound
Emboli arising from mural thrombi   4. Echocardiography
    in a diseased heart             ■ Indicated to detect mural
                                        thrombi in the heart if
                                    no carotid lesion has been
                                        identified that could
                                    explain the patient’s symptoms
                                    ■ 5. Computed tomography (brain)
                                    ■ Can evaluate for infarction, but
                                        less sensitive than
                                    magnetic resonance imaging (MRI)




                                                                   107
    Aphasia/Ataxia/Stroke
   Disorder of language                      ■ 1. Computed tomography
    comprehension or production               ■ Rapidly identifies or excludes
   resulting from a cerebral                     intracranial hemorrhage
    abnormality                               or mass, but cannot definitively exclude
   Receptive aphasia (Wernicke’s area)       acute infarction. “gold standard”
   Conduction aphasia (arcuate               2. Magnetic resonance imaging
    fasciculus)
   Expressive aphasia (Broca’s area)
   May be associated with right
    hemiparesis (usually due
   to a cortical lesion in the left middle
    cerebral artery
   distribution) or right hemisensory
    deficit
   Cerebral infarction (dominant
    hemisphere)
   Intracerebral hematoma
   Intracerebral neoplasm or abscess
    (slower, subacute onset)




                                                                                   108
Carotid Bruit (Asymptomatic)

■ 1. Duplex, color-flow Doppler
  ultrasound
■ Accurate noninvasive screening
  study




                                   109
Dementia

■ 1. Magnetic resonance imaging
■ 2. Positron emission tomography




                                    110
Headache
   Increased intracranial pressure        Suggested guidelines for
    (neoplasm, abscess,                     neuroimaging in adult patients
   hemorrhage, meningeal irritation)      with new-onset headache are:
   Vascular disturbance (migraine,        First or worst headache
    hypertension, cluster                  Increased frequency and increased
   headaches)                              severity of headache
   Toxins (alcoholism, uremia, lead,      New-onset headache after age 50
    systemic infection)                    New-onset headache with history of
   Trauma                                  cancer or immunodefi
   Extracranial site (disorders of        ciency
    paranasal sinuses, eye,                Headache with fever, neck stiffness,
   ear, teeth, cervical spine)             and meningeal signs
   Temporal arteritis (in elderly         Headache with abnormal
    population)                             neurological examination
                                           There is no need for neuroimaging
                                            in patients with migraine
                                           and normal neurologic examination.
                                           1. Magnetic resonance imaging




                                                                             111
Optic Chiasm Lesion
   Bitemporal visual-field defects (although
    deficit may be substantially greater in one
    eye than in the other)
   Pituitary tumor
   Parasellar mass (meningioma,
    craniopharyngioma,
   aneurysm)              ■ 1. Magnetic
                           resonance
   Multiple sclerosis     imaging
   Sarcoidosis            ■ Preferred study
                          for detecting a
                          lesion

                                             112
    Central Nervous System
    Manifestations in AIDS

   Spectrum of neurologic deficits depending
    on region and extent of involvement-
    HIV encephalitis
   Progressive multifocal
    leukoencephalopathy (PML)
                                 ■ 1. Magnetic
   Cytomegalovirus              resonance
   Toxoplasmosis                imaging
                                 ■ Preferred study
   Cryptococcosis               for detecting a
                                 lesion
   Lymphoma (primary CNS)

                                                     113
Brain Neoplasm

1. Magnetic resonance imaging
■ Preferred screening technique
  for detecting and
characterizing intracranial
  masses (may not
require contrast infusion)




                                  114
    Intracerebral Metastases
   Headache           1. Magnetic resonance
                          imaging
   Focal neurologic
    deficits           ■ Nonenhanced MRI is
                          extremely sensitive
   Drowsiness            for
   Papilledema        detecting brain
   Seizures              metastases
   Lung
   Breast
   Melanoma
   Gastrointestinal
    tract
   Kidney
   Thyroid

                                           115
    Acute Brain Infarction (Stroke)
   Abrupt, dramatic      1. Computed
    onset of focal          tomography
    neurologic deficit      (noncontrast ±
    that does not           contrast)
    resolve within 24 h   ■ Preferred initial
   Possible headache       procedure for
    or seizure              assessing a
                            suspected
                          acute stroke


                                            116
Lacunar Infarction
   Focal neurologic   1. Magnetic
    deficit that can     resonance
    be pinpointed to     imaging
    a                  ■ Only modality
    locus less than      that can
    15 mm in             consistently
    diameter             demonstrate




                                         117
Cauda Equina Syndrome
   Bilateral             ■ 1. Magnetic
    radiculopathy           resonance imaging
   Saddle anesthesia     ■ Preferred study for
   Flaccid paralysis       demonstrating
   Urinary retention       complete
                            subarachnoid
   Ruptured              block and the
    intervertebral disk     underlying cause
   Tumor                 This is a surgical
   Infection               emergency requiring
   Trauma                  immediate
                          imaging for a precise
                            diagnosis.



                                              118
          Herniated Nucleus Pulposus)
   Pain in the distribution of
    compressed nerve roots (may be         ■ 1. Magnetic resonance
    sudden and severe or more                 imaging- Most
    insidious)
   Pain increased by movement or
                                              sensitive study
                                               ■ 2. Computed tomography
    Valsalva maneuver
                                           
                                              ■ Useful for detecting herniated disk and
   Paresthesias or numbness in the            canal
    sensory distribution of the affected      stenosis,
    roots
   Reduced or absent deep tendon
    reflexes in the distribution of
    involved nerve roots
   Weakness and eventual atrophy of
    muscles supplied by affected nerves
   Positive straight leg raising test
    (lumbosacral region)
   Urinary incontinence or retention
    (from loss of sphincter function in
    lumbosacral involvement)
   Most common in the lower
    lumbosacral and lower cervical
    regions



                                                                                      119
Progressive Multifocal
Leukoencephalopathy

   Hemiparesis        1. Magnetic
   Seizures             resonance
   Blindness            imaging
                       ■ Demonstrates
   Intellectual
    dysfunction          asymmetric
                         focal white
   Cerebellar or        matter lesions
    brain stem
    dysfunction that   CT is not as
    is relentlessly      effective in
                         showing this
    progressive          primarily
                       white matter
                         process.         120
     REPRODUCTIVE:
     Abnormal Uterine Bleeding
   Excessive menstrual bleeding (menorrhagia)          ■ 1. Ultrasound
   Nonmenstrual or intermenstrual bleeding             ■ Combined transabdominal and
    (metrorrhagia)                                       transvaginal
   Postmenopausal bleeding                             ultrasound (TVUS) is the preferred initial
   Ovulation (functional ovarian cysts)                imaging procedure for detecting
   Cervicitis                                           abnormalities
   Birth control pills                                 of the female genital tract
   Anovulatory cycle                                   ■ 2. Magnetic resonance imaging
   Pregnancy                                           ■ Very useful problem-solving tool (e.g.,
   Leiomyoma                                            leiomyoma
   Adenomyosis                                         versus adenomyosis)
                                                        ■ Modality of choice for staging
   Malignancy                                           endometrial cancer
   POSTMENOPAUSAL
   Endometrial atrophy
   Endometrial polyp
   Endometrial hyperplasia
   Endometrial cancer
   HORMONAL
   Vaginal atrophy
   Endometrial cancer (about 20% of patients with
    postmenopausal
   bleeding)




                                                                                                121
    Dysmenorrhea
    (Painful Menstruation)

   Pain associated     ■ 1. Ultrasound
    with menses         ■ Imaging
    during ovulatory      procedure of
    cycles                choice for
   Endometriosis         detecting or
   Chronic pelvic      excluding lesions
    inflammatory          of the female
    disease               genital tract
   Cervical
    stenosis,
    infection, or
    neoplasm
                                            122
Missing Intrauterine
Device (IUD)
■ 1. Ultrasound
■ Preferred initial imaging technique if an
   intrauterine
position of the device cannot be confirmed
by pelvic examination, uterine sound, or biopsy
instrument
■ 2. Magnetic resonance imaging
■ IUDs can be safely imaged with MRI, and their
presence does not create artifacts that impede
image interpretation.
■ 3. Computed tomography
■ Can accurately depict the presence of the device
within the pelvic cavity.


                                                 123
    Infertility
   MALE FACTORS (40%)
   Deficient
    spermatogenesis           ■ 1. Hysterosalpingography
   Varicocele                ■ Preferred imaging study
   Cryptorchidism               for demonstrating
   Retrograde ejaculation    obstruction of the fallopian
    into the bladder             tubes
   Congenital anomalies      2. Ultrasound or magnetic
                                 resonance imaging
   FEMALE FACTORS (60%)
                              ■ Indicated if the
   Ovulatory dysfunction        hysterosalpingogram is
    (20%)                        normal,
   Tubal dysfunction (30%)
   Cervical mucus
    dysfunction (5%)
   Other uterine
    abnormalities (5%)




                                                        124
Chronic Pelvic Pain
   Chronic pelvic pain    1. Ultrasound
    is defi ned as         ■ Primary imaging
    noncyclic pelvic          technique for the
   pain of greater than      major gynecologic
    6 months duration      causes
    that is not relieved   ■ 2. Magnetic
   by strong                 resonance imaging
    analgesics.Pelvic      ■ Problem-solving
    inflammatory              modality
    disease
   Endometriosis
   Leiomyoma
   Adenomyosis
   Pelvic congestion
    syndrome

                                              125
Congenital Uterine Anomalies
   Amenorrhea               ■ 1. Ultrasound
   Infertility, recurrent   ■ Preferred initial
    miscarriages                imaging modality.
   Intrauterine growth      ■ 2. Magnetic
    retardation,                resonance imaging
    premature birth          ■ MRI is the modality
                                of choice
                             ■ 3.
                                Hysterosalpingogra
                                phy
                             ■ Indicated only if US
                                or MRI not
                                available,

                                                 126
Leiomyoma (Fibroid)
of the Uterus
   Asymptomatic         ■ 1. Ultrasound
    (detected            ■ Preferred initial
    incidentally on         imaging technique
    routine pelvic       2. Magnetic resonance
   examination or on       imaging
    an imaging study      ■ Indicated if US is
    performed for           negative or
    another reason)         inconclusive
   Abnormal vaginal      ■ 3. Interventional
    bleeding                radiology
   Pressure symptoms     ■ Uterine artery
    caused by               embolization (UAE)
    increasing size of
    the uterus
   Acute abdomen
                                             127
Adenomyosis
   Menorrhagia and       1. Ultrasound
    intermenstrual        ■ TVUS is the
    bleeding                 recommended
   Smooth                   initial imaging
    enlargement of the       procedure
    uterus                2. Magnetic resonance
   Nonspecific pelvic       imaging
    pain and bladder      ■ Highly sensitive for
    and rectal pressure      detecting
                             adenomyosis and
                          accurate in making
                             the critical
                             distinction from
                          leiomyoma


                                              128
Endometrial Hyperplasia
   Postmenopausal   1. Ultrasound
    bleeding,        ■ TVUS is the
    menorrhagia,       modality of
    menometrorrhag     choice, with a
    ia                 very high
                     sensitivity and
                       specificity




                                        129
Cancer of the Cervix
   Usually detected by     1. Magnetic resonance
    screening                  imaging
    Papanicolaou (Pap)      ■ Preferred study for:
    test                    ■ Demonstrating the
   Vaginal discharge and      tumor
    bleeding (especially    ■ Measuring its size
    after intercourse)
                            ■ Aiding treatment
                               selection
                            MRI is superior to CT
                            2. Computed
                               tomography
                            ■ Valuable in advanced
                               disease and in the
                               search
                            for lymph node
                               metastases
                                                 130
Cancer of the Endometrium
   Abnormal           ■ 1. Ultrasound
    uterine bleeding     (TVUS approach
    (postmenopausa       preferred)
    l or recurrent     ■ Used to measure
   metrorrhagia in      endometrial
    a                    thickness
    premenopausal      1. Magnetic
    woman)               resonance
   Mucoid or            imaging
    watery vaginal     ■ Procedure of
    discharge            choice for
                         staging
                                       131
Endometriosis
   Pelvic pain associated   1. Ultrasound
    with menses              ■ May demonstrate one or
    (dysmenorrhea)              more cystic masses filled
   Dyspareunia              with old blood
   Pelvic mass                 (endometrioma)
   Effect of implants on     2. Magnetic resonance
    other organs (e.g.,         imaging
    lesions involving         ■ Most sensitive
   large bowel or bladder      modality
    may cause pain with
    defecation,
   abdominal bloating,
    rectal bleeding with
   menses, or hematuria
    and suprapubic pain
    during
   urination)



                                                      132
Cancer of the Ovary
   Asymptomatic (until     1. Ultrasound
    very large)             ■ Preferred initial
   Vague lower                imaging procedure
    abdominal discomfort    2. Magnetic resonance
   Mild digestive             imaging or computed
    complaints              tomography
   Vaginal bleeding        ■ Indicated when the US
   Late findings include      findings are
    abdominal swelling         inconclusive
    due to ascites           ■ 1. Computed
   and a lobulated or         tomography
    fixed solid mass         ■ CT is the most
    associated with            commonly performed
   nodular implants in        study for the
    the cul-de-sac           preoperative staging




                                                 133
Pelvic Inflammatory Disease
   ACUTE                    ■ 1. Ultrasound
   Lower abdominal          ■ Demonstrates
    pain, fever, and            pyosalpinx or tubo-
    purulent vaginal            ovarian abscess
    discharge that usually   complicating pelvic
    begins shortly after        inflammatory disease
    menses                   ■ Assesses response to
   CHRONIC                     therapy
   Chronic pain             ■ 2. Computed
   Menstrual                   tomography
    irregularities           ■ May be performed
   Infertility (due to         after US to visualize
    mucosal destruction         the full
    and tubal obstruction)   extent of disease in
                                severe cases
                             ■ Indicated if clinical
                                symptoms mimic
                                appendicitis
                                                   134
Scrotal Pain (Acute)
                  1. Ultrasound with
                     color Doppler
                  ■ Torsion: decreased
                     or absent flow on
                     the symptomatic
                  side
                  ■ Epididymo-orchitis:
                     diffuse increase in
                     blood flow
                  on the affected side




                                       135
Benign Prostatic
Hyperplasia (BPH)

                       1. Ultrasound




                                        136
OBSTETRICS Unknown Gestational
Age

                 1. Ultrasound
                 ■ Preferred
                   imaging
                   technique




                                 137
Ectopic Pregnancy
   Cramping pelvic          1. Ultrasound
    pain                     ■ Procedure of
   Spotting                  choice
    (occasionally rapid
    bleeding leading to
    shock)
   Enlarged uterus but
    smaller than
    expected for dates
   Possibly tender
    mass in one adnexa
   Lower than
    expected β-hCG
    level that does not
    rise
   normally
                                               138
Early Pregnancy Failure
and Embryonic Demise

   Vaginal bleeding      1. Ultrasound
    and cramping          ■ Procedure of
   Failure of the         choice
    uterus to grow
   Absence of
    embryonic
    cardiac activity
   Decreasing β-
    hCG levels


                                            139
Intrauterine Growth Restriction
(IUGR)

   Estimated fetal      1. Ultrasound
    weight below         ■ Preferred
    the 10th              initial imaging
    percentile for        study
    gestational age




                                            140
Placental Abruption
   Third-trimester   ■ 1. Ultrasound
    bleeding          ■ Major value is its
                        ability to
                        exclude a
                        placenta previa




                                        141
142

				
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