Things I wish I had known sooner in Radiology

							Pearls for 1st year.

By Naveen Garg PGY3
    Radiology Physics Board
• PGY-2Registration with
  the ABRJuly 1st - September 30th
• $400 late fee
• http://www.theabr.org/DR_Dates.htm
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1. AMSA Radiology Interest Group or Radiology
   Resident e-mail listserv.
2. Contrast Reactions and Creatinine Clearance
3. Vague statistics in radiology reports: rare,
   unlikely, likely, probably, relate with more clear
   numbers for how common? Once a day, once
   a month, once a year, once a career…
4. Internet Journal Club
5. Radiology Decision Support
    General Approach to Imaging
•   Have a differential diagnosis before you look at any images
•   Look at one organ at a time.
•   Look at tissue of interest
•   Is this image limited or the wrong modality?
•   What would it look like on ct, us, mri, nucs
•   Compare with normals and internet pictures if confused.
                           Fractures
• Ask mechanism of injury and region of focal pain
• If it looks abnormal: its usually either a limited view, fracture, or both.
• Limited views (no rotation views) may be because fracture or injury
  limits mobility.
• Look at bones individually.
• Lower threshold for getting ct of pelvis, midfoot, spine, face
                           Fluoro
• Ted’s cheat sheet, w&w protocols.
• When Single contrast?
   – <12 years old
   – Old >70, limited mobility
   – Ruleout obstruction or known anatomic defect
• Why scout? Obstruction, poop, barium, stones, pregnancy, free
  air.
• Bronch, Hystero, etc: get angled views
• Male vcug, get urethra views frontal and lateral
• Esophageal perforation: ct with esophocat contrast
• Bladder perforation: ct with 200cc contrast through foley.
                                         CT
•   Windows: named after tissue that is gray and has best contrast (some of it is brighter
    and some darker than gray).
•   Inflammation: fat gets whiter with edema and hyperemia. Walls get thicker with
    edema.
•   Abscess: air, central necrosis, peripheral enhancement, reactive lymph nodes.
•   Vascular organs are denser and enhance more.
•   Tumors are usually neo (hypervascular)
•   Hematoma: heterogenous (layering / hematocrit effect)
•   Fat anywhere, water in csf spaces or bladder, air and contrast in bowel are your
    friend. If you don’t see them, you have a limited exam or pathology.
                         CT Head
• Ischemia windows: look at basal ganglia, insular ribbon (temporal
  lobe), cortex
• Subdural window: look at quadrigeminal plate cistern, tentorium, csf
• Soft tissue: look at scalp, sinuses
• Bone: look at orbits, nose, zygoma, lytic lesions, fracture if scalp
  swelling.
• Only subtle finding to really worry about is hemorrage.
Ischemia and Bone Windows
                    IV Contrast
• See http://www.svhrad.com/CallGuide/OnCall.htm
  for article on contrast allergy.
• Contrast timing:
   – PE, AAA, Dissection
     PE: pulmonary artery must be whiter than aorta.
     AAA: without contrast to see crescent sign.
     Dissection: with contrast to see flap
• Abdomen: get 3.2mm cuts if no contrast IV or oral or
  can’t see what’s going on.
                      Ultasound
• Whiter = hyperechoic,
  Darker = hypoechoic


   •Fat:            hyperechoic
   •Hemorrage       hyperechoic
   •Bone            white line with shadowing
   •Air             white line with shadowing
   •Cyst:            hypo to anechoic
   •Vessels:         doppler
   •Veins:          compressible
                               MRI
•   http://www.radiology.residentmanual.com/index.php/MRI_protocols
•   Water and pathology: White on T2, dark on T1 and FLAIR
•   Fat: white on T1 and T2, dark on STIR and out of phase
•   Bone Marrow: normally fatty (white on t1), replaced with edema or
                          other pathology (dark on T1)
•   Axons: fatty
•   Gray matter infarct: opposite of csf on DWI and ADC.
•   Bone cortex, stones, and ligaments: dark on everything.
    Contusion is white
•   Tumor: hypervascular (neovascularity): white with gadolinium
•   Liver, Kidney, adrenals, Pancreas: tumor patterns, just look up in
    brant and helms or mri book.
                      Nuclear Medicine
• V/Q scan:              if not clearly normal or high prob, look for artifacts or matched
    defects.

  – pioped criteria
• Bone Scan: if new abnormal uptake
          •    spine get obliques (to localize)
          •    Others get laterals
          •    X-ray or ct to confirm probably benign fx, djd
          •    Mri for cancer
•   Don’t bother asking anyone other than bader, mukai, bertrand, chen, gupta for help.