Ultrasonography CT and MRI Dr Suman Sharma Associate Professor Department of Shalya Tantra National Institute of Ayurveda Emailsumanhp2006gmailcom Phone 9418159666 USG Basics ID: 914404
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Slide1
rabiezahran@Gawab.com
Basics of Ultrasonography, CT and MRI
Dr.
Suman
Sharma
Associate Professor, Department of Shalya Tantra
National Institute of Ayurveda
E-mail-sumanhp2006@gmail.com
Phone- 9418159666
Slide2USG
- Basics
Slide3Definition
Ultrasonography is study of internal organs or blood vessel using high frequency sound waves, the actual test called ultrasound scan or sonogram.
Slide4Definition
Ultrasound are sound waves of frequencies greater than audible to human ear i.e. greater than 20,000Hz
.
Slide5Indications
detecting abnormalities of heart, uterus, pancreas, urinary bladder, liver, stomach, kidney, eye & teeth.
2)
confirm
intrauterine &
exclude
ectopic pregnancy, fetal sex determination, viable fetus, missed abortion, retained products after termination, evaluate anomalies,
3)
Guided
amniocentesis,
choroinic
vilius
biopsy, intrauterine fetal transfusion.
4)
Check
tumor,
cholecystitis
,
intussuception
,gall stone, bile duct obstruction, cirrhosis,
splenomegaly
, & pancreatic abscess.
Slide6Indications
Detect renal abnormalities, tumor, urinary calculi of urinary bladder, morphology of kidney. 6) Diagnose the prostatic malignant diseases.
7) Useful in Echocardiography& congenital heart defect.
8) Ultrasound also used to clean teeth in dental hygiene.
9) Ocular
sonography
used evaluation of internal ocular structures. Also useful in cataract treatment,
Retrobulbar
abnormalities which may be difficult to detect
radiographically
but easily identified
sonographically
.
Slide7A sound waves travels in a pulse & when it is reflected back it becomes an echo. The pulse-echo principle is used for ultrasound imaging.
A pulse generated by one or more piezo-electric crystals in an ultrasound probe or transducer.
* Ultrasound probe crystal is shocked by single extremely short pulse of electricity to vibrate at a frequency determined by its thickness.
Principle
Slide8Principle
- Once echo are converted into electrical signals, these are processed & transformed into a visual display of the measure of the amplitude of the echo this is echo quantification.
- The
transducer picks up the return echo & record any changes in the pitch or direction of the sound, the image is immediately visible on the screen.
Slide9sound waves travel faster in solids than liquids or gases. The major cause of attenuation in soft tissue is absorption,
Slide10Principle
Slide11Ultrasonography
Advantages
No
ionizing
radiation
Safe
in
pregnancy
No
known side
effect
Cheap
, portable
machine
Minimum
preparation of patient
.
Painless
,
noninvasive
- Direct
vision for biopsy
Disadvantages
-
Sonographer
should be expert in
diagnosis .
- Performing
& interpreting
the examination can be extremely difficult.
Slide12Portable Ultrasound machine
Slide13Ultrasonography Machine
Slide141. Ultrasound waves
They are waves of very high frequency ranging between 3.5 – 10 MHz and up to 20 MHz in endo-sonography.When the frequency the resolution and penetration .
Slide15In adults the frequency used
=3.5 MHz.In children the frequency used=5 MHz.
In small parts =
7
MHz.
In
endosonography
=
7.5-20
MHz.
Slide162.
Echo patternEchofree :
When ultrasound waves pass through fluids ( ascites- simple cyst- blood vessels) no reflection occurs and these areas appears as black areas with posterior enhancement .
Slide17rabiezahran@Gawab.com
Posterior enhancement & mirrored side
Slide182.
Echo patternEchogenic : When ultrasound waves pass through solids (bones – stone) all waves are reflected and appears as white color with posterior shadow .
Slide19Posterior shadow
Slide20a. Shape
LinearSectorLinear convex
b. Frequency
Single
Dual
Range
3. Transducers
Slide21Slide22Liver
Slide231. Size .
2. Focal lesion .3.Diffuse liver disease .4.Hepatic vasculature . ( portal vein & hepatic veins )
5.
Intrahepatic
biliary
radicles
.
Liver
Slide24Size:
Lt. Lobe span (5-10 cm). Rt. Lobe span (8-15 cm).Liver
Slide25Focal lesions
1. Single or Multiple.2. Size3. Site (segmental anatomy)
Liver
Slide26( lesions) focal - Liver
4 .
Echopattern
Echofree
e.g. hepatic simple cyst, hydatid cyst
.
Hypoechoic
e.g. amoebic liver abscess, lymphoma
.
Hyperechoic
(echogenic)
e.g.haemangioma
.
Heterogeneous
e.g. cancer, secondary metastasis.
Slide27Hemangioma of liver (hepatic
hemangioma):
Images
show
a
large (8 cms.) rounded, well defined,
hyperechoic
, non-
calcific
mass in the right lobe of liver. There is a moderate amount of acoustic enhancement posterior to the lesion.
Slide28Multiple metastases in the liver
Heterogeneous
echogenicity
Slide29Liver metastases
Heterogeneous
echogenicity
Slide30Hydatid cyst or
echinococcosis of liver
Ec
h
o-free
Slide31Amebic liver abscess
hypoechoic
nature of the lesions suggesting further breakdown of the solid liver tissue
(
liquifactive
necrosis)
Slide32Diffuse liver disease
Liver cirrhosis: coarse echopattern with:
(
Miliary
=
echogenic
fine liver dots).
Irregular surface.
Large caudate
lobe
Attenuated hepatic veins
.
Liver
Slide33Liver
Slide34Liver
Slide35Diffuse liver disease
Bright liver: Increase brightness “less dark”.Normally, the echopattern of the liver is slightly brighter than the renal parenchyma.
D.D of Bright liver .
Fatty liver (DM –
Hyperlipidemia
-obese patients)
Chronic hepatitis
Liver cirrhosis
Liver
Slide36Liver
Bright liver
Slide37Liver
Bright liver
Slide38Hepatic Vasculature
A- Portal Vein:- The diameter is normally up to 12mm, in fasting adults.- From 13-17mm in suspected cases of portal hypertension.
Liver
Slide39Liver
Normal HVs.
Slide40Intra-hepatic Biliary
Radicles* Normally they are not seen, when dilated as in Obstructive Jaundice
“double barrel sign” (portal vein tributary and intra-hepatic bile
radicle
).
Liver
Slide41Intra-hepatic Biliary Radicles
*When the obstruction is intra-hepatic (e.g.
hilar
cholangio
-carcinoma) there is no dilatation of CBD.
when
the obstruction is extra hepatic there is dilatation of CBD. more than 8 mm
Slide42Liver
double barrel sign
Slide43Causes of bile duct obstruction
Stones in the CBD, hepatic duct, or ampulla of vater
*
Cancer head of pancreas
,
ampulla
of
vater
,
cholangiocarcinoma
.
Lesions in the
porta
hepatis
as
porta
hepatis
lymph node enlargement.
* Fasciola or ascaris.
Liver
Slide44Gall Bladder
Slide45Normal Anatomy of Gall bladder
Slide46Size
Wall thickness.ContentsStone.Parasites. Mud.Masses polyp cancer
Gall Bladder
Slide47Size
Long axis 6-12 cm , short axis 3-5 cm
- Contracted < 5 cm.
- Distended > 12 cm when the patient is fasting.
Gall Bladder
Slide48Wall thickness
Measured in the side in contact with the liver.Normally it is up to 3 mm.
- From 3-5 mm >>> suspect thick wall.
Gall Bladder
Slide49Liver
Wall thickness
>
5 mm
It
is a thick wall gall bladder which is seen in
:
Cholecystitis (acute-chronic
).
Ascites
.
Hepatitis ( viral).
Slide50Slide51Contents
* Stones:seen inside the gall bladder in all positions, mobile except at the neck. they appear white with posterior shadow. *
Mud (infected bile)
* Thick bile.
Change with changing position with or without presence of stones. The picture occurs in the presence of thick bile in patients on IV fluids for 3-4 days with inflamed GB.
Gall Bladder
Slide52Gall Bladder
Slide53Slide54Gall Bladder
Slide55Gall Bladder
Slide56Gall bladder sludge
thickened gall bladder wall (suggestive of
cholecystitis
) with the GB (gall bladder) lumen filled with echogenic debris which is typical of gall bladder sludge.
Slide57Carcinoma of gall bladder
Slide58rabiezahran@Gawab.com
Ultrasound images of double gall
bladder
Slide59Spleen
Slide60Size
Measure the diagonal axis: Normally it covers the upper 1/3 of the left kidney.- Longest axis (diagnostic) < 12 cm.
- Relation to kidney.
- Relation to costal margin.
Spleen
Slide61Focal Lesions
* Causes: Lymphoma.Cyst (simple-hydatid ). Infarction of a part (triangular area & base toward the edge).
Sarcoma.
Spleen
Slide62Spleen
Longest axis
Slide63Normal kidney
Slide64Sonographic
AppearanceUreters are normally not seen
Renal pelvis is black when visible
Renal sinus is echogenic due to fat
Medullary
pyramids are
hypoechoic
Cortex is mid-gray, less echogenic than liver or spleen.
Capsule is smooth and echogenic
Slide65Liver
Diaphragm
Sinus
Cortex
Anterior
Posterior
Superior
Inferior
Right Kidney Long Axis
Slide66Right Kidney Short Axis
Vertebral
Body
R Kidney
Aorta
Renal a.
GB
IVC
Liver
Anterior
Posterior
Right
Left
Slide67Left Kidney Long Axis
Anterior
Posterior
Superior
Inferior
Spleen
Kidney
Rib
Shadow
Slide68Left Kidney Short Axis
Anterior
Posterior
Right
Left
Liver
Spleen
L Kidney
Slide69Right Kidney ( normal)
Left Kidney ( normal)
Rt. lobe
Spleen
Slide70Slide71Slide72Slide73Slide74Slide75Slide76Slide77Slide78OTHER CYSTIC LESIONS OF THE KIDNEYS:A) Cortical cysts or simple renal cyst
Slide79Exophytic cortical cysts of the kidney
Slide80complex renal cysts
Slide81B) Calyceal
diverticulum or calyceal cyst
Slide82Ectopic/ Pelvic kidney
Ectopic/ Pelvic kidney
Slide83Horseshoe kidney:
Slide84Renal cell carcinoma
Slide85Chronic renal failure (Medical renal disease)
Slide86Slide87rabiezahran@Gawab.com
Large
urinary
bladder calculus
Slide88Fungating bladder mass
Slide89Benign prostatic hyperplasia
Slide90rabiezahran@Gawab.com
Normal pancreas.
Slide911-
liver;S2- head of the
pancreas
3- pancreatic body;
4- Wirsung's duct;
5- tail of the pancreas;
6- superior mesenteric artery;
7-
IVC.
8-
Aorta
;
9- spine.
10-
GB
Normal
pancreas
.
Slide92ULTRASONIC ANATOMY OF PANCREAS
Normal pancreas is more echogenic in adults and less echogenic in children than liverIt is about 15-20 cm. longPancreatic duct or duct of Wirsung measures 2-3 mm. at head regionHead – 2.5+/- .5 cm.Body – 2.0+/- .5 cm.Tail – 1.5 +/- .5 cm.
Slide93NORMAL PANCREAS
Slide94FATTY PANCREASE
Slide95FATTY PANCREASE
Slide96Tumors of the pancreatic head
Slide97Tumors of the pancreatic head
Slide98an oval, echo-negative formation with well-defined,
even outline visualised within the pancreatic body projectionPancreatic cyst
Slide99PSEUDO-PANCREATIC CYST
Slide100Slide101Slide102cervix
length;body length
;
3) antero -posterior length
on
the
level
of the uterine body
;
4
)
width
;
5)
endometrium
thickness.
Measuring the uterine dimensions
Slide103Uterine
fibromyoma .
Slide104Pleural
effusion:
large, clear,
hypoechoic
fluid collection in the left pleural space. The left lung has collapsed into a small mass of tissue compressed by the effusion. A small fibrotic band is seen traversing the fluid.
Slide105Ultra sound in Pregnancy
Slide106First Trimester Scan
To know the early pregnancy.
To know the Expected date of delivery (EDD).
To know the normal growth of feotus.
To find out twin pregnancy, rule out fetal anomaly at the earliest, placental localization.
Slide107Normal uterine pregnancy.
Duration of gestation: 4 weeks
Slide108Transvaginal ultrasound view of the uterus clearly showing the echogenic decidualized endometrial cavity. Located within it is an echogenic line (fiercely white circle) around a sonolucent center (black).
Slide109Transvaginal ultrasound image showing highly magnified view of an intrauterine gestation at 5 to 6 weeks LMP. The gestation sac is clearly visualized. Within there is a 3-mm yolk sac barely visible.
Slide110Highly magnified transvaginal ultrasound view of an intrauterine pregnancy. The yolk sac is clearly visible with the thickening of the embryo seen along its lateral border.
Slide111Transvaginal ultrasound image showing intrauterine pregnancy at 55 days LMP. This 13-mm embryo is a C-shaped tadpole-like structure.
Slide112Transvaginal ultrasound image showing intrauterine gestation at 10 weeks LMP. This fetus (CRL = 35 mm) is now totally recognizable as a human offspring.
Slide113Slide114A case of twins at 8 weeks imaged transvaginally. Note the single chorionic cavity, which contains two amniotic cavities, confirming this is a case of monochorionic diamniotictwins
A
di
-chorionic twin pregnancy demonstrating one sac containing a live fetus (CRL 21.4mm) and a dead twin (CRL 11.9mm) in the second sac.
Multiple Pregnancy
Slide115The aims of usual second trimester scans are
1. Determine the number of fetuses 2. longitudinal lie of the fetus
3. Measure the BPD, HC and TCD, evaluate the intracranial anatomy
4. four-chamber view of the fetal heart
5. the femur length.
6. Look for normal presence of long bones of upper and lower limbs.
7) Localization of placenta and evaluation of amniotic fluid volume.
8) Observe the fetal activity in terms of body and limb movements.
2
nd
Trimester
Slide116Measuring the BPD, HC, FL
:The BPD is the maximum diameter of a transverse section of the fetal skull at the level of the parietal eminences- A single optimal measurement of the BPD will predict the gestational age to within ± 5 days. It is more precise than the optimum menstrual history to ascertain the EDD.
Head circumference is also measured along with BPD using the formula for circumference of a circle.
FL is as accurate as BPD to determine gestational age, can be measure anytime after 12 weeks of pregnancy to term to confirm the gestational age determined by BPD or HC
Slide117Measuring the BPD, HC, FL
Slide118Placenta seen as a separate organ by ultrasound by 8th week. Its site can change relative to the internal
os. It is best identified longitudinally and has more echogenic pattern compared with that of the underlying
myometrium
.
Placenta may be anterior walled, posterior walled,
fundic
, or low lying.
Placenta
previa
may be marginal, partial,
complete.Low
lying
palcenta
is the one which remains 0.5-5cm away from internal
os
. Internal
os
is at max 6 cm from external
os
.(after28wk)
Placental Localization
Slide119Grade 0:
placenta uniformly granular, echogenic.Grade 1:
chorionic plate slight indulating.
Linear echogenic densities in placental substance
parallel to basal plate
Grade 2:
marked indentation of chorionic plate,
but not up to basal plate. The basal plate contains
echogenic lines in single row.
Grade 3:
chorionic plate shows deep indentation
up to basal layer so placenta divided into
cotyledons, calcification areas are seen giving acoustic shadow. Grade3 placenta was thought to be indicator of fetal lung maturity but resent studies could not find these.
placental thickness >5cm is pathological, eg. maternal DM, Rh incompatibility, syphillis, molar pregnancy
PLACENTAL GRADING
Slide120It is as simple as passing X-Rays through the patient and obtaining Information with a detector on the other side.
The X-ray source and the detector are interconnected and rotated around the patient during scanning period. Digital computers then assemble the data that is obtained and integrate it to provide a cross sectional image (tomogram) that is displayed on a computer screen.
The image can be photographed or stored for later retrieval and use as the case may be.
CT Scanning
-
Basics
Slide121Slide122CT Scan
Slide123Slide124Dense tissues
such as the bones appear white on CT film Soft tissues such as the brain or kidney appear gray.
Cavities filled with air
such as the lungs appear black.
CT Scanning
-
Basics
Slide125Causes of ICP: Epidural Hematomas
Examples
(A, B-arrows) of epidural hematomas in CT scans on the patient's right side. The smaller lesion in A is obviously of traumatic origin; this patient has soft tissue damage, a fractured skull, blood in the substance of the brain, and blood in the anterior horn of the lateral ventricle and in the third ventricle. The cause of the larger lesion (B) is not obvious.
Slide126Causes of ICP: Subdural Hematomas
An
example of a subdural hematoma (arrows) in CT scan on the patient's left side. This lesion is long and thin and extends for considerable distance over the surface of the hemisphere: note the shift in the midline.
Slide127Causes of ICP: Swelling
Observe swelling (darker tissue) on brain CT scan of a 7-month-old victim of child abuse. What other injuries are present?
Slide128Head
To detect
infarction
,
tumours
,
calcifications
,
haemorrhage
and
hyperdense
(bright) structures indicate calcifications and
hemorrhage
and bone trauma.
Lungs
Acute and chronic changes in the
lung
parenchyma, (e.g.
emphysema
,
fibrosis
, and so forth),
Cardiac
Excellent imaging of the
coronary arteries
(cardiac CT angiography).
Abdominal and pelvic
Wilms
' tumor
,
abdominal
diseases and to determine stage of
cancer
and to follow progress. It is also a useful test to investigate
acute abdominal pain
.
Extremities
Fractures
, especially ones around joints, because of its ability to reconstruct the area of interest in multiple planes.
Fractures, ligamentous injuries and dislocations
can easily be
recognised
.
Diagnostic uses
Slide129Contra – indications
(NO ABSOLUTE CONTRAINDICATION)Pregnancy
Breast Feeding (If contrast to be given)
Allergic to contrast media
May produce Tumors
Slide130Magnetic Resonance Imaging (MRI), uses radio frequency waves and a strong magnetic field rather than x-rays to provide remarkably clear and detailed pictures of internal organs and tissues.
MRI
-
Basics
Slide131The technique has proven very valuable for the diagnosis of a broad range of pathologic conditions in all parts of the body including cancer, heart, and vascular diseases, stroke and joint and musculoskeletal disorders.
MRI
-
Basics
Slide132The patient is placed on a moveable bed that is inserted into the magnet. The magnet creates a strong magnetic field that
aligns the protons of hydrogen atoms, which are then exposed to a beam of radio waves. This spins the various protons of the body, and they produce a faint signal that is detected by the receiver portion of the MRI scanner. The receiver information is processed by a computer, and an image is produced.
MRI
-
Basics
Slide133MRI - Machine
Slide134The image and resolution produced by MRI is quite detailed and can detect tiny changes of structures within the body. For some procedures, contrast agents, such as gadolinium, are used to increase the accuracy of the images.
MRI
-
Basics
Slide135An MRI scan is a painless radiology technique that has the advantage of avoiding x-ray radiation exposure. There are no known side effects of an MRI scan. The benefits of an MRI scan relate to its precise accuracy in detecting structural abnormalities of the body.
MRI
-
Basics
Slide136One advantage of an MRI scan is that it is harmless to the patient. It uses strong magnetic fields and non-ionizing radiation in the radio frequency range, unlike
CT scans and traditional X-rays, which both use
ionizing radiation
.
MRI
-
Basics
Slide137
Slide138Slide139MR imaging of the body is performed to evaluate:
Organs of the chest and abdomen—including the heart, liver
,
biliary
tract
,
kidneys
,
spleen
, bowel,
pancreas
and adrenal glands.
pelvic organs including the reproductive organs in the male (prostate and testicles) and the female (uterus, cervix and ovaries).
blood vessels (MR Angiography).
breasts.
Slide140MRI - Indications
HeadEyesSpineCNS
Abdomen
Pelvis
MR - Angiography
Hepato-billiary System
Musculo-skeletal System
MR – Cholangiography
Joints
Epiphyseal Injuries
Micro - fractures
Slide141Contra – indications and precautions
Brain aneurysm clipsCertain types of artificial heart valves
Heart defibrillator or pacemaker
Inner ear (cochlear) implants
Kidney disease or dialysis
(Pt. may not be able to receive contrast)
Recently placed artificial joints
Certain types of vascular stents
Worked with sheet metal in the past
(Pt may need tests to check for metal pieces in His eyes)
Slide142Because the MRI contains strong magnets, metal objects are not allowed into the room with the MRI scanner:
Pens, pocketknives, and eyeglasses may fly across the room.Items such as jewelry, watches, credit cards, and hearing aids can be damaged.
Pins, hairpins, metal zippers, and similar metallic items can distort the images.
Removable dental work should be taken out just before the scan.
Slide143Thank You