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State Educational Establishment of Higher Professional

Education «Kursk State Medical University»


Federal Agency of Public Health
and Social Development

DEPARTMENT OF MEDICAL RADIOLOGY

Vlasova L.V., Piskunov I.S.

GUIDELINES

GUIDELINES
IN MEDICAL RADIOLOGY

for the 3-4th year students

Kursk - 2008
Vlasova L.V., Piskunov I.S. Methodological recommendations for foreign
students to be used in preparation for tutorials in Medical Radiology. – Kursk:
KSMU, 2008. – 92 p.

Technical editors: Vlasova M.M., R. Senthil Ramkumar

The manual is devised for foreign students studying at the department of


Medical Radiology of the medical universities. It is based on the syllabus
worked out by Ministry of Education and Science, Russian Federation
(Moscow, 2006).

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Государственное образовательное учреждение
высшего профессионального образования
«Курский государственный медицинский университет
Федерального агентства по здравоохранению
и социальному развитию»

Кафедра лучевой диагностики и терапии

Власова Л.В., Пискунов И.С.

Методические рекомендации
для самоподготовки и самостоятельной работы
иностранных студентов лечебного факультета
на практических занятиях
по медицинской радиологии

(3-4 курс)

Курск – 2008
3
УДК 615.849(072) Печатается по решению
ББК 53.6я73 редакционно-издательского
В 57 совета ГОУ ВПО КГМУ
Росздрава

Власова Л.В., Пискунов И.С. Методические рекомендации для


самоподготовки и самостоятельной работы на практических занятиях по
медицинской радиологии для иностранных студентов лечебного факультета
(3-4 курс). – Курск: ГОУ ВПО КГМУ Росздрава, 2008. - 92 с.

Технические редакторы: Власова М.М., R. Senthil Ramkumar

Методические рекомендации по медицинской радиологии предназначены


для иностранных студентов (преподавание на английском языке) и составлены
в соответствии с Примерной программой по дисциплине «Лучевая
диагностика и терапия» Министерства образования и науки Российской
Федерации
(Москва, 2006).

ISBN 978-5-7487-1222-4 ББК 53.6я73

 Власова Л.В., Пискунов И.С., 2008


 ГОУ ВПО КГМУ Росздрава, 2008

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CONTENTS

Introduction…………………………………………………………………… 6
Topic: The subject of Medical Radiology. Basic methods of radiodiagnosis
and its importance for medicine. Physicotechnical basics of roentgenology
and ultrasound diagnostics……………………………………………………. 7
Topic: Different types of X-ray examinations…...…………………………… 11
Topic: Radioanatomy and X-ray examination of the chest……………………. 15
Topic: The basic roentgenological syndromes of the respiratory system
pathology. Differential diagnosis of the total and limited shadowing
syndromes……………………………………………………………………...
...... 19
Topic: The syndromes of the round and ring-shaped shadows. Limited and
diffuse dissemination of the nidal shadows. Intrasyndromic differential
diagnostics………..
………………………………………………………............... 24
Topic: The syndromes of the lung pattern pathology, lung root pathology,
lung field transradiency. Intrasyndromic differential diagnosis………………. 29
Topic: Roentgenodiagnostics of the cardiovascular system…………….…….. 34
Topic: Roentgenodiagnostics of the illnesses of the cardiovascular system….. 38
Topic: X-ray examination of the gastro-intestinal tract. Radiological anatomy
of the gastro-intestinal tract……………………………………………………. 42
Topic: Principal syndromes of diseases in organs of gastro-intestinal tract…... 46
Topic: Radiodiagnostic of ulcerous diseases and tumours of the
gastro-intestinal
tract……………………………………………………………… 51
Topic: Radio-diagnostic methods of bone and joint diseases. Radiological
diagnosis of the bone-joint
systems……………………………………………... 56
Topic: X-ray diagnostics of inflammatory disease of bones and
joints………………........................................................................................... 62
Topic: Radiodiagnostics of tumours in bones and joints……………………… 67
Topic: Computed tomography………………………………………………… 72
Topic: Magnetic resonance imaging…………………………………………... 76
Topic: The basic physics of ultrasound imaging, ultrasound instrumentation… 78
Appendix 1…………………………………………………………………….. 84
Appendix 2…………………………………………………………………….. 86

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INTRODUCTION

Proper usage of the various investigative procedures is of immense importance


in the diagnostic endeavors of the treating physicians and surgeons. Medical
Radiology with its ever growing range of newer and improved modalilities, occupies
a very important place. Through the years and decades since 1895 when the X-rays
were first discovered by Wilhem Conrad Roentgen, there have been rapid advances in
Medical Radiology with the introduction of ultrasonography, computed tomography,
magnetic resonance imaging, radionuclide scanning etc. The Department of
Radiodiagnosis and Radiotherapy of KSMU is already 50 years old. During the years
of its existence, there have been numerous advances in the field of Medical
Radiology world wide. The Department has managed to keep itself in tune with the
latest technological advancements with the introduction of Spiral CT, latest
radiographic apparatus, Mammography etc.
The course of Medical Radiology for the undergraduate students is of 2
semester duration (6th and 7th semester), during which period the student is expected
to be acquainted with radiographic images of the chest, GIT, musculo-skeletal system
and newer imaging modalities like Computed Tomography, Magnetic Resonance
Imaging, Ultrasonography. Attendance is a very important aspect at our department.
The students should undertake periodic credit tests on the completed topics according
to the schedule of the department. At practical classes the students should work
individually with the given radiological images.
The forthcoming pages of this methodical presentation are expected to aid the
student in their academic endeavor.

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Topic: THE SUBJECT OF MEDICAL RADIOLOGY. BASIC METHODS OF
RADIODIAGNOSIS AND ITS IMPORTANCE FOR MEDICINE.
PHYSICOTECHNICAL BASICS OF ROENTGENOLOGY AND
ULTRASOUND DIAGNOSTICS.
I. AIMS OF MOTIVATION:
In the new century the role of radiodiagnostics in medical practice immensely
increases. It can be explained as a result of the introduction of new technique, for
example automatic equipment, television, computers and quick development of the
latest technologies which presuppose for obtaining high-quality images of internal
organs including stereoscopic picture. In all medical branches of science, and first of
all in surgery, therapy, oncology, Conventional Radiology has improved its position
as a basic method of early and accurate detection of many illnesses. To learn the
essence of radiodiagnostic methods and their diagnostic capabilities we must
recollect the historical development and the physicotechnical basis of roentgenology
and ultrasound diagnosis as well as the methods of protection of medical staff and
patients from radiation.
II. AIM OF SELFPREPARATION:
As a result of self-training a student is supposed:
 to know the history of the roentgen (X-) rays discovery;
 to know the nature and the main characteristics of X-rays;
 to know the principles of an X-ray tube and X-ray machine work;
 to know the nature and main characteristics of the ultrasound wave;
 to know the principles of an ultrasound diagnostic machine operation;
 to know the basis of labor protection and of safety engineering.

III. INITIAL LEVEL OF KNOWLEDGE:


To study the topic the students are supposed to know from physics:
 the nature of X-rays and their properties;
 the principles of an X-ray tube and X-ray machine work;
 the nature of the ultrasound wave and its properties;
 the principles of an ultrasound diagnostic machine operation.

IV. THE WAY TO STUDY THE TOPIC:


Sequence of actions Methods to carry out actions
1. The definition of Medical Medical Radiology is the science dealing
Radiology. with the diagnoses and treatment of
patients by using different types of rays.

Radiodiagnosis is a science which uses


2. The definition of the radiodiagnosis. different types of rays to study the
structure and functions of normal and
pathologically changed organs and
human systems with the purpose of
prophylaxis and illness detection.
Roentgenological method.
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3. Components of radiodiagnosis. Radionuclide imaging.
Ultrasound.
Magnetic resonance imaging.
Interventional radiology.

Roentgenological method is a way to


4. The definition of roentgenology. study the structure and functions of
different organs and systems. It is based
on the qualitative and quantitative
analyses of the X-ray beam which is
passed through a body.

William Conrad Roentgen, November, 8,


5. The history of the X-rays discovery. 1895.
The circumstances of discovery of X-
rays.

1. The nature of the X-rays.


6. Physicotechnical bases of 2. The production of the X-rays.
roentgenology. 3. Its characteristics.
4. The properties of the X-rays.

1. Power supply.
7. The main parts of an X-ray machine. 2. The roentgen tube (X-ray generator).
3. Fluorescent screen.
4. Secondary radiation grid.
5. Cassette with X-ray film.

1. X-ray examination room.


8. Basic functions of the main rooms in 2. Photolaboratory.
an X-ray department. 3. Apparatus monitoring room.
4. Patient’s room.
5. Doctor’s room.

Protection by time, distance, shielding.


9. The principles of protection.
Immobile, mobile and individual
10. Medical staff protection. protectors.

Protection by time, diaphragming,


11. Patient’s protection. shielding.

Using diagnostic methods with the least

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12. Specific features of children radiation dose;
protection. following the rules of radiation
protection.

Determinated threshold effects are the


13. Biological effects: biological effects of radiation regarding
which we can presume (presuppose) the
existence of the boundary, above which
consequences of the effect depend on the
dose, e.g. radiation sickness, radiation
burn, radiation cataract, anomaly of a
fetus development.
Stochastic (nonthreshold) effects are the
harmful biological effects of radiation
which might not depend on the dose. It is
supposed that probability of these effects
appearance is in proportion to the dose;
the consequences of their development do
not depend on the dose, e.g. malignant
tumors, leucosis, heritable diseases.

1. The danger of the electric current.


14. Other forms of harmful effects for a 2. Air ionization.
human in an X-ray room and 3. Leaden dust.
protective measures.
The ultrasound method is a way of the
15. The definition of the ultrasound distant detection of the form, position,
diagnosis. size, structure and motions of organs and
tissues as well as pathologic foci by
means of the ultrasound wave.

1. The nature of the ultrasound waves.


16. Physicotechnical basis of the 2. Their characteristics.
ultrasound diagnosis. 3. The properties of the ultrasound
waves.

1. Electronic unit.
17. The main parts of an ultrasound 2. Ultrasound transducers and their types.
machine. 3. High-frequency amplifier.
4. A monitor.
5. Different types of transducers.

The radionuclide (isotopic) method is a

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18. The definition of the radionuclide way of examination of the functional and
(isotopic) method. morphological condition of organs and
systems by means of radionuclides or
radiopharmaceuticals.

The magnetic resonance imaging method


19. The definition of the magnetic is a way of examination of the functional
resonance imaging method. and morphological condition of organs
and systems by means of the constant and
alternating magnetic field.

The interventional radiology is a medical


20. The definition of the interventional intervention under the control of the radio
radiology. investigations.

V. RECOMMENDED LITERATURE:
1. Peter Armstrong, Martin L. Wastie “Diagnostic Imaging”, Blackwell Scientific
Publications, Oxford, 1992. - Р. 1-14, 429-436.
2. Paul W. Goaz, Stuart C. White “Oral Radiology”, B.I. Publications Pvt. Ltd.,
New Delhi, 1998. - Р. 1-96.
3. P.R. Patel Lecture Notes on Radiology, 1998. - Р. 1-18.
4. George Simon, Arthur T.A. Wightman “Clinical Radiology”, Butterworths,
Jaypee Brothers. - Р. 1-16.

VI. QUESTIONS FOR CONTROL:


1. The nature and production of the X-rays.
2. When and under what circumstances were the X-rays discovered?
3. What does the quantum energy of the X-rays depend on?
4. To what is the energy of the X-ray quantums that are produced in the X-ray
tube equal?
5. Which property of X-rays will be changed if we change the voltage of the tube
electrodes?
6. Point out the results of the electrons braking in the anode atom’s electric field
of an X-ray tube.
7. What is the source of X-rays for medical purposes?
8. Enumerate five properties which let to use the X-rays in radiodiagnosis.
9. Enumerate the components which take part in any roentgenological
examination (put the components according to the path of an X-ray beam).
10. Name the two main receivers of the X-rays during the X-ray radiodiagnosis.
11. What kind of effect do X-rays and visible light take on an X-ray film.
12. What kind of effect does the voltage change of an X-ray tube electrode
produce on the X-rays penetration power?
13. Enumerate the main parts of the radiodiagnosis machine.
14. Enumerate the main structural components of an X-ray tube.

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15. What kind of changes will take place when we change the voltage in an X-ray
tube?
16. Name three factors that can have influence on the absorption rate of the X-
rays?
17. Name four mediums of human body which are different in the degree of
absorption of X-rays.
18. Name the basic properties of the ionizing radiation.
19. Name the necessary rooms for the installation of a radiodiagnosis machine and
name these rooms’ functions.
20. Name the individual protectors from the ionizing radiation.
21. Name the immobile and mobile protectors.
22. Enumerate three principles of protection from the ionizing radiation.
23. What does “protection by distance” mean?
24. What does “protection by time” mean?
25. Name the requirements for securing the medical staff and patients from
radiation.
26. Tell about the nature of the ultrasound waves.
27. Specify the main factors that determine the spreading of the ultrasound waves.
28. Do the ultrasound waves relate to the ionizing type of radiation?
29. What is the ultrasound waves intensity?
30. What are the advantages of the ultrasound diagnosis?
31. Give the definition of the ultrasound method.

VII. THE PLAN OF STUDENTS WORK DURING THE CLASSES:


1. Control and check the answers by the test methodic.
2. Discussion on the day’s topic.
3. Acquaintance with the rules of work in the department and in the X-ray room
(safety measures).
4. Acquaintance with the roentgenologic (X-ray) department and an X-ray
machine.

Topic: DIFFERENT TYPES OF X-RAY EXAMINATIONS.

I. AIMS OF MOTIVATION:
The present-day roentgenology is well methodically and technically
prepared. Numerous X-ray examinations enable us to get important information
about morphology and functions of all the organs and systems of a human body.
The doctor of every specialty ought to know the resources of the radiodiagnostic
methods, their indications and contraindications.

II. AIM OF SELFPREPARATION:


As a result of self-training, a student is supposed:
 to learn the right radiodiagnostic method to work out a certain (an
appointed) task;

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 to become acquainted with the principles of natural and artificial
contrast;
 to become acquainted with the roentgenopositive and roentgenonegative
contrast materials (substances);
 to define correctly the object of shooting, method and projection of an
investigation;
 to define the indication and contraindication to this or that kind of radiation
research.

III. INITIAL LEVEL OF KNOWLEDGE:


To study the topic the students are supposed to know from physics:
 the nature and properties of X-rays;
 the factors that influence the penetration power of X-rays;
 the factors that influence the absorbing power of X-rays.

IV. THE WAY TO STUDY THE TOPIC:


Sequence of actions Methods to carry out actions
1. Main X-ray examinations:
1.1. Fluoroscopy (roentgenoscopy) 1. Physics.
2. Fundamental resources.
3. Advantages.
4. Disadvantages.
5. Indications.
6. Contraindications.
7. Basic positions of the patient during the
investigation.

1.2. Radiography 1. Physics.


2. Fundamental resources.
3. Advantages.
4. Disadvantages.
5. Indications.
6. Contraindications.
7. Types of roentgenograms.
8. Peculiar properties of the radiographical
image.
9. Radiographical rules.
2. Modern types of X-ray
examinations:
2.1. Fluoroscopy derivatives: 1. Fluoroscopy with an intensifier of
images.
2. Roentgentelevision.
3. Recording a transmission on videotape.
4. The essence of these methods, their
advantages and diagnostic capabilities.
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2.2 Types of Roentgenography 1. Teleroentgenography.
(radiography) derivatives: 2. Radiography with the magnification of
2.2.1 Analog methods of image an image.
registration: 3. Photoroentgenography.
4. Conventional (lineal) tomography.
2.2.2 Digital methods of obtaining 5. Digital radiography.
images: 6. Computed tomography (CT).
7. The essence of these methods, their
advantages and diagnostic capabilities.

3. Special (contrast) methods: 1. Angiography.


2. Coronarography.
3. Bronchography.
4. Cholecystography.
5. Urography.
6. Lymphography.
7. Fistulography.
8. Arthrography.

4. Natural contrast study 1. The definition.


2. The influence of the chemical
composition, density and weight of an
organ.

5. Artificial contrast study


1. The reasons for the necessity of using
artificial contrast study of organs.
Ways of contrast study:
- cavities of an organ;
- cavity and surrounding tissues of an
organ;
- blood vessels;
- parenchyma of an organ;
- fistulas.
6. Contrast media (substances)
Groups:
1. Roentgenpositive (high atomic)
- barium sulfate;
- oily (Omnipak, Verograffin,
Magnevist);
- iodinated organic compounds.
2. Roentgennegative (low atomic)
- nitrous oxide;
- carbon dioxide;

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- oxygen;
- air.
V. RECOMMENDED LITERATURE:
1. Peter Armstrong, Martin L. Wastie "Diagnostic Imaging", Blackwell
Scientific Publications, Oxford, 1992. - Р. 2-4.
2. Paul W.Goaz, Stuart C.White "Oral Radiology", B.I. Publications Pvt. Ltd.,
New Delhi, 1998. - Р. 97-142.
3. P.R.Patel Lecture Notes on Radiology, 1998. - Р. 1-18.
4. George Simon, Arthur T.A. Wightman "Clinical Radiology", Butterworths,
Jaypee Brothers. - Р. 1-16.
5. Techniques in Diagnostic Imaging, Graham H.Whitehouse, Brian
S.Worthington, Blackwell Science, Third edition. - Р. 479-493.

VI. QUESTIONS FOR CONTROL:


1. Name two main (common) methods of the roentgenological investigation.
2. What is the essence of the fluoroscopy method?
3. What is the period of adaptation for the doctor's eyes before fluoroscopy?
What purpose is it for?
4. Name the advantages of the fluoroscopy.
5. Enumerate the main disadvantages of the fluoroscopy.
6. Name three main positions of a patient during the fluoroscopy.
7. Name the special equipment that improves the quality of the fluoroscopy?
8. Enumerate the organs whose motor function can be examined during the
fluoroscopy?
9. Explain the nature of the roentgenography (radiography).
10. Enumerate the main advantages of the radiography.
11. Enumerate the main disadvantages of the radiography.
12. What is the purpose of the fluorescent screen and cassette?
13. Name two types of roentgenograms (radiograms).
14. What rules should we to follow during radiography process?
15. What are the particular features of the X-ray image?
16. Explain the essence of the photo roentgenography.
17. Enumerate the advantages of photoroentgenography.
18. Name the variants of photoroentgenography.
19. Explain the physics of the conventional tomography.
20. Explain the physics of the computed tomography.
21. Enumerate the modern types of the fluoroscopy method.
22. Explain the physics of roentgentelevision.
23. What is implied by natural contrast?
24. Give the examples of the natural contrast of organs and tissue by taking the
thoracic cavity into consideration.
25. How can we decrease the magnification of an image?
26. What is the geometrical blurriness of a shadow?
27. What is the dynamic blurriness of a shadow?
28. Give the examples of special methods of X-ray examination.

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29. Give the examples of X-ray positive contrast materials.
30. Give the examples of X-ray negative contrast materials.
31. Name the main methods of the roentgenological investigation of the patients
with lung illnesses.
VII. THE PLAN OF STUDENTS WORK DURING THE CLASSES:
1. Test on the day’s topic.
2. Analysis of the main positions of the theme.
Topic: RADIOANATOMY AND X-RAY EXAMINATION OF THE CHEST.
I. AIMS OF MOTIVATION:
Different lung illnesses (inflammatory process, pulmonary tuberculosis,
tumors) have many common clinical symptoms. For example chest pain, cough, high
temperature. Roentgenological examination let us diagnose correctly these illnesses
and in accordance with it, choose the right method of treatment. In order to conclude
our diagnosis, we should have a good knowledge on radioanatomy and aspects of
general medicine.
II. AIM OF SELFPREPARATION:
As a result of self-training a student is supposed:
 to study X-ray anatomy (radioanatomy) of the chest organs of a healthy
human.
III. INITIAL LEVEL OF KNOWLEDGE:
To study the topic, the students are supposed to know:
from anatomy:
 the anatomy of the respiratory system (of a trachea, bronchi, lobar and
segmental lungs structure), anatomy and topography of pleura, the vessels of
the lesser circulation.
from physiology:
 physiology of the respiratory system, physiology of the respiration and
pulmonary circulation.
IV. THE WAY TO STUDY THE TOPIC:
Sequence of actions Methods to carry out actions
1. Basic X-ray investigation of the chest 1. Teleradiography.
organs: 2. Photoroentgenography.
3. Lineal tomography.
4. Computed tomography.
5. Fluoroscopy.

2. Special contrast examinations used 1. Bronchography.


for different organs: 2. Angiopneumography.
3. Cavography.
4. Artificial pneumothorax.
5. Artificial pneumoperitoneum.

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6. Artificial pneumomediastinum.
7. Introduction tracts for the contrast
substances.
3. Indications and contraindications 1. Study the anamnesis.
for the different X-ray examinations. 2. Study the clinical evidences
(findings).
3. Study the laboratory evidences.

4. Forming X-ray requisition form for 1. In a polyclinic:


an investigation. -indicate first name, last name and
middle initials; age; sex; address of a
patient;
-date of examination
-preliminary diagnosis;
-indicate region and the type of the
X-ray examination;
-name and initials of doctor.
2. In a hospital:
-indicate in the case history the region
and method of the roentgenological
investigation.

5. X-ray anatomy of a normal chest. 1. Chest shape.


2. Image of soft tissues.
3. Image of bony skeleton.
4. Shape and size of lung fields.
5. Transparency of the symmetric
lung fields.
6. Lung pattern.
7. Lung roots.
8. Position / contour of the domes of
diaphragm.
9. Condition of sinuses.
10. Position of the cardiovascular
shadow.
11. Projections of lung lobes on a
chest.
Lobar and segmental structure of lungs.

V. RECOMMENDED LITERATURE:
1. Peter Armstrong, Martin L. Wastie “Diagnostic Imaging”, Blackwell
Scientific Publications, Oxford, 1992. - Р. 15-22.
2. Frank Slaby, Eugene R.Jacobs “Radiographic Anatomy”, NMS, Harwal
Publishing Company, Media, Pennsylvania, 1990. - Р. 93-124.

16
3. Graham H.Whitehouse, Brian S. Worthington “Techniques in Diagnostic
Imaging”, Blackwell Scientific Publication, 1996. - Р. 250-265.
4. P.R. Patel Lecture Notes on Radiology. - Р. 20-23.
5. Emergency and Chest Radiology, Manorame Berry, Sima
Mukhopadhyay, Sudha Suri, Jaypee, 1996. - Р. 85-98.

VI. QUESTIONS FOR CONTROL:


1. Name the main methods of the roentgenological investigation of the patients
with lung illnesses.
2. Name the special methods of the roentgenological investigation of the patients
with lung illnesses.
3. Explain the essence of the bronchography method.
4. Name the contrast materials that are used for bronchography.
5. Indicate the projections of the main interlobar fissures on a chest.
6. Name the landmarks that let us differentiate left and right parts of a chest.
7. Name four factors that let us differentiate the posterior ribs part from the
anterior one on the X-ray film.
8. Enumerate the names of the lobes and segments of a right lung.
9. Enumerate the names of the lobes and segments of a left lung.
10. Name the pleural sinuses and indicate what bounds them.
11. Name the anatomic structures of an X-ray image of a lung pattern.
12. Indicate the shape, width and position of the lungs’ roots.
13. Name three anatomic sections of the mediastinum which can be differentiated
on a plain radiograph of a chest.
14. Name four groups of the intrathoracic lymph nodes through which lung
lymphokinesis takes place.
15. Form an X-ray requisition form for the roentgenological investigation of chest
organs.

VII. IMPORTANT TASKS FOR SELFWORK:


Draw as a scheme:
1. The projections of lung lobes on a frontal and lateral roentgenograms.
2. Segmental structure of a bronchial tree.
3. Bronchopulmonary segments.

VIII. THE PLAN OF STUDENTS WORK DURING THE CLASSES:


1. Test on the day’s topic.
2. Total analysis of the main sections of the day’s topic.
3. Individual work with roentgenograms according to the scheme of description of
X- ray images.

IX. SCHEME OF ACTIONS FOR PRACTICAL CLASSES:


Sequence of actions Methods to carry out actions
1. Preparation phase. 1. Sort the images according to
names and dates.

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2. Study the patient’s case history, if
available.

2. Determine the type of the Whether it is a plain or spot film.


roentgenograms, the position of Whether the body was in vertical or horizontal
the patient’s body and the position.
projection (view). Whether the projection is frontal (PA, AP) or
lateral (left, right).
3. Determine a film quality. A) Quality of a film depends on the conditions
of the X-rays generation in the X-ray tube:
1. Optimal conditions – the film is of normal
quality.
2. The conditions are greater than optimal –
hard film.
3. The conditions are lesser than optimal – soft
film.
B) Artefacts.
4. The order of studying a 1. Plain film in frontal projection.
roentgenogram. 2. Plain film in lateral projection.
3. The films in non-standard,
additional oblique projections, spot
films.
4. Tomograms, bronchograms,
angiograms, computed tomograms.
5. Correct placing of 1. The position of the heart’s shadow.
roentgenograms on the 2. The position of the stomach gas bubble.
negatoscope.
The symmetry of the sternal ends of the
6. Check the position of a clavicles in the ratio to the central line of a
patient during the investigation. chest, indicated by the line through the spinous
process of the thoracic vertebrae.

1. Chest shape.
7. The order of studying chest 2. The analysis of soft tissues.
organs on a roentgenogram. 3. The analysis of the bones.
4. Studying the forms and sizes of
lung fields.
5. Studying the transparency of the
symmetric lung fields.
6. Studying the lung pattern.
7. The analysis of lung roots.
8. The analysis of the position of the
domes of a diaphragm.
9. Studying the recesses or sinuses.

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10. The analysis of mediastinum.
Make your practical work in the form of a protocol as it is pointed above.

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Topic: THE BASIC ROENTGENOLOGICAL SYNDROMES OF THE
RESPIRATORY SYSTEM PATHOLOGY. DIFFERENTIAL DIAGNOSIS OF
THE TOTAL AND LIMITED SHADOWING SYNDROMES.

I. AIMS OF MOTIVATION:
Long-term observations of the roentgenologists which are based on
examination of millions of people allow to define the “normal” lungs picture and to
describe age-specific, sex and individual variants which are not the development of
an illness. The morphological and functional rate changes of the “norm” are the
symptoms of illnesses. There are many roentgenological symptoms. The sum of
roentgenological symptoms forms the roentgenological syndrome. There are nine
most important roentgenological syndromes; they are typical for certain pathologic
processes and they make it easier and faster to diagnose the illnesses.
Diagnosis - a complicated process where the doctor’s actions and thoughts are
closely linked with each other. We can mark out three main stages in making a
roentgenological conclusion:
1. The roentgenological examination of a patient and analyzing the X-ray
symptoms of an illness;
2. Syndrome formation; performing intersyndromic and intrasyndromic
differential diagnostics;
3. Logical analysis of the acquired information and making a conclusion.

II. AIM OF SELFPREPARATION:


As a result of self-training a student is supposed:
 to know the definition of every prevailing syndrome;
 to differentiate the basic roentgenological syndromes;
 to know the pathologoanatomic substratums of total and limited shadowings;
 to know the main illnesses which declare themselves in total and limited
shadowings.

III. INITIAL LEVEL OF KNOWLEDGE:


To study the topic the students are supposed to know:
 the roentgen pictures of the chest organs in principal projections, the structure
of a bronchial tree, projections of lobes and segments;
 the techniques of the roentgenological study of lungs: the roentgenography,
conventional (or lineal) tomography, photoroentgenography, computed
tomography (CT), fluorography, contrast study of bronchi and vessels;
 the scheme for analyzing the roentgenograms of thoracic cavity organs in
frontal and lateral projections.

IV. THE WAY TO STUDY THE TOPIC:


Sequence of actions Methods to carry out actions
1. Main types of the pathological To find these changes on the roentgenograms.
changes of the respiratory system:
a. shadowing,

20
b. transradiancy or translucency,
c. changing of lungs pattern and
roots.

2. The basic roentgenological Definition of every syndrome. To find


syndromes of lungs illnesses: corresponding images on the X-rays.
-total or subtotal shadowing, Intersyndromic differential diagnosis.
-limited shadowing,
-round shadow,
-ring-shaped shadow,
-(nidal) focal shadows,
-limited and diffused
disseminations of the focal
shadows,
-the pathology of a lung
pattern,
- the pathology of lungs’
roots and bronchial lymph
nodes,
- transradiancy of a lung
field.

3. The syndrome of the extensive 1. The syndrome of the total shadowing - is the
shadowing of a lung field. shadow more or less of the whole lung field.
2. Pathologoanatomic substratums and main
illnesses which cause this syndrome:
-lung’s atelectasis as a result of lumen
obstruction of the major bronchus (caused
by tumor, foreign body or by injury);
-fibrothorax;
-cirrhosis of lung;
-acute pneumonia;
-collection of fluid in the pleural cavity.
3. Intrasyndromic differential diagnosis.

4. The syndrome of limited 1. The syndrome of limited shadowing of lungs


shadowing of the lung field. field can be shadowing of a subsegment,
segment, lobe’s part, of lung’s lobe or a part of
lung field.
2. Pathologoanatomic substratums and main
illnesses which cause this syndrome:
-pneumonia;
-atelectasis as a result of complete lumen
obstruction of the lobar (segmental)
bronchus (caused by tumor or foreign
body);
- pneumosclerosis;
21
- pulmonary infarction;
- infiltrative tuberculosis;
- exudative pleurisy;
- diaphragmatic hernia.
3. Intrasyndromic differential diagnosis.

V. RECOMMENDED LITERATURE:
1. Peter Armstrong, Martin L. Wastie “Diagnostic Imaging”, Blackwell Scientific
Publications,Oxford,1992. - Р. 15-37.
2. Graham H. Whitehouse, Brian S. Worthington “Techniques in Diagnostic
Imaging”, Blackwell Scientific Publication, 1996. - Р. 250-265.
3. P.R.Patel Lecture Notes on Radiology, 1998. - Р. 20-23.
4. Field Guide to the Chest X-ray, Wallace T. Miller, Lippincotl Williams and
Wilkins. - Р. 53-67.
5. Emergency and Chest Radiology, Manorame Berry, Sima Mukhopadhyay,
Sudha Suri, Jaypee, 1996. - Р. 136-158.
6. "Clinical Radiology", George Simon, Arthur T.A. Wightman, Butterworths,
Jaypee Brothers, Fourth Edition. - Р. 188-206.

VI. QUESTIONS FOR CONTROL:


1. Enumerate nine most important roentgenological syndromes that are most
common in practice.
2. Enumerate the reasons which cause the decreasing of a lung field.
3. Point out the reasons for one side high position of the dome of diaphragm.
4. Name the reasons which cause narrowing of intercostal spaces.
5. Point out the reasons for one side low position of the dome of diaphragm.
6. Point out the reasons which cause enlargement of a lung field.
7. Name the reasons which cause dilatation of intercostal spases.
8. Formulate the definition of the “total shadowing of a lung field” syndrome.
9. Name the main pathologoanatomical substratums which cause the total
shadowing of a lung field.
10. Give the definition of the “limited shadowing of a lung field” syndrome.
11. Name the main pathologoanatomical substratums which cause the limited
shadowing of a lung field.
12. What causes segmental shadowing of a lung?
13. What causes lobar shadowing of a lung?
14. In which cases shadow has concavity border?
15. In which cases shadow has convexity border?
16. Name two main reasons of endobronchial obstruction.
17. Name three stages of bronchostenosis.
18. Name roentgenological signs of lung’s hypoventilation due to presence of
tumor in the major bronchus.
19. Name roentgenological signs of valvular emphysema of lobar bronchus.
20. Enumerate roentgenological signs of complete obturation of lobar bronchus.
21. Enumerate the reasons that cause mediastinal displacement to affected side.
22. Enumerate the reasons that cause mediastinal displacement to normal side.
23. Name eight signs that characterize pathologic shadow in lung field.
22
24. Name the gradations of shadow’s intensity and how these gradations can be
determined.
25. Name the pathologoanatomic stages of acute pleuropneumonia.
26. What roentgenological syndrome causes stages of hepatization?
27. What modern types of examination can confirm presence or absence of an
endobronchial tumor?

VII. IMPORTANT TASKS FOR SELFWORK:


Draw in the form of schemes:
1. Atelectases of the upper, middle and lower lobes of the right lung in two
projections.
2. Atelectases of upper and lower lobes of the left lung in two projections.
3. Acute pneumonia of the middle lobe in two projections.
4. Exudative pleurisy of the right side.

VIII. THE PLAN OF STUDENTS WORK DURING THE CLASSES:


 Test on the day’s topic.
 Total analysis on the main sections of the day’s topic.
 Individual work with an X-ray images, and description of the images
based on the scheme.

IX. SCHEME OF ACTIONS FOR PRACTICAL CLASSES:


Sequence of actions Methods to carry out actions
1. Preparation phase. 1. Sort out the roentgenograms according
to the methodics and dates. Enter first,
middle and last name, the age of the
patient and sex into the protocol.
2. Study the anamnesis of illness.
3. Study the clinical presentation.

2. Mark off “norm” and Schematically study the chest’s shape,


“pathology” by the X-ray films. the image of soft tissues and chest bones;
the size, shape and transparency of the
lung fields, the image of lung pattern,
lungs’ roots, the location of domes of
diaphragm and mediastinum.
Make a conclusion: is it “norm” or
“pathology”?

3. Define prevailing - total or subtotal shadowing,


roentgenological syndrome: - limited shadowing,
- round shadow,
- ring-shaped shadow,
- focal shadows,
- limited or diffused disseminations of
the focal shadows,
- the pathology of lung pattern,

23
- the pathology of lungs’ roots and
bronchial lymph nodes,
- diffused and limited transradiancy of
lung field.
Make a conclusion: which of the
syndromes is presented on the studied
roentgenogram?

4. Describe and draw the X-ray picture of When describing the syndrome do not
the detected syndrome: forget to indicate the following:
1. The localization:
- in lungs (lobe, segment);
- outside of a lung (pleural cavity, chest’s
wall, mediastinum, lymph nodes,
diaphragm).
2. Number of pathological changes:
- single,
- multiple.
3. Shape (configuration):
- round,
- oval,
- triangular,
- linear etc.
4. Sizes.
5. Density or intensity of shadow:
- small,
- middle,
- intensive,
- density of calcificated structures,
- density of metal.
6. Structure (pattern):
- homogeneous,
- heterogeneous (cellular, corded, spotted
etc.)
7. Circuits (contours):
- Well defined or ill defined,
- Regular or irregular (convex, concave,
tuberous, polycyclic, radiant and etc.)
Make preconclusion: to which group of
illnesses does the concrete observation
belong?
Let the teacher check the accuracy of
your answer.
Make your practical work in the form of a protocol as it is pointed above.
Topic: THE SYNDROMES OF THE ROUND AND RING-SHAPED
SHADOWS. LIMITED AND DIFFUSE DISSEMINATION OF THE NIDAL
SHADOWS. INTRASYNDROMIC DIFFERENTIAL DIAGNOSTICS.

24
I. AIMS OF MOTIVATION:
The last decades of the twentieth century are marked with an increase in the
number of cases in tuberculosis and lung cancer and the destructive complications of
pneumonia. The prognosis of the disease depends on the confirmed diagnosis of the
pathology. That’s why early diagnosis of such patients is the most important factor in
medicine. When patient’s complaints indicate, some respiratory tract illness, a doctor
should send him for photoroentgenography paying no attention to the date of the
previous investigation. The first step of the doctor is to choose the basic method of
examination needed for the patient. With the help of its results, its up to him to
choose whether the patient should be examined with other specialized methods
(investigations). The next step should be the following order of the necessary
investigations, starting from the most common and not difficult till the more
expensive and invasive.

II. AIM OF SELFPREPARATION:


As a result of self-training a student is supposed:
 to know the definition of the syndrome;
 to differentiate the roentgenological syndromes;
 to know the pathologoanatomic substratums of the round, ring-shaped and
nidal shadows;
 to know the main diseases which pictuarize themselves in the syndromes: the
round and ring-shaped shadows; in the limited, extensive and diffuse
dissemination of nidal shadows.

III. INITIAL LEVEL OF KNOWLEDGE:


To study the topic the students are supposed to know:
 the roentgen pictures of the chest organs in principal projections, the structure
of a bronchial tree, projections of lobes and segments;
 the techniques of the roentgenological study of lungs: the roentgenography,
conventional (or lineal) tomography, photoroentgenography, computed
tomography (CT), fluorography, contrast study of bronchi (bronchography) and
vessels;
 the scheme for analyzing the roentgenograms of the chest in frontal and lateral
projections.

IV. THE WAY TO STUDY THE TOPIC:


Sequence of actions Methods to carry out actions
1. The syndrome of the round 1. The syndrome of the round
shadow: shadow is a limited shadowing of a lung
field having round or oval form with
diameters more then 1 cm.
2. The pathologoanatomic
substratums and the main illnesses which
cause this syndrome:

25
- malignant tumors (primary or
metastatic);
- benign tumor;
- tuberculous infiltration or tuberculoma;
- eosinophylic infiltration;
- pneumonic infiltration;
- lung’s infarct;
- non drained pulmonary abscess;
- close cyst;
- encapsulated exudative pleurisy.
3. Intrasyndromic differential
diagnosis.
2. The syndrome of the ring-
shaped shadow: 1. The syndrome of the ring-shaped shadow
is a shadowing that has an X-ray image taken
in different projections in the form of a
closed ring and representing a cavity.
2. The pathologoanatomic substratums and
the main illnesses which cause this
syndrome:
- pulmonary abscess;
- tuberculous caverna;
- spherical form of peripheral lung cancer
with decay (cavitary carcinoma);
- congenital lung cyst.
3. Intrasyndromic differential diagnosis.
3. The syndrome of the nidal
shadows: 1. The syndrome of the nidal shadows are the
formations of round or irregular-shaped
shadows and have sizes from 1 mm to 1
3.1. Limited dissemination of the (1,5) cm.
nidal shadows. If the nidal shadows occupy the apex or in the
intercostal region (on an X-ray image in the
frontal projection) it is called “Limited
3.2. Extensive and diffusive dissemination”.
dissemination of the nidal Extensive dissemination - within one lung
shadows. field; and diffusive dissemination - in both
lung fields.
2. The pathologoanatomic substratums and
the main illnesses which cause this
syndrome:
- nidal tuberculosis;
- miliary tuberculosis;
- bronchopneumonia;
- pneumoconiosis (nodular type);

26
- carcinomatosis of lungs;
- alveolitis;
- haemosiderosis (caused by mitral stenosis).
3. Intrasyndromic differential diagnosis.

V. RECOMMENDED LITERATURE:
1. Peter Armstrong, Martin L. Wastie “Diagnostic Imaging”, Blackwell Scientific
Publications, Oxford, 1992. - Р. 22-95.
2. P.R. Patel Lecture Notes on Radiology, 1998. - Р. 24-59.
3. Wallace T.Miller, Wallace T.Miller jr. “Field guide to Chest X-ray. - Р. 68-91.
4. George Simon, Arthur T.A. Wightman "Clinical Radiology", Butterworths,
Jaypee Brothers, Fourth Edition. - Р. 214-223.
5. Emergency and Chest Radiology, Manorama Berry, Sima Mukhopadhyay,
Sudha Suri, Jaypee, 1996. - Р. 219-227.

VI. QUESTIONS FOR CONTROL:


1. What pathologoanatomic substratums cause round shaped shadowings?
2. What do you understand by syndrome of nidal shadows?
3. What pathologoanatomic substratums cause ring-shaped shadowings?
4. Name the most significant sign of a cavity presence in a lung.
5. Enumerate the most frequent illnesses that cause cavity development in a lung.
6. Enumerate two roentgenological symptoms of simultaneous presence of air and
liquid in a cavity formation in a lung or in pleural cavity.
7. Describe some distinctive features of a roentgenological picture of the
bronchopneumonia.
8. What are the sizes of the nidal shadows in case of the acinar
bronchopneumonia?
9. What are the sizes of the nidal shadows in case of the lobular
bronchopneumonia?
10. Describe the specific features of the staphylococcal bronchopneumonia.
11. Describe the specific features of the septic metastatic pneumonia.
12. What is the roentgenological approach to children with staphylococcal
pneumonia?
13. Name the variants of the primary lung cancer.
14. Enumerate the forms of the peripheral lung cancer.
15. Enumerate the anatomical structures and epithelium forms the peripheral
cancer.
16. Describe the roentgenological signs of the spherical cancer.
17. Describe the roentgenological signs of the metastatic (secondary) lung tumors.
18. Describe the roentgenological picture of the “closed” lung abscess.
19. Describe the roentgenological picture of the “opened” lung abscess.
20. Describe the roentgenological picture of the solitary congenital cyst of a lung.
21. Enumerate the illnesses for which limited dissemination of the nidal shadows
is typical.

27
22. Enumerate the illnesses for which extensive dissemination of the nidal
shadows is typical.
23. Name the illnesses for which diffusive dissemination of the nidal shadows is
typical.
24. Describe the differential diagnosis between bronchopneumonia and nidal
pulmonary tuberculosis.
25. Which illnesses constitute pneumoconiosis?

VII. IMPORTANT TASKS FOR SELFWORK:


Draw in the form of schemes:
1. The acute acinar pneumonia of the lower and middle lobes of the right lung.
2. Pneumonia of the upper lobe of the lung complicated by abscess.
3. Tuberculosis’ caverna of the apical segment of the left lung.
4. Metastatic lesion of the lungs.
5. Peripheral malignant tumor of the sixth segment of the right lung in two views.
6. Miliary tuberculosis of the lungs.
VIII. THE PLAN OF STUDENTS WORK DURING THE CLASSES:
1. Test on the day’s topic.
2. Total analysis on the main sections of the day’s topic.
3. Individual work with an X-ray images, and description of the images based on
the scheme.
IX. SCHEME OF ACTIONS FOR PRACTICAL CLASSES:
Sequence of actions Method to carry out actions
1. Preparation phase. Sort out the roentgenograms according to
methodics and dates. Enter first, middle and
last name, the age of the patient and sex into
the protocol.
Study the anamnesis of illness (if provided).
Study the clinical presentation.

2. Mark off “norm” and Sequentially study the chest’s shape, the image
“pathology” by the X-ray films. of soft tissues and chest bones; the size, shape
and transparency of the lung fields, the image
of lung pattern, lung roots, the location of
domes of diaphragm and mediastinum.

3. Define prevailing Make a conclusion: is it “norm” or


roentgenological syndrome: “pathology”?
- total or subtotal shadowing,
- limited shadowing,
- round shadow,
- ring-shaped shadow,
- focal shadows,
- limited or diffused disseminations of the
focal shadows,
28
- the pathology of lung pattern,
- the pathology of lung roots and
bronchial lymph nodes,
- diffused and limited transradiancy of
lung field.

4. Describe and draw the X-ray Make a conclusion: which of the syndromes is
picture of the detected syndrome: presented on the studied roentgenogram?
While describing the syndrome do not forget
to indicate the following:
1. The localization:
- in lungs (lobe, segment);
- outside of a lung (pleural cavity, chest’s
wall, mediastinum, lymph nodes,
diaphragm).
2. Number of pathological changes:
- single,
- multiple.
3. Shape (configuration):
- round,
- oval,
- triangular,
- linear etc.
4. Sizes.
5. Density or intensity of shadow:
- small,
- middle,
- intensive,
- density of calcificated structures,
- density of metal.
6. Structure (pattern):
- homogeneous,
- heterogeneous,
7. Circuits (contours):
- Well defined or ill defined,
- Regular or irregular (convex, concave,
tuberous, polycyclic, radiant and etc.)
Make preliminary conclusion: to which group
of illnesses does the concrete observation
belong?
Let the teacher check the accuracy of your
answer.
Make your practical work in the form of a protocol as it is pointed above.
Topic: THE SYNDROMES OF THE LUNG PATTERN PATHOLOGY, LUNG
ROOT PATHOLOGY, LUNG FIELD TRANSRADIENCY.
INTRASYNDROMIC DIFFERENTIAL DIAGNOSIS.

29
I. AIMS OF MOTIVATION:
The changes in lung pattern and in lung root structure can be observed in case
of different lung pathologies and which occur in the majority of the patients. It is
difficult to interpret these changes even by a professional radiologist. Sometimes only
by the combined efforts of a radiologist and a clinician precise clinical –
roentgenological diagnosis can be arrived at.

II. AIM OF SELFPREPARATION:


As a result of self-training a student is supposed:
 to know the definition of the syndromes;
 to differentiate the roentgenological syndromes;
 to know the pathologoanatomic substratums of the lung pattern pathology, lung
root and bronchial lymph nodes pathologies, transradiancy of a lung field;
 to know the main illnesses which declare themselves in the lung pattern
syndromes pathology, lung’s root and bronchial lymph nodes pathologies,
extensive and limited transradiancy of a lung field.

III. INITIAL LEVEL OF KNOWLEDGE:


To study the topic the students are supposed to know:
 X-ray pictures of the chest organs in principal projections, the structure of a
bronchial tree, projections of lobes and segments;
 X-ray pictures of the lung pattern and lung roots of a healthy man;
 the techniques of the roentgenological study of lungs: the radiography,
conventional (or lineal) tomography, photoroentgenography, computed
tomography (CT), fluoroscopy, contrast study of bronchi and vessels;
 scheme for analyzing the roentgenograms of thoracic cavity organs in frontal
and lateral projections.

IV. THE WAY TO STUDY THE TOPIC:


Sequence of actions Methods to carry out actions
1. The syndrome of a lung pattern 1. The syndrome of a lung pattern pathology:
pathology:
1.1 Enchancement 1.1 Enchancement is an increase in the number
elements of a lung pattern in an unit of area of a
lung field and increase in the quantity of these
elements.
1.2 Deformation 1.2 Deformation is a change of form and gauge,
direction and branching of components of a lung
pattern.
1.3 Weakening 1.3 Weakening is a decreasing in the number of
components in a lung pattern in a unit of area of
a lung field, e.g. pneumothorax.
2. Pathologoanatomic substratums and main
illnesses which cause this syndrome:

30
- congestional hyperemia of lungs in case
of mitral stenosis;
- hypoventilation of a lung in case of
endobronchial tumor growth;
- foreign body in the bronchus;
- viral pneumonias;
- interstitial form of pneumoconiosis;
- pneumosclerosises;
- chronic bronchitis;
- multiple bronchiectasis.
3. Intrasyndromic differential diagnosis.

2. The syndrome of a lung roots 1. The syndrome of lung roots pathology is the
pathology: change of the sizes, form and structure of a
root.
2. Pathologoanatomic substratums and main
illnesses which cause this syndrome:
2.1 Increasing 2.1 Arterial and venous hyperemia in case of
congenital and acquired malformations;
infiltration and edema of a root-fatty tissue;
enlargement of the bronchopulmonary
lymph nodes.
2.2 Decreasing 2.2 Heart diseases with decreasing blood afflux
to lungs.
2.3 Unstructured 2.3 Venous hyperemia;
pneumonias;
lung abscess;
tuberculous bronchoadenitis;
infiltrative tuberculosis;
enlargement of the bronchopulmonary
lymph nodes.
2.4 Fibrous deformation of a root 2.4 Pneumosclerosis of different etiology.
2.5 Shifting of a root to the 2.5 Atelectasis and cirrhosis of lung
pathology side
3. Intrasyndromic differential diagnosis.

3. The syndrome of transradiancy 1. The syndrome of transradiancy of a lung


of a lung field: field is the increase of transparency of a lung
field or its part.

3.1 Limited transradiancy 2. Pathologoanatomic substratums and main


3.2 Diffusive transradiancy illnesses which cause this syndrome:
- pneumothorax;
- pulmonary emphysema;
- decrease in blood circulation of a lung (in

31
case of some congenital malformations).
3. Intrasyndromic differential diagnosis.

V. RECOMMENDED LITERATURE:
1. Peter Armstrong, Martin L. Wastie “Diagnostic Imaging”, Blackwell Scientific
Publications, Oxford, 1992. - Р. 22-95.
2. Lectures.
3. P.R. Patel Lecture Notes on Radiology, 1998. - Р. 24-59.
4. Wallace T. Miller, Wallace T. Miller jr. “Field guide to Chest X-ray”. - Р. 8-28.
5. Emergency and Chest Radiology, Manorama Berry, Sima Mukhopadhyay,
Sudha Suri, Jaypee, 1996. – Р. 136-191; 204-228.
6. "Clinical Radiology", George Simon, Arthur T.A. Wightman Butterworths,
Jaypee Brothers, Fourth Edition, 1994. - Р. 242-245.

VI. QUESTIONS FOR CONTROL:


1. Enumerate the variants of lung pattern changes.
2. What do we mean by the term “enchancement” of a lung pattern?
3. What do we mean by the term “weakening” of a lung pattern?
4. What do we mean by the term “deformation” of a lung pattern?
5. Enumerate the illnesses in case of which the “enchancement and deformation”
of a lung pattern are detected.
6. Name the reasons that determine the absence of a lung pattern against a
background of increased transparency.
7. Name the reasons that determine the onset of the diffuse increased
transparency of lung fields.
8. Name the most frequent reason of the air entrapment in soft tissues of a chest
and in tissues of mediastinum.
9. Name the variants of bronchi changes which can be detected by
bronchography.
10. In case of what illnesses the enlargement of lymph nodes near the lung root
can occur?
11. What illnesses cause the decrease of a lung root?
12. Enumerate the illnesses that cause the increase of a lung root.
13. In case of what illnesses image of lung root is loss the normal structure?
14. Enumerate the illnesses that cause shifting of lung root to the side of
pathology.
15. What illnesses cause fibrous deformation of a root?
16. Enumerate the illnesses that are accompanied with the “enchancement” of a
lung pattern.
17. Enumerate the illnesses that are accompanied with the “weakening” of a lung
pattern.
18. Enumerate the illnesses that are accompanied with the “deformation” of a lung
pattern.
19. Describe the normal X-ray picture of a lung root.
20. Give the definition of a “lung pattern” in norm.

32
21. In which parts of a lung field is absent the image of lung pattern?
22. What structures compound the X-ray image of a lung pattern?
23. In what cases may a lung pattern be absent?
24. What can cause pneumothorax?
25. Describe the typical roentgenological picture of the spontaneous
pneumatothorax.

VII. IMPORTANT TASKS FOR SELFWORK:


Draw as a scheme:
1. Tuberculosis’ bronchoadenitis.
2. Right pneumothorax.
3. Hydropneumothorax.
4. Enchancement and deformation of a lung pattern.

VIII. PLAN OF STUDENTS WORK DURING THE CLASSES:


1. Test on the day’s topic.
2. Total analysis on the main sections of the day’s topic.
3. Individual work with an X-ray image and description of the images based on
the scheme.
4. Final test on the topic: “X-ray diagnosis of the pulmonary illnesses”.

IX. SCHEME OF ACTIONS FOR PRACTICAL CLASSES:


Sequence of actions Methods to carry out actions
1. Preparation phase. 1. Sort out the roentgenograms according to
methodics and dates. Enter first, middle and last
name, the age of the patient and sex into the
protocol.
2. Study the anamnesis of illness.
3. Study the clinical presentation.

2. Mark off “norm” and Sequentially study the chest’s shape, the image
“pathology” by the X-ray films. of soft tissues and chest bones; the size, shape
and transparency of the lung fields, the image of
lung pattern, lungs’ roots, the location of domes
of diaphragm and mediastinum.

3. Define prevailing Make a conclusion: is it “norm” or “pathology”?


roentgenological syndrome: - total or subtotal shadowing,
- limited shadowing,
- round shadow,
- ring-shaped shadow,
- focal shadows,
- limited or diffused disseminations of the
focal shadows,
- the pathology of lung pattern,
- the pathology of lungs’ roots and
bronchial lymph nodes,

33
- diffused and limited transradiancy of lung
field.
4. Describe and draw the X-ray Make a conclusion: which of the syndromes is
picture of the detected syndrome: presented on the studied roentgenogram?
While describing the syndrome do not forget to
indicate the following:
1. The localization:
- in lungs (lobe, segment);
- outside of a lung (pleural cavity, chest’s
wall, mediastinum, lymph nodes,
diaphragm).
2. Number of pathological changes:
- single,
- multiple.
3. Shape (configuration):
- round,
- oval,
- triangular,
- linear etc.
4. Sizes.
5. Density or intensity of shadow:
- small,
- middle,
- intensive,
- density of calcificated structures,
- density of metal.
6. Structure (pattern):
- homogeneous,
- heterogeneous (cellular, corded, spotted
etc.)
7. Circuits (contours):
- Well defined or ill defined,
- Regular or irregular (convex, concave,
tuberous, polycyclic, radiant etc.)
Make preliminary conclusion: to which group of
illnesses does the concrete observation belong?
Let the teacher check the accuracy of your
answer.
Make your practical work in the form of a protocol as it is pointed above.

34
Topic: RADIODIAGNOSTICS OF THE CARDIOVASCULAR SYSTEM.

I. AIMS OF MOTIVATION:
In order to diagnose cardiac pathology with the help of radiology, the doctors
should have adequate knowledge in different types of symptoms present in various
cardiac diseases. Visualizing the contractile heart was impossible till the invention of
roentgenological methods. After the invention of artificial contrastive methods, the
path-anatomical and path-physiological studies have improved and expanded. In
1970’s the introduction of ultrasound methods, in 1980’s computerized methods and
magnetic resonance tomography, in 1990’s spiral computed tomography are playing
an important role in diagnosing cardiac pathology. In the present decade, the usage of
special catheters in interventional radiology, has improved the aspects of treatment
and diagnosis.

II. AIM OF SELFPREPARATION:


As a result of preparation the students should know the following:
 acquaintance with the various types of radiological methods in examining the
cardiovascular system;
 learn the radiological anatomy of the cardio-vascular system.

III. INITIAL LEVEL OF KNOWLEDGE:


To study the topic the student should know the following:
from the course of general anatomy:
 general anatomy of the cardio-vascular system;
from the course of physiology:
 physiology of heart and blood circulation.

IV. THE WAY TO STUDY THE TOPIC:


Sequence of actions Methods to carry out actions
1. Main types of examinations 1. Radiography, teleroentgenography (in 3
projections with administration of contrast in
the esophagus).
2. Fluoroscopy.
3. Conventional tomography.
4. Importance of the above examinations, its
advantages and disadvantages.

2. Specialized types of 1. Roentgenokimography.


examinations 2. Roentgenocinematography.
3. Angiocardiography.
4. Cardioangiography.
5. Aortagraphy.
6. Coronarography.
7. Importance of the above examinations, its
advantages and disadvantages.

35
3. Anatomy of the heart and 1. Chambers of the heart.
circulatory system 2. Greater and lesser circulation.

4. Physiology of heart 1. Hemodynamics.


2. Gas volume.
3. Pathway of ventricular diastole and
systole.

5. Roentgenoanatomy of the 1. Position of the heart in normal


cardiovascular system conditions.
1.1. Changes in the position.
2. Shape of the cardio-vascular shadow.
3. Measurements of the arches of
cardiovascular shadow in:
- Frontal (straight) view;
- Right oblique projection;
- Left oblique projection.

V. RECOMMENDED LITERATURE:
1. Peter Armstrong, Martin L.Wastie “Diagnostic Imaging”, Blackwell Scientific
Publications, Oxford, 1992. - Р. 99-131.
2. Frank Slaby, Eugene R.Jacobs “Radiographic Anatomy”, NMS, Harwal
Publishing Company, Media, Pennsylvenia, 1990. - Р. 93-124.
3. Graham H. Whitehouse, Brian S. Worthington “Techniques in Diagnostic
Imaging”, Blackwell Scientific Publication, 1996. - Р. 119-193.
4. P.R. Patel Lecture Notes on Radiology, 1998. - Р. 62-64.

VI. QUESTIONS FOR CONTROL:


1. Name the main types of examinations used in visualizing the cardio-vascular
system.
2. Prepare an X-ray requisition form for the patients with cardiovascular
pathology.
3. List out the various specialized types of examination used in visualizing the
cardio-vascular system.
4. Define angiocardiography and the ways to use it.
5. Which type of radiological examination gives the exact images of the arches of
the cardio-vascular system?
6. Name the contrast substances used in angiocardiography.
7. What is the aim of administering contrast in the esophagus, during the
examination of the cardio-vascular system?
8. What will the position of the patient be while taking a right oblique projection?
9. What will the position of the patient be while taking a left oblique projection?
10. In which projections can the left atrium be visualized?
11. In which projections can the right atrium be visualized?
12. In which projections can the left ventricle be visualized?

36
13. In which projections can the right ventricle be visualized?
14. In which projections can the various parts of aorta be visualized?
15. What is the aim of taking images of the heart in conventional tomography?
16. What is the relation between the constitution of the patient and the orientation
of axis of the heart?
17. Name the various arches seen in the left and right contours of cardio-vascular
shadow, in frontal (PA) view.
18. Name the various arches seen in the anterior and posterior contours of cardio-
vascular shadow in right oblique projection.
19. Name the various arches seen in the anterior and posterior contours of cardio-
vascular shadow in left oblique projection.
20. List the various configurations of cardio-vascular shadow.

VII. IMPORTANT TASKS FOR SELF WORK:


Draw schemes of:
1. Vertical, oblique and horizontal position of axis of the heart.
2. Image of the normal heart in the straight, right and left oblique views: name the
arches of the cardiovascular shadow.

VIII. PLAN OF STUDENTS WORK DURING THE CLASSES:


1. Test on the day’s topic.
2. Discussion on the day’s topic.
3. Individual work with X-ray images, and description of the images based on
the scheme.

IX. SCHEME OF ACTIONS FOR PRACTICAL CLASSES:


Sequence of actions Methods to carry out actions
1. Preparation phase. 1. Examine the X-ray film to know the
method and the date of examination.
Prepare a protocol of the patient’s name,
sex and age.
2. Learn the case history of the patient.

2. Analysis of the type of X-ray 1. Plain or spot X-ray films.


film, position of the patient 2. Upright or supine position of the patient.
during examination and 3. Frontal (anterior, posterior) or oblique
projections in which the (left, right) projections.
images are taken.

3. Determination of the quality Quality of the image based on the exposure


of images. to X-rays:
- Optimal level of exposure – image is of
normal quality;
- Higher level of exposure – overexposed
images;

37
- Lower level of exposure – underexposed
images.

4. Schematic analysis of a 1. Plain X-ray in frontal view;


radiogram. 2. Plain X-rays in oblique projections;
3. Images taken in non-standard positions,
spot films;
4. Conventional tomograms,
bronchograms, angiograms, computed
tomograms.

5. Correctly orient the 1. Position of the cardio-vascular shadow,


roentgenograms on a 2. Position of the gas bubble of stomach.
negatoscope
1. Symmetrical placement of the clavicles
6. Proper positioning of the with the relation to the midline of the
patient while examining. chest.

1. Shape of the chest.


7. Examine the chest organs in 2. Analysis of the soft tissues.
an X-ray film: 3. Analysis of the bones.
4. Learn the shape and sizes of the lung
field.
5. Observe the symmetrical transparency of
the lung fields.
6. Observe the lung pattern.
7. Analysis of the roots in a lung.
8. Analysis of the position of the
diaphragm.
9. Observe the sinuses.
10. Analyze the mediastinal position.
11. Observe the cardio-vascular shadow:
 axial placement of the heart;
 configuration,
 sizes of the heart;
 sizes of the chambers (based on
arches).
12. Observe the functional condition of the
heart muscles (with the help of
fluroscopy or with modern
modifications).
Form a conclusion whether it is “norm” or
“pathology”.
Compose your practical work with the help of the above given scheme of actions.

38
Topic: ROENTGENODIAGNOSTICS OF THE ILLNESSES OF THE
CARDIOVASCULAR SYSTEM.

I. AIMS OF MOTIVATION:
Diagnosis of cardiac pathology can be accomplished by various types of
examinations like ultrasound diagnostics, computed tomography, coronary
angiography, etc., but the first and foremost fundamental type of examination is the
radiography. The importance of radiography in cardiac medicine is to visualize and
analyze the state of central circulation and the activity of heart. Any cardiac
pathology is always reflected in the lung image.

II. AIM OF SELFPREPARATION:


As a result of self-preparation, the students should know:
 various radiological syndromes of various valvular and vascular pathologies.
III. INITIAL LEVEL OF KNOWLEDGE:
To study the topic the student should know the following from the courses of
path-anatomy, path-physiology and internal medicine:
 etiology, pathogenesis and clinical features of mitral stenosis and
incompetence:
 etiology, pathogenesis and clinical features of aortic stenosis and
incompetence;
 etiology, pathogenesis and clinical features of acute and chronic
pericarditis;
 path-anatomy and clinical features of vascular diseases (aneurysm,
chronic thrombosis of aorta, atherosclerotic occlusion of the peripheral artery).
IV. THE WAY TO STUDY THE TOPIC:
Sequence of actions Methods to carry out actions
1. Valvular heart disease, with 1. Mitral valve stenosis:
mitral configuration: 1.1. Path-anatomical changes.
1.2. Blockages of blood flow.
1.3. Changes in the lung.
1.4. Diffusive constriction of the small
pulmonary vessels.
1.5. Changes in the chambers of heart.
1.6. Radiological symptoms of mitral stenosis.
2. Mitral valve Incompetence:
2.1. Path-anatomical changes.
2.2. Hemodynamic disturbances.
2.3. Changes in the chambers of heart.
2.4. Radiological symptoms of mitral
incompetence.
2.5. Radio-functional symptoms.
3. Mixed Mitral valvular disease:

39
roentegnological signs prevailing stenosis and
incompetence.
2. Valvular heart disease, with 1.Aortic stenosis:
aortic configuration: 1.1. Hemodynamic changes.
1.2. Path-anatomical changes.
1.3. Radiological changes.
1.4. Radio-functional symptoms.
2. Aortic incompetence:
2.1. Path-anatomical changes.
2.2. Hemodynamic changes.
2.3. Radiological changes.
2.4. Radio-functional symptoms.

3. Syndromes of trapezoid and 1. Diffusive impairment of myocardium:


spherical shapes of heart: 1.1. Radiological signs.
2. Accumulation of fluid in the
pericardium:
2.1. Radiological signs.
3. Adhesive mediastino-pericarditis:
3.1. Radiological signs.

4. Vascular diseases: 1. Aneurysms of aorta.


2. Aneurysms of the peripheral arteries.
3. Atherosclerotic occlusions of blood
vessels.
4. Embolus and thrombosis (acute and
chronic).
5. Aortitis and arteritis.

V. RECOMMENDED LITERATURE:
1. Peter Armstrong, Martin L.Wastie “Diagnostic Imaging”, Blackwell
Scientific Publications, Oxford, 1992. - Р. 107-131.
2. P.R. Patel Lecture Notes on Radiology, 1998. - Р. 65-81.
3. Emergency and Chest Radiology, Manorama Berry, Sima Mukhopadhyay,
Sudha Suri, Jaypee, 1996. - Р. 229-250.

VI. QUESTIONS FOR CONTROL:


1. List the various types of configurations of heart.
2. Define the mitral configuration of heart.
3. Describe the aortic configuration of heart.
4. Which shape of cardio-vascular shadow is typical for accumulative
pericarditis?
5. Dilatation of which chamber of heart causes the closure or absence of retro-
cardial space in oblique views?

40
6. Dilatation of which chamber of heart causes the closure or absence of the
“aortic window” and in what view it is visualized?
7. Indicate the shape of apex of the heart with aortic stenosis and aortic
incompetence.
8. In which form of mitral valve disease can we observe regurgitation of blood?
Name the radio-functional symptom.
9. List out the radiological signs of mitral incompetence.
10.What are the changes observed in the blood vessels of the lung caused by
mitral stenosis?
11.List out the radiological signs of mitral stenosis.
12.What are the prevailing signs that help to differentiate mitral incompetence
from mitral stenosis?
13.Which chambers of the heart undergo changes in patients with aortic stenosis?
14.What changes are observed in the frequency and amplitude of contractions of
the myocardium during aortic stenosis?
15.What changes are observed in the frequency and amplitude of contractions of
the myocardium during aortic incompetence?
16.What type of pulsation is seen in the aorta due to aortic stenosis?
17. What type of pulsation is seen in the aorta due to aortic incompetence?
18.Which diseases are characterized by mitral configuration of heart?
19.Which diseases are characterized by aortic configuration of heart?
20. List out the signs causing an increase in sensitivity of iodine.

VI. IMPORTANT TASKS FOR SELF WORK:


Draw the schemes of:
1. The images of the heart with mitral stenosis in the frontal (straight), first and
second oblique views.
2. The image of heart with mitral incompetence in the frontal (straight), first and
second oblique views.
3. The shifting of the esophagus by the small and large radii.
4. The image of aortic shaped heart.
5. The image of spherical and trapezoidal shaped heart.

VII. THE PLAN OF STUDENTS WORK DURING THE CLASSES:


1. Test on the day’s topic.
2. Discussion on the day’s topic.
3. Individual work with an X-ray images, using the scheme.

VIII. SCHEME OF ACTIONS FOR PRACTICAL CLASSES:


Sequence of actions Methods to carry out actions
1. Preparation phase. 1. Examine the X-ray film to know the
method and the date of examination.
Prepare a protocol by adding the patient’s
name, initials and age.

41
2. Learn the case history of the patient.

2. Analysis of the X-ray film, 1. Plane or spot X-ray films.


position of the patient while 2. Upright or supine of the patient.
examining and projecting. 3. Straight (PA or AP) or oblique (left,
right) projection.

3. Determination of the quality of Quality of the image based on the exposure


images. of x-rays:
- Optimal level of exposure – image is of
normal quality;
- Higher level of exposure – overexposed
images;
- Lower level of exposure –
underexposed images.
4. Learning a roentgenogram: 1. Straight view image in upright position.
2. Straight view images in oblique
projections.
3. Images taken in non-standard positions,
spot images.
4. Tomograms, bronchograms, angiograms,
computed tomography.
5. Position of roentgenograms on a 1. Position of the cardio-vascular shadow.
negatoscope is correct (incorrect): 2. Position of the gas bubble of stomach.

6. Orientation of the patient while 1. Symmetrical placement of the clavicles


examining. with the relation to the midline of the
chest.
7. Examine the chest organs in X- 1. Shape of the chest.
rays: 2. Analysis of the soft tissues.
3. Analysis of the bones.
4. Learn the shape and sizes of the lung
field.
5. Observe the symmetrical transparency
of the lung fields.
6. Observe the lung pattern.
7. Analysis of the roots in a lung.
8. Analysis of the position of the
diaphragm.
9. Observe the sinus.
10. Analyze the mediastinal position.
11. Observe the cardio-vascular shadow:
- axial placement of the heart;
- configuration,
- sizes of the heart;

42
- sizes of the chambers (based on
arches).
12. Observe the functional condition of the
heart muscles (with the help of
roentgenoscopy or with the latest
modifications).
8. Determine the principal Make a conclusion whether it is a “norm” or
visible radiological syndrome: a “pathology”.

1. Mitral shape of the heart.


2. Aortal shape of the heart.
3. Trapezoid or spherical shape.
9. Check with inter-syndromic Form a result, which is presented on an X-ray
differential diagnosis: image, according to the shapes given above.

Use the diagnostic algorithms to detect the type


of syndrome (shape of the heart), and make a
radiological conclusion.
Confirm with the teacher whether the
conclusion is correct.
Compose a description of the given X-ray image, with the help of the above
given scheme of actions.

Topic: X-RAY EXAMINATIONS OF THE GASTRO-INTESTINAL TRACT.


RADIOLOGICAL ANATOMY OF THE GASTRO-INTESTINAL TRACT.

I. AIMS OF MOTIVATION:
The Radiology of clinical diseases of the digestive system is of great
importance. Gratitude towards the vast success in the method and techniques of
examination, in the present time radiology has an important place in diagnosing
diseases of gastro-intestinal tract.
Careful usage of radiological examination allows us to get a clear -cut picture
on the morphological and functional condition of the organs in the gastrointestinal
tract.

II. AIM OF SELF PREPARATION:


As a result of self-preparation the student should know:
 to get introduced with the different radiological methods of examination
of the gastro-intestinal tract;
 to learn the indications and contra-indications for radiological
examination of the gastro-intestinal tract.

III. INITIAL LEVEL OF KNOWLEDGE:


To learn the topics the students should have known from the course of
anatomy:

43
 anatomy of organs of the GIT; location and structure of esophagus,
stomach, small and large intestines; liver, gall bladder, pancreas.
From the course of physiology:
 physiology of the gastrointestinal tract.

IV. PREPARATION OF TOPICS:


Sequence of actions Method to carry out actions
1. Contrast substances 1. Roentgeno-positive.
2. Roentgeno-negative.
3. Preparation methods.
4. Route of administration of the contrasts.

2. Main types of X-ray 1. Fluoroscopy and their present


examination modification.
2. Radiography.
3. Indications.
4. Contraindications.

3. Specialized types of X-ray 1. Fluoroscopy with barium sulphate.


examination for the esophagus 2. Radiography.
3. Double contrast studies.
Prepare the patient for examination.

4. Specialized types of X-ray 1. Fluoroscopy with barium sulphate.


examination for the stomach 2. Radiography.
3. Double contrast studies.
4. Parietography and Tomoparietograhy.
5. Triple contrast studies.
6. Polygraphy.
7. Examination with the intake of
pharmacological mediums.
Prepare the patient for examination.

5. Specialized types of X-ray 1. Fluoroscopy with intake of barium


examination for the duodenum sulphate.
2. Radiography.
3. Relaxative Duodenography (with
catheter or with special medium).
Prepare the patient for examination.

6. Specialized types of X-ray 1. Plain X-ray of the abdominal cavity.


examination for the large 2. Irrigoscopy(barium enema).
intestine 3. Double contrast studies.
4. Triple contrast studies.
5. Parietography and tomoparietography.

44
6. Per Os contrast studies.
Prepare the patients for examination.
7. Radiological anatomy of the 1. Pharynx.
GIT 2. Esophagus.
3. Stomach.
4. Duodenum.
5. Small intestine.
6. Large intestine.
7. Location, form, identification of the
various GIT parts, pattern of the
mucosal folds.

8. Roentgeno-physiology of the GIT 1. Peristalsis.


2. Tonus.
3. Evacuation.

V. RECOMMENDED LITERATURE:
1. Peter Armstrong, Martin L. Wastie “Diagnostic Imaging”, Blackwell Scientific
Publications, Oxford, 1992. - Р. 133,145-147,157-158,174-175.
2. Graham H. Whitehouse, Brian S.Worthington “Techniques in Diagnostic
Imaging”, Blackwell Scientific Publication, 1996. – Р. 13-73.
3. Frank Slaby, Eugene R. Jacobs “Radiographic Anatomy”, NMS, Harwal
Publishing Company, Media, Pennsylvania, 1990. - Р. 137-156.
4. P.R. Patel Lecture Notes on Radiology, 1998. - Р. 84-86.

VI. QUESTIONS FOR CONTROL:


1. Formulate directions for a patient requiring radiological examination of
the esophagus, stomach and duodenum.
2. Formulate directions for a patient requiring radiological examination of
the large intestine.
3. Enumerate the main and specialized types of radiological examination of
the esophagus, stomach and duodenum.
4. Fix an appointment for the patient for irrigoscopy (barium enema).
5. Enumerate the directions for preparing the patient for irrigoscopy (barium
enema).
6. Describe, in brief, irrigoscopy.
7. Name two main types of examinations for large intestine.
8. Name the types of examinations, which indicate the presence of morphological
changes in the large intestine.
9. Describe the radiological image of normal mucous folds of the esophagus.
10. What are the normal contours of the esophagus?
11. Name the parts of the stomach and duodenum.
12. Enumerate the parts and physiological narrowing of the esophagus.
13.Enumerate the characteristics of the normal mucosal pattern of the stomach.
14.In what cases is compression of the stomach done?

45
15.Name the configurations of the normal stomach.
16.Describe the contours of lesser and greater curvatures of the stomach when it is
completely filled by contrast.
17.Name the parts of the large intestine.
18.Define the double contrast studies of GIT.
19.What are the advantages of double contrast studies?
20.Define the triple contrast studies and enumerate its advantages.

VII. IMPORTANT TASKS FOR SELF-WORK:


Draw the schemes of:
1. The esophagus completely filled by contrast in the straight and oblique views.
2. The image of the stomach and duodenum completely filled with the contrast in
the straight view, indicate the anatomical parts.
3. The image of the large intestine completely filled with the contrast in the
straight view, indicate all anatomical parts.

VIII. PLAN OF STUDENTS WORK DURING THE CLASSES:


1. Test on the day’s topic.
2. Discussion on the day’s topic.
3. Individual work with an X-ray film, using the scheme.

IX. SCHEME OF ACTIONS FOR PRACTICAL CLASSES:


Sequence of actions Methods to carry out actions
1. Preparation phase 1. Examine the X-ray film to know the
method and the date of examination.
Prepare a protocol by adding the patient’s
name, initials and age.
2. Learn the case history of the patient.
3. Learn the clinical features.

2. Analysis of the X-ray film 1. Identify the part, which is examined.


2. Identify the type of radiological
examination.
3. Type of the X-ray film (plane or spot).
4. Identify the orientation of the patient.
5. Projection in which the image has been
taken (straight, oblique, lateral).
6. Identify whether contrast agents are
used or not. If yes, name the contrast
used.
7. Identify the route of administrating
contrast.
8. Indicate the extent to which the organ is
filled with contrast.

46
Compose your practical work with the help of the above given scheme of
actions.
Topic: PRINCIPAL SYNDROMES OF DISEASES IN ORGANS OF GASTRO-
INTESTINAL TRACT.

I. AIMS OF MOTIVATION:
In evaluation of the esophagus for presence of pathologies or otherwise,
endoscopic procedures may have a role to play, but their utility is restricted in
conditions such as presence of pathological strictures of the esophagus or varicose
veins. It is here in the assessment of such cases that the radiological methods and
techniques of evaluation come into play. Proper choice of the radiological
investigative modalities available and their proper interpretation by trained
radiologists is of paramount importance in diagnosing the various pathologies of the
esophagus.

II. AIMS OF SELFPREPARATION:


As a result of self-preparation, the students should know:
 The basic radiological syndromes in pathology of the GIT.
 The different types of diseases of esophagus with the help of
radiological signs (Diverticulosis, Achalasia, Varicosis, Corrosive Strictures,
Tumours).
 The methods, by which the presence of foreign body in gastro-intestinal
tract may be detected.

III. INITIAL LEVEL OF KNOWLEDGE:


To learn the topic the students should know the following items, from the
course of therapy and surgery:
 the clinical features of diseases of esophagus.

IV. THE WAY TO STUDY THE TOPICS:


Sequence of actions Methods to carry out actions
1. Principal syndromes of the 1. Syndromes of dilatation of the GIT:
GIT - Diffusive
- Local.

2. Syndromes of narrowing of the GIT:


- Diffusive
- Local.

3. Syndromes of changes in contour.


4. Syndromes of changes in the mucous
pattern.
5. Deformation of the esophagus, stomach or
intestines.
6. Displacement of the esophagus, stomach

47
or intestines.

2. Radiological signs of diseases 1. Diverticuli of the esophagus:


of the esophagus - Types,
- Pathogenesis,
- Forms,
- Complications.
2. Achalasia of the esophagus.
- Definition,
- Clinical features,
- Stages of the process,
- Radiological features.
3. Corrosive strictures of the esophagus:
- Time of the radiological examination after
the patient has consumed alkalis or acids,
- Location of the corrosive strictures.
- Radiological features.
- Prognosis.
4. Varicosis of the esophagus:
- Pathogenesis.
- Location.
- Radiological features.
5. Tumours of the esophagus:
- Radiological features of the Exophytic
(intraluminal) tumour.
- Radiological features of the Endophytic
(intramural) tumour.

3. Methods used to identify 1. Fluoroscopy and radiography in different


foreign bodies views.
3.1. Roentgeno-positive 2. Per oral study of Gastro-intestinal tract
with barium sulphate or contrast enema, to
confirm the location of the foreign body.
3. Examinations with roentgeno-negative
contrasts (gases).

3.2. Roentgeno-negative 1. Radiography of the pharynx in lateral


view.
2. Examination of pharynx and esophagus,
with water soluble contrast mediums
(Gastrograffin).

48
V. RECOMMENDED LITERATURE:
1. Peter Armstrong, Martin L. Wastie “Diagnostic Imaging”, Blackwell Scientific
Publications, Oxford, 1992. - Р. 133,145-156.
2. Graham H. Whitehouse, Brian S.Worthington “Techniques in Diagnostic
Imaging”, Blackwell Scientific Publication, 1996. - Р. 13-73.
3. Frank Slaby, Eugene R. Jacobs “Radiographic Anatomy”, NMS, Harwal
Publishing Company, Media, Pennsylvania, 1990. - Р. 137-156.
4. P.R. Patel Lecture Notes on Radiology, 1998. - Р. 84-86.
5. George Simon, Arthur T.A. Wightman "Clinical Radiology", Butterworths,
Jaypee Brothers, Fourth Edition. - Р. 267-273.
VI. QUESTIONS FOR CONTROL:
1. Define Achalasia.
2. Enumerate the radiological signs which differentiate achalasia of esophagus
and the tumour in the cardiac part of the stomach.
4. Define Diverticulum.
5. What are the divisions of Diverticulosis on the basis of origin?
6. Describe the pathogenesis of the traction diverticuli.
7. Describe the pathogenesis of the pulsion diverticuli.
8. Enumerate the complications of diverticuli.
9. Describe the radiological features of diverticulitis.
10. In which diseases do varicosis of esophagus and varicosis of the upper part of
the stomach appear?
11. Write the radiological signs of varicosis of esophagus.
12. Which examinations are used to find out the presence of a metallic foreign
body in the patient’s GIT?
13. Which examinations are used to find out the presence of a radio-negative
foreign body in the patient’s GIT?
14. What are the causes of corrosive strictures in the esophagus?
15. Write radiological features of corrosive strictures of the esophagus.
16. If a patient has consumed acids or alkalis, after what duration of time should
he be examined radiologically for the confirmation of the presence of corrosive
strictures?
17. Which part of the esophagus is affected more often due to the intake of acids
and alkalis.
18. Write the radiological signs for exophytic (intraluminal) tumour in the
esophagus.
19. Write the radiological signs for endophytic (intramural) form of tumour in the
esophagus.
20. Describe the mucosal pattern of the esophagus.
21. How will you differentiate the physiological narrowings of the esophagus
from the intraluminal form of esophageal tumour?
VII. IMPORTANT TASKS FOR SELF-WORK:
1. Achalasia of the esophagus.
2. Tractional and pulsating diverticuli.
3. Exophytic tumour of esophagus.

49
4. Endophytic tumour in the middle one-third of the esophagus.
5. Corrosive strictures of the esophagus.
6. Free gas in the peritoneal cavity caused by the perforation of stomach.
VIII. PLAN FOR STUDENTS WORK DURING THE CLASSES:
1. Test on the day’s topic.
2. Discussion on the day’s topic.
3. Individual work with an X-ray film, using the scheme.
IX. SCHEME OF ACTIONS FOR PRACTICAL CLASSES:
Sequence of actions Method to carry out actions
1. Preparation phase 1. Examine the X-ray film to know the
method and the date of examination.
Prepare a protocol by adding the patient’s
name, initials and age.
2. Learn the case history of the patient.
3. Learn the clinical features.

2. Analysis of the X-ray film 1. Identify the part, which is examined.


2. Identify the type of radiological
examination.
3. Type of the X-ray film (plane or spot).
4. Identify the orientation of the patient.
5. Projection in which the image has been
taken (straight, oblique, lateral).
6. Identify whether contrast agents are
used or not. If yes, name the contrast
used.
7. Identify the route of administering the
contrast.

1. Indicate the extent to which the organ


3. Check in the X-ray film the is filled with contrast.
differences between the normal 2. Learn the position of the organ.
and the pathological image - Normal location,
- Displaced.
3. Learn the form of the organ:
- Normal,
- Deformed.
4. Size of the organ:
- Normal size,
- Decreased,
- Increased.
5. Learn the contours of the organ:
- Bulging,
- Invaginating,
Indicate the sizes, amount and a form of
the changes.

50
6. Mucous pattern
- Thickness,
- Direction,
- Quantity,
- Forms.
7. Gas bubble of the stomach (presence of
additional shadows, thickening of the
fundus, deformation).
8. Learn the shadow of the organ which is
completely filled with the contrast:
- Homogenous shadow,
- Filling defect (amount, forms, sizes,
contours, collection of contrast in the
defect).
9. Condition of the organ, in double
contrast studies (presence or absence
of additional shadow in the lumen of
organ).
10. Tonus.
11. Peristalsis.
12. Evacuation.
Confirm whether it is a normal image or a
pathological image.
1. Syndromes of dilatation of the GIT:
- Diffusive,
4. Define the prevailing - Local.
roentgenological syndrome 2. Syndromes of narrowing of the GIT:
- Diffusive,
- Local.
3. Syndromes of changes in contour.
4. Syndromes of changes in the mucous
pattern.
5. Deformation of the esophagus,
stomach and intestines.
6. Displacement of the esophagus,
stomach and intestines.
Formulate the radiological diagnosis. Check
your conclusion with the clinical presentation
of a patient. Which additional investigative
5. Formulate your diagnosis procedures can help to confirm your
diagnosis? Check your conclusion with the
teacher.
Compose a description of the given X-ray image, with the help of the above given
scheme of actions.

51
Topic: RADIODIAGNOSTICS OF ULCEROUS DISEASES AND TUMOURS
OF THE GASTRO-INTESTINAL TRACT.

I. AIMS OF MOTIVATION:
An ulcer in the gastro-intestinal tract is defined as – loss of mucous surface
causing gradual disintegration and necrosis of the tissues. An ulcerous disease is a
chronic process, which doctors come across in day to day life. Duodenal ulcerations
are four times more common than gastric ulcerations, duodenal ulcer has an even age
distribution, whereas gastric ulcers tend to occur after the age of forty.
In most of the developing countries, tumours of the gastro-intestinal tract are
more frequently experienced. In Japan, the prevalence of gastric carcinoma is high,
where successful screening programs have been developed.
The early diagnosis and differential diagnosis of tumours of the gastro-
intestinal tract always pose a difficulty which can be overcome by the usage of
certain radio-diagnostic methodologies and endoscopy.

II. AIM OF SELF PREPARATION:


As a result of self preparation, the students should know the following:
 learn the basic X-ray symptoms of ulcers and its complications;
 learn the various X-ray images of different types of tumours of GIT;
 learn the X-ray symptoms of acute abdomen.

III. INITIAL LEVEL OF KNOWLEDGE:


In order to study the topic, the students should know the following items
 from the course of pathoanatomy:
- usual forms of Gastro intestinal tumours;
- gastric ulcers.
 from the course of surgery:
- clinical presentations of ulcerous diseases and its complication;
- clinical presentations of gastric carcinomas and intestinal tumours;
- clinical presentation of acute intestinal obstruction.

IV. THE WAY TO STUDY THE TOPIC:


Sequence of actions Methods to carry out actions
1. Gastric and Duodenal ulcers. 1. Definition, frequency and localizations.
2. Pathoanatomical picture.
3. Clinical features.
1.1. Roentgeno-semiotics of ulcers: 1. Possible radiological methods.
2. Direct symptom.
3. Indirect symptoms:
- roentgenomorphological;
- roentegnofunctional.
4. Associated pathologies.
1.2. Complications:
1.2.1. Penetration 1.2.1. Clinical, Radiological symptoms

52
1.2.2. Clinical, Radiological symptoms and
1.2.2. Perforation
radiological tactics in cases of perforation.
1.2.3. Clinical presentation and peculiarities in
1.2.3. Haemorrhage
radiological examinations.
1.2.4. Frequency of the malignization of ulcers,
1.2.4. Malignization
peculiarities of clinical features,
Radiological symptoms.
1.2.5. Types of stenosis: Compensative, sub-
1.2.5. Stenosis of the pyloric canal
compensative and de-compensative.

Classification, Roentgenomorphological and


2. Chronic gastritis
roentgenofunctional symptoms.

3. Tumours of gastro-intestinal tract


Polyps, leiomyoma, fibroma, etc., roentgeno-
3.1. Benign
semiotics of benign tumours.
Carcinoma, sarcoma. Classifications, patho-
3.2. Malignant
anatomical features of the main types of gastric
carcinomas, clinical features, metastatic
pathways.
Roentgenosemiotics of dish-like or ulcerative,
polypoid or fungative, patchlike , primary
ulcerative, diffusive infiltrative and infiltrative
ulcerative.
Peculiarities in the roentgenosemiotics of the
tumours in the proximal part of the stomach.
Roentgenosemiotics of large bowel
carcinomas.
Reasons and clinical features.

Roentgenodiagnostics of perforation of the


4. Acute abdomen
peritoneal organs.

V. RECOMMENDED LITERATURE:
1. Peter Armstrong, Martin L. Wastie “Diagnostic Imaging”, Blackwell Scientific
Publications, Oxford, 1992. - Р. 157-192.
2. H. Whitehouse, Brian S.Worthington “Techniques in Diagnostic Imaging”,
Blackwell Scientific Publication, 1996. - Р. 22-73.
3. Clinical Radiology, George Simon, Arthur J.A.Wightman, Bulterworthe,
Jaypee Brothers, Fourth Edition. - Р. 100-137.
4. P.R. Patel Lecture Notes on Radiology, 1998. - Р. 84-86.

VI. QUESTIONS FOR CONTROL:


1. What are the path-anatomical substratums of “symptom of niche”?
2. What are the path-anatomical substratums of “symptom of filling defect”?

53
3. List out the reasons of the convergence of mucosal folds.
4. List out the reasons of the divergence of mucosal folds.
5. Point out the reasons why there is an “amputation of mucosal folds”?
6. Name two pathological features which indicate the absence of peristaltic
movements in any part of stomach.
7. Differentiate the filling defects of a polyp from gastric carcinoma.
8. Point out the path-anatomical substratums that can characterize the combination
of a “filling defect” and a “niche”.
9. Describe the roentgenological picture of “Niche en face”.
10. Describe the roentgenological picture of “Niche in profile”.
11. List the variants of deformation of stomach due to the scarring of ulcer.
12. List out the types of chronic gastritis.
13. List out the roentgeno-morphological symptoms of chronic gastritis.
14. List out the roentgeno-functional symptoms of chronic gastritis.
15. List out the path-anatomical forms of gastric carcinomas.
16. Describe the principle symptoms of intraluminal type of carcinomas of
stomach?
17. Describe the principle symptoms of intramural type of carcinomas of
stomach?
18. List out the localization of gastric carcinomas which may be visualized
without contrast administration.
19. What is the shape of stomach in infiltrative types of gastric carcinomas?
20. What are the radiological features which indicate the maliginization of an
ulcer?
21. Describe the typical image of penetrative type of ulcers?
22. Point out path-anatomical substratums of “kloibers cup”.
23. List out the peculiarities of the kloibers cup in small and large bowel
obstructions.
24. Which radiological symptom shows signs of peritoneal organ perforation?
25. In which orientation of the patient can free gas in the abdomen be visualized?
26. What radiological signs characterize the rigid antral gastritis?
27. Describe the radiological picture of erosive gastritis?
28. Describe the radiological picture of polypoid gastritis?
29. Describe the sites of extrinsic gastric compressions?

VII. IMPORTANT TASKS FOR SELF-WORK:


Draw schemes of:
1. Niche (in profile) in the lesser curvature of the body of the stomach;
2. Niche (en face) in the body of stomach;
3. Deformations of the stomach – “hour-glass”, “cochlea” and “tobacco pouch”;
4. Deformations of the duodenum – “clover leaf”;
5. Penetrating ulcer in the lesser curvature;
6. Free gas in the abdominal cavity due to the perforation of ulcer;
7. X-ray symptoms of acute intestinal obstruction.

54
8. Image of gastric polyps in contrast filled stomach and in double contrast
examination;
9. Principle forms of gastric carcinomas;
10. Proximal intraluminal gastric carcinomas;
11. Proximal intramural gastric carcinomas;
12. Dish like or ulcerative type of caecal carcinomas;
13. Intramural carcinomas of descending colon;
14. Symptom of amputation of ascending colon.

VIII. PLAN FOR STUDENTS WORK DURING THE CLASSES:


1. Test on the day’s topic.
2. Discussion on the day’s topic.
3. Individual work with an X-ray, using the scheme.

IX. SCHEME OF ACTIONS FOR PRACTICAL CLASSES:


Sequence of actions Method to carry out actions
1. Preparation phase 1. Examine the X-ray film to know the
method and the date of examination.
Prepare a protocol by adding the
patient’s name, initials and age.
2. Learn the case history of the patient.
3. Learn the clinical features.

2. Analysis of the X-ray film 1. Identify the part, which is examined.


2. Identify the method of radiological
examination.
3. Type of the X-ray film (plane or spot).
4. Identify the orientation of the patient.
5. Projection in which the image has been
taken (straight, oblique, lateral).
6. Identify whether contrast agent are
used or not. If yes, name the contrast
used.
7. Identify the route of administration of
the contrast.
8. Indicate the extent to which the organ
is filled with contrast.

3.1. Check in the X-ray film the 1. Learn the position of the organ.
differences between normal - Normal,
image and pathological - Displaced.
image 2. Learn the form of the organ:
- Normal,
- Deformed.
3. Size of the organ:

55
- Usual,
- Decreased,
- Enlarged.
4. Learn the contours of the organ:
- Bulging,
- Invagination.
Indicate the sizes, amount and form of
changes.
5. Mucous pattern
- Thickness,
- Direction,
- Quantity,
- Forms.
6. Gas bubble of the stomach (presence
of additional shadows, thickening of
the fundus, deformation).
7. Learn the shadow of the organ which
is completely filled with contrast:
- Homogenous shadow,
- Filling defect (amount, forms, sizes,
contours, collection of contrast in the
defect).
8. Condition of the organ, in double
contrast studies (presence or absence
of additional shadow in the lumen of
organ).
9. Tonus.
10. Peristalsis.
11. Evacuation.
Confirm whether normal image or
pathological image.

3.2. Indicate the principle 1. Syndromes of dilatation of the


radiological syndrome of digestive tract:
pathology - Diffusive,
- Local.
2. Syndromes of narrowing of the
digestive tract:
- Diffusive,
- Local.
3. Syndromes of changes in contour.
4. Syndromes of changes in the mucous
pattern.
5. Deformation of the esophagus,
stomach and intestines.

56
6. Displacement of the esophagus,
stomach and intestines.
3.3. Intra-syndrome differential Use the diagnostic algorithms, check with
diagnosis intra-syndrome differential diagnosis.

4. Formulate your diagnosis Formulate a radiological diagnosis. Check


your conclusion with the clinical presentation
of the patient. Which additional investigative
procedures can confirm your diagnosis?
Check your conclusion with the teacher.
Compose a description of the given X-ray image, with the help of the above
given scheme of actions.

Topic: RADIO-DIAGNOSTIC METHODS OF BONE AND JOINT DISEASES.


RADIOLOGICAL DIAGNOSIS OF THE DESTRUCTION OF BONE-JOINT
SYSTEMS.

I. AIMS OF MOTIVATION:
ROENTGENOGRAM - are the fundamental methods of learning the
morphology of bones in normal and pathological conditions. Radiological
examinations show all points when there is a deformation in the skeletal system,
when there is a presence of a foreign body. The doctor can and must have his
diagnosis of bone fracture and dislocation without roentgenograms, but the definite or
complete conclusion of the presence and absence of fracture or crack of bones can
possibly be represented only by analyzing roentgenological representations. The
latest methods of diagnostics used in the present years is the Sonography. Sonograms
represent foreign body, weakly absorbed roentgenological radiation and those which
are not visible in roentgenograms, accumulation of blood and pus in the tissues
surrounding the bone.

II. AIMS OF SELF PREPARATION:


As a result of self preparation a student is supposed:
 to know the indications and contraindications for roentgenological
examinations of bones and joints,
 to know the differences in the roentgenological methods of examination of the
bone-joint systems,
 to learn the radiological anatomy of the bones and joints of adults and children,
 to know the general diseases of the bone-joint system,
 to learn the radiological signs of the fractures of bones and dislocations of
joints.

III. INITIAL LEVEL OF KNOWLEDGE:


For learning the topics the students should know from the course of anatomy:

57
 normal anatomy of bones and joints – structure of bones, growth and
development of bones, anatomical groups of bones, types of bone joints, names
of bones and its parts;
 radiological anatomy of bones and joints – radiological representations of the
development of bones, bones and joints in roentgenograms.
From the course of surgical diseases:
 classification of Fractures: divisions of fractures based on the mechanism of
strength or force, on localization, on the direction of the line of destruction,
complete and incomplete fractures, appearance of changes in the tissues
surrounding the fracture, periods of healing of the fractures, disturbances in the
process of healing of fractures.

IV. THE WAY TO STUDY THE TOPICS:


Sequence of actions Methods to carry out actions
1. Methods of radiological 1. Fundamental.
examination of bones and joints. 2. Specialized.
3. Indications and contra-
indications for examinations of
bones and joints.
4. Definition of methods and
projections of examination.
5. Staging of bones and joints
destruction.

2. Radiological anatomy of bones 1. Anatomical groups of bones.


and joints. 2. Structure of long tubular bones.
3. Peculiarities of the skeleton in
children:
- Period in which the bone skeleton
appears.
- Period in which the growth plate
appears in the epiphysis.
- Epiphyseal zone of growth.
- Peculiarities in the radiological
joint fissures.

3. Radiological diagnostics of fractures 1. Radiological signs


in bones and displacements. of fractures in bones.
2. Types of fractures depending on
the direction of fracture lines.
3. Types of fractures based on
localization.
4. Radiological representation of
fracture lines.
5. Variants of changes in the tissues
surrounding fractured bone.
58
6. Phases of healing based on
radiological examination.
7. Types of fractures in children.
8. Peculiarities in the picture of a
Gun-shot fracture.
9. Disturbances in the healing
processes.
10. Radiological signs of dislocation
and subluxations.

4. Radiological features of diseases in 1. Changes in the position of the


bones and joints. bone.
2. Changes in shape of the bone.
3. Changes in size of the bone.
4. Changes of periosteum:
- Periostitis.
- Periostosis.
5. Changes in the structure of bone:
- Osteoporosis.
- Osteosclerosis.
- Destruction.
- Osteolysis.
- Osteonecrosis.
- Sequestrums.
- Zone of reconstruction of bone.
6. Changes in the radiological
articulation fissure.
7. Changes in the soft tissues
surrounding bone:
-Increase in the intensity of soft
tissues:
-Intensive shadow.
-Calcification.
-Decrease in intensity:
-Collection of gas (soft tissue
gangrene).
Formulate these definitions, name type
and causes of the origin of the disease.

V. RECOMMENDED LITERATURE:
1. Peter Armstrong, Martin L. Wastie “Diagnostic Imaging”, Blackwell Scientific
Publications, Oxford, 1992. - Р. 373-384.
2. Graham H. Whitehouse, Brian S. Worthington “Techniques in Diagnostic
Imaging” Blackwell Scientific Publication, 1996. - Р. 359-369.
3. Frank Slaby, Eugene R. Jacobs “Radiographic anatomy”, NMS, Harwal
Publishing Company, Media, Pennsylvania, 1990. - Р. 1-29, 41-81.
59
4. P.R. Patel Lecture Notes on Radiology, 1998. - Р. 180-181, 206-211.
5. Clinical Radiology, George Simon, Arthur J.A. Wightman, Bulterworthe,
Jaypee Brothers, Fourth Edition. – Р. 20-48.

VI. QUESTIONS FOR CONTROL:


1. Name the basic methods in roentgenological examinations of bones and joints.
2. Enumerate the specialized methods used in roentgenological examinations of
bones and joints.
3. Name the 4 anatomical groups of bones.
4. Name the types of bone substances, by which the bones are formed.
5. What are the anatomical parts of a bone.
6. Which is called “Epiphysis of the long tubular bones”?
7. Which is called “Diaphysis of the long tubular bones”?
8. List the characteristics seen in the roentgenogram of tubular bones in a
growing person.
9. List the differences seen in an X-ray of the cortical plate of a joint cavity.
10. Enumerate the anatomical formation of bones, which do not give shadows in a
roentgenogram.
11. At what age does the fusion of the epiphysis with the metaphysis end?
12. Name two radiological signs of bone fracture.
13. List two variants seen in the plane of fracture with the help of an X-ray.
14. Name the most common features seen in a fracture.
15. Name four changes that occur in the peripheral tissues.
16. List 3 variants of longitudinal displacement of the parts of fractured bone.
17. Write down the indications of bone crack.
18. Which fractures are called “Intracapsular”?
19. Which fractures are called “Compound”?
20. List the radiological signs, which differentiate pseudofractures from medullary
arteries of the bone.
21. What is called “Compression fracture”? In which bones does it occur?
22. What are the differences seen in an X-ray of fractured bone with
representation of bone cartilage.
23. Name two fractures, which are often seen in children.
24. What are the peculiarities seen in old age people in the image of bones?
25. Name the types of callous, which are formed in the process of healing and the
period in which they are formed?
26. Name the complications that occur during the process of healing of a
fracture.
27. What are called “dislocations”?
28. What are called “subluxations”?
29. Which bone shows the direction of displacement caused by subluxations?
30. Which fractures are called “T-pattern”?
31. Which fractures are called “Y-pattern”?
32. List two variants of displacement in breadth of the parts of a fractured bone.
33. What is known as the displacement in angle of the parts of a fractured bone?

60
34. What is known as “Green stick fracture”?
35. In which fractures does displacement of the parts of a fractures bone in axis
occur?

61
VII. IMPORTANT TASKS FOR SELF WORK:
Please draw schemes of the following:
1. Epiphyseal joint fracture
2. Epiphysiolysis
3. Transverse fractures with changes in breadth.
4. Transverse fractures with changes in angles.
5. Longitudinal fracture.
6. Y-shaped fracture.
7. T-shaped fracture.
8. Oblique fractures with displacements of parts of a fractured bone in length
(divergence).
9. Oblique fractures with displacement of parts of a fractured bone in length
(convergence).
10. Impacted fracture.
11. Green Stick fracture.
12. Subperiosteal fracture.
VIII. PLAN FOR STUDENTS WORK DURING THE CLASSES:
1. Test on the day’s topic.
2. Discussion on the day’s topic.
3. Individual work with an X-ray images, and description of the images based on
the scheme.
IX. SCHEME OF ACTIONS FOR PRACTICAL CLASSES:
Sequence of actions Methods to carry out actions
1. Preparation phase. 1. Examine the roentgenogram to
know the method and date of
examination. Prepare a protocol by
adding the patient’s name, initials
and age.
2. Learn the case-history of the
patient.

2. Analysis of the X-ray film. 1. To determine the region of


examination.
2. To determine the method of
examination.
3. To determine the type of the X-ray
film.
4. To determine in which projection
the image has been taken.
5. To determine the quality of the X-
ray film (soft, hard, normal quality,
with or without artefacts).
1. Symptoms of injury of the bones
3. Learn to differentiate between and joints that are not exposed.
normal and pathology. 2. Changes in the axis of the limbs.
3.1. Display the basic 3. Exposure of symptoms of the
62
roentgenological symptoms of injury. fracture (show in which bone its
present).
4. Displacement of the fragments of a
fractured bone.
5. Presence of bone fragments.
6. Presence of foreign bodies.
7. Complete disturbances in
accordance to the disposition of the
joint.
8. Incomplete disturbances in
accordance to the disposition of the
joint.
9. Haemotoma in soft tissues.
10. Combination of different signs.
1. Diaphyseal fracture.
2. Metaphyseal fracture.
3.2. Localization of the fracture: 3. Epiphyseal fracture.
4. Fracture located inside a joint.
5. Fracture line is continuous with
many other parts of the bone.
Transverse, oblique, longitudinal,
spiral, subperiosteal, combination of
3.3. Type and direction of the different fractures, fragmented,
fracture: compound, impacted, multiple.

1. Displacement of the fragments is


absent.
3.4. Types of displacement of 2. In breadth; longitudinal
fragments in a fractured bone: displacement of fragments, with
divergence, convergence,
impacted, changes in angle,
changes in axis, isolation of bone
fragments from the main bone
mass, combination of different
types of displacements.
Displacements are described in
centimeters or degrees from the
peripheral fragments of the bone.
Compare with the primary X-ray
films, after treatment (after
3.5. Radiological control on the position repositioning, metal plates, Gibbs
of fragments. bandage, splints, etc.).
1. Signs of healing not seen.
2. Weak bone callous.
3.6. Analysis of fracture healing. Results 3. Formation of callous.
and complication. 4. Consolidated fracture.
63
5. Abundant bone callous.
6. False joint (Pseudoarthrosis).
7. New joint (Neoarthrosis).
8. Myositis ossificans.
9. Calcificated hematoma of soft
tissues.
10. Gas gangrene in soft tissues.

Form the roentgenological conclusion.


Compare your conclusion with the
clinical diagnosis and correct with the
help of the teacher.
Compose your practical work with the help of the above mentioned scheme of
actions.

Topic: X-RAY DIAGNOSTICS OF INFLAMMATORY DISEASE OF BONES


AND JOINTS.

I. AIMS OF MOTIVATION:
Pathology of bone and joints – is difficult to understand and it has many
divisions. The fundamental method used in examinating the human skeleton is the X-
ray method. Different diseases with different etiology and morphological changes
may have symptoms that may be similar to each other or may be quite different from
each other. Each of them has their own phases with differences in their radiological
pictures. In the present decade it is much easier to diagnose and differentiate between
diseases with the help of Computed Tomography (CT) and Magnetic Resonance
Imaging (MRI). At present the importance in the usage of these methods used for the
examination of the spinal cord, is that it can detect edema, necrosis and infarction of
the spinal cord and also the starting stages of pathological processes in the skeleton.

II. AIM OF SELF-PREPARATION:


As a result of self-preparation, the students should know:
 to get acquainted with X-ray films, consisting of different types of bone-joint
diseases.

III. INITIAL LEVEL OF KNOWLEDGE:


To learn the topic the students should know the following from the course of
anatomy:
 basic anatomy of bones and joints;
 radiological anatomy of bones and joints.
From the course of pathological anatomy:
 path-anatomy of osteomyelitis, bone-joint tuberculosis.
From the course of surgery:
 clinical features of acute, sub-acute and chronic hematogenous osteomyelitis;
 clinical features of bone-joint tuberculosis.
IV. THE WAY TO STUDY THE TOPICS:
64
Sequence of actions Methods to carry out actions
1. X-ray diagnostics of Osteomyelitis. 1. General clinical characteristics;
frequency, age, gender, clinical
features, ways of infections,
pathologoanatomical substratums.
2. X-ray features of acute
hematogenous osteomyelitis.
3. X-ray features of chronic
hematogenous osteomyelitis.
4. Atypical forms of chronic
osteomyelitis (Garre’s
osteomyelitis, Broddie’s abcess).

2. X-rays diagnostics of bone-joint 1. Etiology, pathologoanatomical


tuberculosis. substratums, localization, phases,
clinical features.
2. X-ray features of pre-arthritic stage
(pre-spondilolytic).
3. X-ray features of arthritic stage
(spondilolytic).
4. X-ray features of post-arthritic stage
(post-spondilolytic).

V. RECOMMENDED LITERATURE:
1. Clinical Radiology, George Simon, Arthur J.A.Wightman, Butterworths, Jaypee
Brothers, Fourth Edition. 1994. - Р. 49-61.
2. Musculoskeletal and Breast Imaging, Manorama Berry, Veena Chowdhury,
Sudha Suri, Jaypee. - Р. 46-81.
3. Lecture.

VI. QUESTIONS FOR CONTROL:


1. Prepare a protocol for the destructive lesions in bones according to the scheme
of description.
2. What is periosteal reaction? Types? In which diseases does it occur?
3. List the changes in bone measurement.
4. Narrate the sequence to describe an X-ray film of bones and joints.
5. Point out the reasons, which cause the changes in bone position.
6. Point out the possible deformations of bones.
7. Enumerate the possible changes in bone structure.
8. What changes in the radiological articulation fissure are experienced in practice.
9. Define Osteoporosis.
10. Enumerate the types of osteoporosis.
11. Define Osteosclerosis.
12. What is meant by Destruction?

65
13. Write down the roentgenological representation of destructive nidus (or)
lesion.
14. Name the principal pathological processes, that lead to the destruction of a
bone.
15. List the primary locations of destructive lesions due to acute hematogenous
osteomyelitis.
16. Name the types of periosteal reactions in acute osteomyelitis.
17. List the primary locations of destructive lesions due to chronic osteomyelitis.
18. Name the types of periosteal reaction in chronic osteomyelitis.
19. List the principal locations of tuberculosis in long tubular bones.
20. Enumerate the phases or stages of bone- joint tuberculosis.
21. What is Osteonecrosis? How is it caused?
22. Name the X-ray signs of sequestrums.
23. Enumerate the types of sequestrums, based on their localization of destructive
lesions.
24. Which diseases lead to the decrease in the radiological articulation fissure?
25. List the anatomical structures present in the radiological articulation fissure.
26. In which part of the bone is localized the sequestrum?
VII. IMPORTANT TASKS FOR SELFWORK:
Draw schemes of:
1. Acute stage of hematogenous osteomyelitis in the distal metaphysis of femur.
2. Pre-arthritic stage of Tuberculosis of the knee joint.
3. Chronic stage of hematogenous osteomyelitis in the meta-diaphysis of femur.
4. Atypical forms of chronic osteomyelitis.
VIII. PLAN FOR STUDENTS WORK DURING THE CLASSES:
1. Test on the day’s topic.
2. Discussion on the day’s topic.
3. Individual work with an X-ray films, and description of the images based on
the scheme.
IX. SCHEME OF ACTIONS FOR PRACTICAL CLASSES:
Sequence of actions Methods to carry out actions
1. Preparation phase. 1. Examine the X-ray film to know the
method and the date of examination.
Prepare a protocol by adding the
patients name, initials and age.
2. Learn the case history of the patient.
2. Analysis of the X- 1. To determine the region of
ray film. examination.
2. To determine the method of
examination.
3. To determine the type of the X-ray
film.
4. To determine in which projection
the X-ray film has been taken.

66
5. To determine the quality of the X-
ray film (soft, hard, normal quality,
with or without artifacts).
1. Learn the position of the bone:
3. Learn to - normal,
differentiate normal image and - displaced ( congenital anomalies,
pathological image. fractures, dislocations).
3.1 List the basic symptoms of pathology 2. Learn the shape of the bone:
- normal,
- distortion,
- deformation.
3. Learn the size of the bone:
- no changes,
- lengthening,
- shortening,
- swelling,
- combination of different changes.
4. Learn the contours of the bone:
- regular,
- irregular,
- well-defined,
- ill-defined,
- combination of different changes.
5. Learn the bone structure:
- no changes,
- osteosclerosis,
- osteoporosis,
- osteonecrosis,
- osteolysis,
- destruction (frequency and position
of the lesion, form and size,
contours, types of sequestrums and
reactions of surrounding bone
tissues),
- zone of reconstruction.
Point the location and the extent of
changes.
6. Learn the condition of periosteum
and cortical layer:
- no changes,
- periosteal reaction (type).
Point out the localization, the extent,
and number of bones, that have the
changes.
7. Learn the radiological articulation
fissure:

67
- no changes,
- narrowing,
- broadening,
- deformation.
8. Learn the condition of the
articulation surface and the
subchondral layer of the epiphysis
of the bone:
- no changes,
- irregularity,
- thinning,
- disappearance of the articulation
surfaces,
- destructive lesions,
- subchondral sclerosis,
- bony ankylosis.
9. Learn the condition of the
surrounding soft tissues:
- calcification,
- bone fragments,
- accumulation of gas.

Formulate your conclusion whether it


has normal image or pathological
image. If you find a pathology, pass
over to the next sequence of actions.

1. Congenital anomalies of bone-joint


systems.
2. Traumatic injury or their
3.2. Define the pathological process: complications.
3. Inflammatory process.
4. Degenerative-dystrophic processes.
5. Neuro-dystrophic processes.
6. Reticuloendotheliasis.
7. Fibrous Osteodystrophy.
8. Benign tumours.
9. Malignant tumours.

Use the diagnostic algorithms and


fundamental criterias to formulate
which pathological process is present
3.3. Intra-syndromic differential and compare with their differential
diagnosis diagnosis.

Form the roentgenological conclusion.


Compare your conclusion with the
68
clinical diagnosis and correct with the
help of the teacher.

4. Establishing
individual diagnosis.

Compose your practical work with the help of the above mentioned scheme of
actions.

Topic: RADIODIAGNOSTICS OF TUMOURS IN BONES AND JOINTS.

I. AIMS OF MOTIVATION:
The success of the modern therapeutic and operative interventions much
depends on the early and accurate diagnosis of the various bone pathologies. In
clinical practice, sarcoma often presents in advanced stages of the disease, whereas
patients with benign bone tumours often receive inadequate surgical treatment. The
early diagnosis and favourable prognosis of the bone pathologies depends on the
clinical acumen and knowledge of the treating physicians and on the proper usage of
the modern advanced investigative and diagnostic modalities.

II. AIMS OF SELF PREPARATION:


As a result of self-preparation, students should know the following:
 to learn the X-ray signs of Benign and Primary Malignant tumours of bones,
 to learn the X-ray signs of Metastatic tumours of bones.

III. INITIAL LEVEL OF KNOWLEDGE:


To learn the topic the students should know from the course of anatomy:
 basic anatomy of bones and joints;
 radiological anatomy of bones and joints.
From the course of pathological anatomy:
 pathoanatomy of tumours in bones.
From the course of surgery:
 clinical features of tumours in bones.

IV. THE WAY TO STUDY THE TOPIC:


Sequence of actions Methods to carry out actions
1. X-ray diagnostics of tumours in
bones:
1.1. Classification. 1. Benign.
2. Malignant:
- Primary.
- Secondary.

1.2. Differences between Benign 1. Clinical features.


and Malignant tumours of 2. Forms of tumours.

69
bones. 3. Contours.
4. Structure.
5. Condition of the cortical layer.
6. Structure of the tissues surrounding
the tumour of the bone.
7. Condition of the periosteum.
8. Condition of the surrounding soft
tissues.
9. Character and the growth rate of
the tumour.
10. Pathological Fractures.
11. Metastasis to other organs.

1.3. Benign Tumours: 1. Osteomas. Osteochondroma,


Chondroma, Hemangioma.
2. Localization, quantity of
destruction, X-ray signs.

1.4. Primary Malignant Tumours: 1. Osteogenic Sarcoma.


1.1. Age of the patient, number of
bones damaged, principal
location, clinical features,
typical periosteal reaction,
peculiarities of metastasis,
varieties.
1.2. X-ray symptoms of osteoblastic,
osteolytic, mixed types of
osteogenic sarcoma.

2. Ewing’s Sarcoma.
2.1. Age of the patient, number of
bones damaged, principal
location, clinical features,
typical periosteal reaction,
peculiarities of metastasis.
2.2. X-ray symptoms.
1.5. Secondary Malignant (metastatic)
tumours: 1. Osteolytic.
2. Osteoblastic.
3. Mixed.
Basic clinical signs and X-ray symptoms.

V. RECOMMENDED LITERATURE:
1. Peter Armstron, Martin.L.Wastie “Diagnostic Imaging”, Blackwell Scientific
Publications, Oxford, 1992. - Р. 373-384, 303-309.

70
2. Lectures.
3. P.R. Patel Lecture Notes on Radiology, 1998. - Р. 182-205.
4. Musculoskeletal and Breast Imaging, Manorama Berry, Veena Chowdhury,
Sudha Suri, Jaypee, 1998. - Р. 128-161.
VI. QUESTIONS FOR CONTROL:
1. The tumours of the bones are divided into what groups?
2. Enumerate the forms of Osteogenic Sarcoma.
3. Write the basic X-ray symptoms of Osteolytic form of Osteogenic Sarcoma.
4. Write the basic X-ray symptoms of Osteoblastic form of Osteogenic Sarcoma.
5. Write the basic X-ray symptoms of the mixed form of Osteogenic Sarcoma.
6. Point out the principal locations of Osteogenic sarcoma in long tubular bones.
7. How does the joint change during osteogenic sarcoma?
8. Which cells cause osteogenic sarcoma?
9. In which organs does the metastasis of osteogenic sarcoma appear mostly?
10.Which cells cause Ewing’s Sarcoma?
11.Which bones are often affected by Ewing’s Sarcoma?
12.Name the principal location of Ewing’s Sarcoma in long tubular bones.
13.From which inflammatory diseases it is necessary to differentiate Ewing’s
Sarcoma?
14.Write the X-ray signs of Ewing’s Sarcoma.
15.Which cells cause myeloma?
16.Write the X-ray signs of myeloma.
17. Name the principal locations of myeloma in bones.
18.Enumerate the benign tumours of bones, which are often seen in clinical
practise.
19.What types of osteoma do you know?
20.Write the X-ray signs of osteochondroma.
21.From which tissue does the chondroma grow?
22.In which bones do we often see chondromas?
23.Enumerate the X-ray signs of the growth of benign tumours.
24.Enumerate the X-ray signs of the growth of malignant tumours.
25.Name the types of metastatic tumours of bones.
26.Write the X-ray signs of osteolytic metastasis.
27.Write the X-ray signs of osteoblastic metastasis.
28.Define Secondary bone tumours.

VII. IMPORTANT TASKS FOR SELFWORK:


Please, draw schemes of:
1. Compact osteomas.
2. Spongy osteoma.
3. Osteochondromas.
4. Osteoblastic osteogenic sarcoma of the tubular bone.
5. Osteolytic sarcoma of the long tubular bone.
6. Sclerotic metastasis of the long tubular bone.
7. Osteolytic metastasis of the long tubular bone.

71
VIII. PLAN FOR STUDENTS WORK DURING THE CLASSES:
1. Test on the day’s topic.
2. Discussion on the day’s topic.
3. Individual work with an X-ray images and description of the images based on
the scheme.
4. Control work.

IX. SCHEME OF ACTIONS FOR PRACTICAL CLASSES:


Sequence of actions Methods to carry out actions
1. Preparation phase. 1. Examine the X-ray film to know the
method and the date of examination.
Prepare a protocol by adding the
patient’s name, initials and age.
2. Learn the case history of the
patient.

2. Analysis of the X-ray film: 1. To determine the region of


examination.
2. To determine the method of
examination.
3. To determine the type of the X-ray
film.
4. To determine in which projection
the X-ray film has been taken.
5. To determine the quality of the X-
ray film (soft, hard, normal quality,
with or without artifacts).

3. Learn to differentiate between


normal image and pathological
image.
1. Learn the position of the bone:
3.1. List the basic symptoms of pathology - normal,
- displaced ( congenital anomalies,
fractures, dislocations).

2. Learn the shape of the bone:


- usual,
- distortion,
- deformation.

3. Learn the size of the bone:


- no changes,
- lengthening,
- shortening,
72
- swelling,
- combination of different changes.

4. Learn the contours of the bone:


- regular,
- irregular,
- well-defined,
- ill-defined,
- combination of different changes.

5. Learn the bone structure:


- no changes,
- osteosclerosis,
- osteoporosis,
- osteonecrosis,
- osteolysis,
- destruction (frequency and position
of the lesion, form and size,
contours, types of sequestrums and
reactions of surrounding bone
tissues),
- zone of reconstruction.
Point the location and the extent of
changes.

6. Learn the condition of periosteum


and cortical layer:
- no changes,
- periosteal reaction (type).
Point out the position, the extent, and
number of bones, that have the
changes.
7. Learn the radiological articulation
fissure:
- no changes,
- narrowing,
- broadening,
- deformation.

8. Learn the condition of the


articulation surface and the
subchondral layer of the epiphysis of
the bone:
- no changes,
- irregularity,
- thinning,
- disappearance of the articulation
73
surfaces,
- destructive lesions,
- subchondral sclerosis,
- bony ankylosis.
9. Learn the condition of the
surrounding soft tissues:
- calcification,
- bone fragments,
- accumulation of gas.

Formulate your conclusion whether


normal image or pathological image.
If you find a pathology, pass over to
the next sequence of actions.

1. Congenital anomalies of bone-joint


systems.
2. Traumatic destruction or their
complications.
3.2. Define the pathological process:
3. Inflammatory process.
4. Degenerative-dystrophic processes.
5. Neuro-dystrophic processes.
6. Reticuloendotheliasis.
7. Fibrous Osteodystrophy.

Use the diagnostic algorithms and


fundamental criterias to formulate
which pathological process is present
and compare with their differential
3.3.Intra-syndromic differential diagnosis diagnosis.

Form the roentgenological conclusion.


Compare your conclusion with the
clinical diagnosis and correct it with the
help of the teacher.
4. Establishing individual diagnosis.

Compose your practical work with the help of the above mentioned scheme of
actions.

Topic: COMPUTED TOMOGRAPHY.

I. AIMS OF MOTIVATION:
Over the past decade the performance of computed tomographic (CT) scanners
has improved dramatically. Scan times have been reduced from minutes to seconds.
Spatial resolution and low contrast detectability have also been improved. Many

74
causes of image artifacts have been discovered and eliminated through proper
hardware design or software correction.
The purpose of this chapter is to present a brief overview of CT systems.
Various computer components and their features that are particularly relevant to CT
will be described. It is assumed that the reader is familiar with the basic aspects of
radiologic equipment and physics. For a more complete discussion, refer to the
excellent work by Newton and Potts.

II. HISTORICAL DEVELOPMENT:


CT systems have been classified according to the motion of the x-ray tube and
detector(s) during scanning. With the earliest (first-generation) scanners, each line
integral was collected using an x-ray tube and a single detector. During the scanning
procedure, the x-ray tube and detector were translated across the scan field of view,
and a series of transmitted intensity measurements were made. The tube and detector
combination were rotated through a small angle (typically 1°), and the translation
repeated. This process of translation and rotation was repeated until 180° of
projection data had been acquired. A substantial drawback of this approach was the
long time necessary to acquire all the measurements. The first commercial scanner,
the EMI Mark I, required 41/2 minutes to complete a scan.
A significant reduction in scan time was obtained by using multiple detectors.
These were placed opposite the tube so that the beams sensed by the detectors
differed in angle by a small amount (e.g., 1°). These second-generation scanners still
required translation but each translation produced many views, one from each
detector position. The rotation angle between translations was increased. With these
systems, scan times were of the order of 20 to 80 seconds.
To decrease scan times further, rotate-only systems have been introduced. In
these systems a fan beam x-ray source irradiates a large array of detectors. For rotate-
rotate, or third-generation systems, both the tube and detector array are rigidly
coupled and rotate jointly about the patient. At any instant of time a complete fan or
view of data is acquired. In rotate-stationary or fourth-generation systems, only the
tube rotates about the patient. A fixed detector array completely surrounds the
patient. The fan beam projections are formed by grouping all the measurements made
by a single detector. Scan times of 1 to 10 seconds are possible with these rotate-only
systems.

III. AIM OF SELF-PREPARATION:


As a result of self-training a student is supposed:
 to know the history of the CT scanning ;
 to know the nature and the main characteristics of computed tomography;
 to know the principles of CT machine work;
 to know the basis of labor protection and of safety engineering.

IV. INITIAL LEVEL OF KNOWLEDGE:


To study the topic the students are supposed to know from physics:
 the physics and various terminology used in CT imaging,

75
 types of contrasts used,
 Safety measures for both the patient and labor,
 Limitations in CT imaging.

76
V. THE WAY TO STUDY THE TOPIC:
Sequence of actions Methods to carry out the actions
1. The main components of a CT 1. X-ray source and generator,
machine 2. Collimator,
3. Detector array,
4. Data acquisition system,
5. Gantry-table,
6. Computational hardware, and
7. Display device.

2. Different types of parameters affecting 1. Spatial resolution.


performance 2. Low contrast detect ability.
3. Scan time.
4. Radiation dose.
5. Artifacts.

3. Principal functions of the computed 1. Use of roentgenological rays.


tomography 2. Images of the thin layers of the body in
transverse scanning.
3. Digital imaging.

4. Methods of operating a CT scanner 1. Working the scanning system with


registering of the images of scintigraphic
transducers.
2. Increasing the electric signals in the
transducers.
3. Working of images in a computer and
creating a matrix of images.
4. Transferring the created images to the
work station.
5. Preparing archives for the images
collected.

5. Qualitative and quantitative analysis 1. Coefficient of x-ray absorption and


of the obtained tomogram Haunsfield’s scale.
2. Visual analysis of the tomogram.

6. Basic CT semiotics 1. Direct and indirect signs of pathology,


2. Hypo-, Iso-, Hyper-, and Hetero-
densive pathologic lesion.

VI. RECOMMENDED LITERATURE:


1. Techniques in Diagnostic Imaging, Graham H. Whitehouse, Brian S.
Worthington, Blackwell science, Third edition, 1996. - Р. 438-460.

77
2. Diagnostic Imaging, Peter Armstrong, Martin. L. Wastie, Blackwell Scientific
Publications, Third edition, 1992. – Р. 8-10.

VII. QUESTIONS FOR CONTROL:


1. Who invented computed tomography?
2. What are the main components of a CT Machine?
3. How does the work of the computed tomograph accomplished, when it is in the
process of examination?
4. What is coefficient of absorption and with the help of what units it can be
measured?
5. What is width and centre of the window, its recommendations?
6. What are the direct signs of pathology in computed tomography?
7. What are the indirect signs of pathology in computed tomography?
8. What are the terms used in describing a pathologic lesion, based on its density?
9. Which organs give us more information when examined under computed
tomography?
10. What is computed tomography with intravenous intensification and how it is
carried out?

VIII. PLAN FOR STUDENTS WORK DURING THE CLASSES:


1. Test on the day’s topic.
2. Acquaintance with the rules of work in the department and safety measures.
3. Acquaintance with the CT cabinet and analyzing the images taken after an
examination of a patient.
4. Individual work with CT images and description of images based on the
scheme.

IX. SCHEME OF ACTIONS FOR PRACTICAL CLASSES:


Sequence of actions Methods to carry out actions
1. Preparatory phase 1. Collect the tomograms as per the name,
date and part of examination.
2. Study the case history of the patient.

2. Determine the tomographic method, 1. Area of examination (brain, chest,


part of examination and the plain of abdomen,etc.).
imaging 2. Axial, Sagittal, Frontal or Oblique
projection.

3. Methods to analyze a tomogram: 1. Condition of the soft tissues.


2. Condition of the bones.
3. Learn the forms and position of the
organs.
4. Study the type of pathology based on
the density of the signals and mention
whether it is hypo-densive or hyper-

78
densive.
Formulate your conclusion and check
with the help of the teacher.
Compose your practical work based on the above scheme of actions.

Topic: MAGNETIC RESONANCE IMAGING.

I. AIMS OF MOTIVATION:
Nuclear magnetic resonance imaging (NMRI), or magnetic resonance imaging
(MRI), is a new technique for imaging the human body that has grown out of
chemical assay techniques that have been in routine use for many years. Basically,
MRI makes use of magnetic fields and radiofrequency waves to generate intensity-
modulated images from specific sections of the body. The intensity of a point within
an image is determined in a complicated fashion by the number of hydrogen nuclei
(protons) at the corresponding point in the patient and also the chemical make-up of
the tissue at that point. Variations in imaging techniques can produce drastic
differences in image appearance by emphasizing different aspects of the chemical
structure. Thus, not only does MRI produce high-quality images of body anatomy, it
also provides the capability for measuring in vivo body chemistry. When comparing
with other techniques like ultrasound and computed tomography, MRI is expensive
and difficult in understanding the technical and theoretic aspects. MRI has
revolutionized the various forms of radiological methods.

II. AIM OF SELF PREPARATION:


As a result of self-training a student is supposed:
 to know the history of the Nuclear magnetic resonance imaging
(NMRI), or magnetic resonance imaging (MRI);
 to know the nature and the main characteristics of Nuclear magnetic resonance
imaging (NMRI), or magnetic resonance imaging (MRI);
 to know the principles of magnetic resonance machine work;
 to know the basis of labor protection and of safety engineering.

III. INITIAL LEVEL OF KNOWLEDGE:


To study the topic the students are supposed to know from physics:
 the physics and various terminology used in NMR or MR imaging,
 types of contrasts used,
 safety measures for both the patient and labor,
 limitations in MR imaging.

IV. THE WAY TO STUDY THE TOPIC:


Sequence of actions Methods to carry out the actions
1. The definition of the NMR or MR The absorption or emission of
imaging electromagnetic energy by nuclei in a static
magnetic field after excitation by a suitable
RF magnetic field. The peak resonance

79
frequency is proportional to the magnetic
field and is given by the Larmor equation.
Only nuclei with a non-zero spin exhibit
MR. Another MR pheno-menon is electron
spin resonance (ESR).

2. Various parts of a typical NMR or MR 1. Magnet,


imaging system 2. Gradient coils,
3. Radiofrequency transmitter/receiver
coils,
4. Shim coils,
5. Computer,
6. Image displays.

3. Different types of scanning 1. T1 scanning,


2. T2 scanning.

4. Indication and contra-indications of 1. Various types of diseases that can be


MRI diagnosed in MRI.

2. Absolute and relative contra-


indications in MRI examination.
5. Knowledge about MR Spectroscopy Basic methods and its use in diagnostics.

V. RECOMMENDED LITERATURE:
1. Techniques in Diagnostic Imaging, Graham H. Whitehouse, Brian S.
Worthington, Blackwell science, Third edition, 1996. - Р. – 462-478.
2. Diagnostic Imaging, Peter Armstrong, Martin L. Wastie, Blackwell Scientific
Publications, Third edition, 1992. – Р. 10-14.
VI. QUESTIONS FOR CONTROL:
1. What are the essential factors which involve in the emission of Magnetic
Resonance signals?
2. What happens to the hydrogen protons when they are excited in a permanent
magnetic field?
3. Which atoms emit magnetic resonance signals?
4. What changes take place in an atom when it is excited by a radiofrequency
signal in a permanent magnetic field?
5. What is proton density?
6. What is spin-echo?
7. What are different types of imaging that can be obtained in magnetic resonance
imaging?
8. What is magnetic resonance angiography?
9. What is the principle of magnetic resonance spectroscopy?
10. List the contraindications of MRI.
11. What are the fatal dangers experienced in MRI?
80
VII. THE PLAN FOR STUDENTS WORK DURING THE CLASSES:
1. Test on the day’s topic.
2. Acquaintance with the rules of work in the department and safety measures.
3. Acquaintance with the MRI room and analyzing the images taken after
examination of a patient.
4. Individual work with MRI images and description of the images based on the
scheme.

VIII. SCHEME OF ACTIONS FOR PRACTICAL CLASSES:


Sequence of actions Methods to carry out the actions
1. Preparatory phase 1. Collect the tomograms as per the
name, date and part of examination.
2. Study the case history of the patient.

2. Determine the tomographic method, 1. Area of examination (brain, chest,


part of examination and the plane of abdomen,etc.).
imaging 2. Axial, Sagittal, Frontal or Oblique
projection.
3. Methods to analyze a tomogram 1. Condition of the soft tissues.
2. Condition of the bones.
3. Learn the forms and position of the
organs.
4. Study the type of pathology based on
the intensity of the signals and mention
whether it is hypo-intensive or hyper-
intensive
Formulate your conclusion and check it
with the teacher.
Compose your practical work with the help of the above given scheme of
actions.

Topic: THE BASIC PHYSICS OF ULTRASOUND IMAGING, ULTRASOUND


INSTRUMENTATION.

I. INTRODUCTION:
Technologies developed for industrial and defense purposes can sometimes be
adapted to medicine with remarkable success. Diagnostic ultrasound is a perfect
example. It is derived from SONAR technologies developed by the Navy to detect
submarines during World War II and from ultrasonic nondestructive testing
technologies developed by industry to detect flaws in metals during the same period.
Although its foundations date to the 1940s, diagnostic ultrasound imaging did
not gain widespread use until the 1970s. Thus, it is a relatively new imaging modality
and, as might be expected, it has seen much development in recent years.

81
II. WHAT IS ULTRASOUND?
Sounds are present throughout our everyday experiences, yet few of us have
ever taken the time to analyze the nature of sound. In a physics sense, sound is a
mechanical wave motion in an elastic medium. It is created by a disturbance in this
medium. For example, when we clap our hands, we disturb the air surrounding us,
and a sound wave travels through the air. The air is the elastic medium. The
molecules in the air tend to return to their equilibrium positions after being pushed
and pulled by the travelling sound waves, and this springing back to equilibrium
property is called elasticity. If we had no elastic medium surrounding our hands, as
would be the situation in outer space, no sound would be created.
Sound can be partitioned into three categories based upon frequency or pitch -
infrasound, audible sound, and ultrasound. Human beings can hear sounds having
frequencies between about 20 cycles per second and 20,000 cycles per second. This is
the audible range; it is the range of frequencies produced by most stereo speakers.
Sounds having frequencies below 10 cycles per second are termed as infrasound, and
those having frequencies above 20,000 cycles per second are termed ultrasound. The
frequencies associated with diagnostic ultrasound instruments are about 50 to 1000
times greater than the highest frequency we hear. (The diagnostic ultrasound
frequency range is about 1 million to 20 million cycles/sec).

III. DOPPLER ULTRASOUND:


When ultrasound is transmitted towards a stationary reflector, the reflected
waves (echoes) will be of the same frequency as those originally transmitted.
However, if the reflector is moving towards the transmitter, the reflected frequency
will be higher than the transmitted frequency. Conversely, if the reflector is moving
away from the transmitter, the reflected frequency will be lower than the transmitted
frequency. The difference between the transmitted and received frequencies is
proportional to the speed with which the reflector is moving away from, or
approaching the transmitter. The phenomenon is called as the Doppler effect and the
difference between the frequencies is called the Doppler shift.

IV. GOAL OF SELFTRAINING:


As a result of selftraining a student is supposed:
 to know the nature and the main characteristics of the ultrasound wave;
 to know the principles of an ultrasound machine operation;
 to know the basis of labor protection and safety engineering;
 to know the various terms used in ultrasound examination.

V. BASELINE OF KNOWLEDGE:
To study the topic the students are supposed to know from physics:
 the nature of the ultrasound wave and its properties;
 the principles of an ultrasound diagnostic machine operation;
 the definition and the principles of Doppler ultrasound.

82
VI. WAY TO STUDY THE TOPIC:
Sequence of actions Methods to carry out the actions
1. The definition of the ultrasound The ultrasound method is a way of the
diagnosis. distant detection of the form, position,
size, structure and motions of organs and
tissues as well as pathologic focuses by
means of the ultrasound wave.

2. Physicotechnical bases of the 1. The nature of the ultrasound waves.


ultrasound diagnosis. 2. Its characteristics.
3. The properties of the ultrasound
waves.
4. Different modes of ultrasound
- A-mode;
- B-mode;
- Real time;
- M-mode.
5. Acoustic coupling agents and types.
3. The main parts of an ultrasound 1. Electronic unit.
machine. 2. Ultrasound transducer.
3. High-frequency amplifier.
4. A monitor.
5. Different types of transducers:
- Linear array;
- Sector scanner;
- Convex transducer;
- Curvilinear.

4. Principles of examining a patient. 1. Preparation of the patient before the


examination.
2. Orientation of the patient while the
examination:
- Supine;
- Upright (in cases when there is
free gas in the abdomen);
- Oblique;
- Lateral;
- Posterior;
- Sitting.
3. Application of the coupling agent.
4. Choice of the transducer.
5. Part to be examined:
- prostate;
- uterus and vaginal;
- abdomen;

83
- heart and blood vessels;
- scrotum and testis;
- pleura;
- neck;
- bones;
- brain.

5. Other specialized methods of 1. Echocardiography;


ultrasound. 2. Neurosonography for pediatric
patients.
3. Doppler method.
4. Intervention (biopsy, ultrasound
guided pleural fluid aspiration,
liver abcess aspiration, etc.).

6. Types of scanning. 1. Longitudinal scanning;


2. Oblique scanning;
3. Transverse scanning;
4. Coronal scanning(in pediatrics);
5. Sagittal scanning(in pediatrics);
6. Transrectal probe;
7. Transvaginal probe.

7. Clinical applications of a Doppler 1. Detecting the fetal heart motion.


unit. 2. Demonstrating the blood flow in the
peripheral vessels of adults.
3. Measuring the rate of movement of
any fluid such as blood.
VII. LITERATURE:
1. Diagnostic Imaging, Peter Armstrong, Martin L. Wastie, Blackwell Scientific
Publications, Third edition, 1992. – Р. 8-10.
2. Techniques in Diagnostic Imaging, Graham H. Whitehouse, Brian S.
Worthington, Blackwell science, Third edition, 1996. - Р. 409-425.
3. Manual of Diagnostic Ultrasound, P.E.S. Palmer, WHO, New Millenium
edition, 2000. - Р. 3-16.
VIII. OBLIGATORY TASKS FOR SELFWORK:
1. To study the physics and various aspects of ultrasound.
2. To study the importance of ultrasound techniques in medicine.
3. To study the various types of examination.
4. Doppler scanning.
5. Echocardiography.
IX. QUESTIONS FOR SELFCONTROL:
1. What is ultrasound?

84
2. What is wavelength of ultrasound?
3. What is Doppler ultrasound and its characteristics?
4. What are the different modes of scanning in ultrasound?
5. What is a transducer?
6. What are the types of transducers?
7. What is a coupling agent? List out some examples of coupling agents.
8. What are the main parts in an ultrasound machine?
9. What are the different types of scanning?
10. List out important features of ultrasound in obstetrics and gynecology.
11. List out the clinical applications of a Doppler ultrasound.
12. What is neurosonography and its importance.
13. List out some specialized methods of ultrasound.
14. What are the necessary features to be taken into account when examining a
patient?
15. What is echocardiography and its significance?
16. Write the different types of probes used in ultrasound?
17. What is acoustic shadowing or acoustic window?
18. Name the various types of echogencity?
X. SCHEME OF ACTIONS FOR PRACTICAL CLASSES:

Sequence of actions Methods to carry out actions


1. Preparation phase 1. Before doing any examination of organs in
the abdominal cavity the patient should
follow these:
- The patient should be examinated on an
empty stomach, for children, they
should not be fed at least for 3 hours.
- Find out the region to be examined.
- Enter the first, middle and last name,
age of the patient and sex in the
protocol.
- Study the anamnesis of the patient.
- Application of the coupling agent,
- Study the images that you see on the
monitor and try to interpret them.
2. Choose the type of transducer.
3. Examine the patient using the various types
of scanning

2. Mark off “norm” and “pathology” by 1. Each organ of the abdominal cavity have
analyzing the images seen on the certain measurements in terms of height,
monitor. thickness and breadth,
2. When normal, the sonologist should
provide the appropriate measurements of the
organs by measuring them and determine the

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type of echo received.
3. When pathology, the sonologist should
provide the appropriate measurements of the
organs by measuring them and determine the
type of echogenicity received, as
- echogenic,
- unechogenic,
- hypoechogenic and
- hyperechogenic.

3. Define the prevailing pathology 1. Size and shape of the pathologic lesion.
2. Contours and margins.
3. Focal shadows.
4. Ring shaped shadows.
5. Cavities or cysts, with or without
accumulations.
6. Acoustic shadows.
7. Accumulations of exudates.
8. Calcification.
9. Sequestrums.
10. Vascular diseases.
11. Pathology of surrounding lymph
nodes.
12. Tumor growths.

Make a conclusion: which of the above


mentioned factors is presented in the image?

Compose your practical work with the help of the above given scheme of
actions.

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Appendix 1

TERMINOLOGY USED IN ULTRASOUND DIAGNOSTICS

1. Acoustic beam – the beam of ultrasound waves (energy) produced by the


transducer (probe). May be divergent, focused or parallel.
2. Acoustic enhancement – the increased echogenecity (echo brightness) of
tissues that lie behind a structure that causes little or no attenuation of the
ultrasound waves, such as a fluid-filled cyst.
3. Acoustic impedance – the resistance offered by tissues to the movement of
partcles caused by ultrasound waves. It is equal to the product of the density of
the tissue and the speed of the ultrasound wave in the tissue. It is because
tissues have different impedances that ultrasound can provide images of the
part of the body being scanned.
4. Acoustic shadowing – the decreased echogenicity of tissues that lie behind a
structure that causes marked attenuation of the ultrasound waves. The opposite
to acoustic shadowing is acoustic enhancement.
5. Acoustic window – a tissue or structure that offers little obstruction to the
ultrasound waves, and can therefore be used as a route to obtain images of a
deeper structure. For example, when the bladder is full of urine it forms an
excellent acoustic window through which the pelvic structures may be imaged.
6. Anechogenic (anechoic) – without echoes; echo-free. For example, normal
urine and bile are anechogenic, i.e. they have no inernal echoes.
7. Artefact – a feature appearing in an ultrasound image that does not correspond
to or represent an actual anatomical or pathological structure, either in shape,
direction or distance. For example, reverberations are artifacts. Some artifacts
may be helpful in interpreting image, but others can be very misleading.
8. Attenuation – the decrease in the intensity of the ultrasound waves as they
pass through tissues, measured in decibels per centimeter. Attenuation results
from absorption, reflection, scattering and beam divergence. In most tissues the
attenuation increases approximately linearly with the frequency of the
ultrasound.
9. Coronal plane – a plane running through the body along the long axis (from
the head to toe) at right angles to the median plane. To scan this plane, the
transducer is placed on the side of the body pointing across to the other side
and is moved parallel to the length of the body. A coronal scan may be
obtained with the patient supine, prone, erect or lying on one side.
10.Coupling agents – a liquid or gel used to fill the gap between the skin and the
ultrasound transducer, so that there is no intervening air to interfere with
ultrasound transmission.
11.Cyst – a fluid-filled structure (mass) with thin walls. A simple cyst
characteristically has anechogenic (echo-free) content, with strong back wall
reflections and enhancement of the echoes behind the cyst. A cyst can be
histologically benign or malignant.

87
12.Doppler effect – the change in apparent frequency of a wave as a result of
relative motion between the observer and the source. The change in frequency
is proportional to the speed of motion.
13.Hyperechogenic (hyperechoic) – describes tissues that create brighter echoes
than adjacent tissues, e.g. bone, perirenal fat, the wall of the gall bladder, and
a cirrhotic liver (compared to a normal liver).
14.Hypoechogenic (hypoechoic) – describes tissues that create dimmer echoes
than adjacent tissues, e.g. lymph nodes, some tumours and fluid. It is
important to note that fluid is not only the hypoechogenic material.
15.Longitudinal scan (sagittal scan) – a vertical scan along the long axis of the
body. ”Longitudinal” is more often used to refer to scans of the abdomen or
neck. A longitudinal scan may be obtained with the patient supine, prone,
erect or lying on one side.
16.Scanning plane – the section of tissue through which the ultrasound beam is
passing during the scan, and which will appear on the image.
17.Transducer – the part if the ultrasound unit that comes into contact with the
patient. It converts electrical energy into ultrasound waves, which pass
through the patient’s tissues; it also receives the reflected waves and changes
them again into electrical energy. A transducer is often called a probe and is
connected to the ultrasound scanner (generator and monitor) by a flexible
cable. Transducers are expensive and fragile, and must be handled very
carefully.
18.Transverse scan (axial scan) – An ultrasound scan at right angles to the long
axis of the body. ‘Axial’ is usually used to refer to scans of the brain, and
‘transverse’ to scans of the abdomen or neck. The beam may be perpendicular
or slightly angled to the head or feet of the patient. A transverse scan may be
obtained with the patient supine, prone, erect or lying on the side.

88
Appendix 2

TERMS USED IN MAGNETIC RESONANCE IMAGING (MRI)

1. Coherence - maintenance of a constant phase relationship between rotating or


oscillating waves or objects. Loss of phase coherence of the spins results in a
decrease in the transverse magnetization and hence a decrease in the MR
signal.
2. Contrast – image contrast is the relative difference of the signal intensities in
two adjacent regions. Object contrast is the relative difference of a parameter
affecting the image (e.g., spin density or relaxation time) in two adjacent
regions. If two intensities or parameters are J1 and J2, a useful quantitative
definition of contrast is (J1 -1 J2)/(J1 +1 J2). Relating image contrast to object
contrast is more difficult in MR imaging than in conventional radiography or
CT because there are more object parameters affecting the image and their
relative contributions are very dependent on the particular imaging technique
used. As in other kinds of imaging, image contrast in MR will also depend on
region size, as reflected through the modulation transfer function (MTF)
characteristics.
3. Diamagnetic – a substance that will slightly decrease a magnetic field when
placed within it (its magnetization is oppositely directed to the magnetic field,
i.e., with a small negative susceptibility).
4. Fourier transform (FT) – a mathematical procedure to separate out the
frequency components of a signal from its amplitudes as a function of time, or
vice versa. The Fourier transform is used to generate the spectrum from the
FID or spin echo in pulse MR techniques and is essential to most MR imaging
techniques. The Fourier transform can be generalized to multiple dimensions,
such as to relate an image to its corresponding k-space representation or to
include chemical shift information in some chemical shift imaging techniques.
5. Free induction decay (FID) – the transient MR signal that occurs immediately
after an RF pulse that produces transverse magnetization of spins.
6. Frequency encoding – encoding the distribution of sources of MR signals
along a direction by detecting the signal in the presence of a magnetic field
gradient along that direction so that there is a corresponding gradient of
resonance frequencies along that direction.
7. Gadolinium – lanthanide element that is paramagnetic in its trivalent state. It
has been used as the active component of some contrast agents in MR imaging
because of its effect of strongly decreasing the T1 relaxation times of the
tissues to which it has access. Although toxic by itself, it can be safely given in
a chelated form such as DTPA that still retains much of its strong effect on
relaxation times.
8. Inversion – a nonequilibrium state in which the macroscopic magnetization
vector is oriented opposite to the static magnetic field; it is usually produced by
180° RF pulses.

89
9. Inversion recovery (IR) – a pulse MR technique incorporated into MR
imaging in which the nuclear magnetization is inverted at a time on the order of
T1 before the regular imaging pulse-gradient sequences. The resulting partial
relaxation of the spins in the different structures being imaged can be used to
produce an image that depends strongly on T1. This may bring out differences
in the appearance of structures with different T1 relaxation times. This does not
directly produce an image of T1. T1 in a given region can be calculated from
the change in the MR signal from the region due to the inversion pulse
compared with the signal with no inversion pulse or an inversion pulse with a
different inversion time (T1).
10. Inversion time (T1) – the time between inversion and the subsequent 90° RF
pulse to elicit MR signal in inversion recovery.
11. K-space – mathematical space in which the Fourier transformation of the
image is represented. The data acquired for MR image reconstruction generally
correspond to samples of k-space.
12. Longitudinal magnetization (Mz) – the component of the macroscopic
magnetization vector along the static magnetic field. Following excitation by
RF pulse, Mz will approach its equilibrium value (Mo) with a characteristic
time-constant T1.
13. M – the conventional symbol for macroscopic magnetization vector.
14. Macroscopic magnetization vector – the net magnetic moment per unit
volume (a vector quantity) of a sample in a given region, considered as the
integrated effect of all the individual microscopic nuclear magnetic moments.
Most MR experiments actually deal with this.
15. Magnetic field (H) – the region surrounding a magnet (or current-carrying
conductor) is endowed with certain properties. One is that a small magnet in
such a region experiences a torque that tends to align it in a given direction.
Magnetic field is a vector quantity; the direction of the field is defined as the
direction that the north pole of the small magnet points when in equilibrium. A
magnetic field produces a magnetizing force on a body within it. Formally, the
forces experienced by moving charged particles, current-carrying wires, and
small magnets in the vicinity of a magnet are due to magnetic induction (B,
magnetic flux density), the net magnetic effect from an externally applied field,
and the resulting magnetization. The magnetic field (H) is defined so as not to
include magnetization. However, both B and H are often loosely used to denote
magnetic fields.
16. Magnetic resonance – the absorption or emission of electromagnetic energy
by nuclei in a static magnetic field after excitation by a suitable RF magnetic
field. The peak resonance frequency is proportional to the magnetic field and is
given by the Larmor equation. Only nuclei with a non-zero spin exhibit MR.
Another MR phenomenon is electron spin resonance (ESR).
17. Magnetic susceptibility (X) – measure of the ability of substance to become
magnetized.
Mo - The equilibrium value of the magnetization, directed along the direction
of the static magnetic field. It is proportional to the spin density, N.

90
18. MR signal – the electromagnetic signal in the RF range produced by the
precession of the transverse magnetization of the spins. The rotation of the
transverse magnetization induces a voltage in a coil, which is amplified and
demodulated by the receiver; the signal may refer only to this induced voltage.
19. Orientation – the standard orientation suggested by the American College of
Radiology (ACR) for the presentation of MR images is (1) transverse ¾
patient's right on the left side of the image, anterior or ventral on top; (2)
coronal ¾ patient's right to the left side of the image, superior or head to the
top; and (3) sagittal ¾ patient's head to the top, anterior to the left right, left, or
midline side of the image (indicate).
20. Paramagnetic – a substance with a small but positive magnetic susceptibility
(magnetizability). The addition of a small amount of paramagnetic substance
may greatly reduce the relaxation times of water. Typical paramagnetic
substances usually possess an unpaired electron and include atoms or ions of
transition elements, rare earth elements, some metals, and some molecules
including molecular oxygen and free radicals.
21. Phase encoding – encoding the distribution of sources of MR signals along a
direction in space with different phases by applying a pulsed magnetic field
gradient along that direction before detection of the signal. In general, it is
necessary to acquire a set of signals with a suitable set of different phase-
encoding gradient pulses to reconstruct the distribution of the sources along the
encoded direction.
22. Proton density (N(H)) – the density of resonating hydrogen atoms in a given
region. Only protons sufficiently mobile microscopically to undergo magnetic
perturbation and relaxation within the time frame of imaging pulse sequences
will contribute signal to pro-ton MR images. The mobile proton density is one
of the principal determinants of MR image signal strength (with T1 and T2).
The vast majority of mobile protons in tissue are those in water.
23. Pulse, 90° ( p1 /2 pulse) – the RF pulse designed to rotate the macroscopic
magnetization vector 90 ° in space as referred to the rotating frame of
reference, usually about an axis at right angles to the main magnetic field. If
the spins are initially aligned with the magnetic field, this pulse will produce
transverse magnetization.
24. Pulse, 180° ( p1 pulse) – the RF pulse designed to rotate the macroscopic
magnetization vector 180 ° in space as referred to the rotating frame of
reference, usually about an axis at right angles to the main magnetic field. If
the spins are initially aligned with the magnetic field, this pulse will produce
inversion.
25. Radiofrequency (RF) pulse – the wave frequency intermediate between
auditory and infrared. The RF used in MR studies is commonly in the
megahertz (MHz) range. The pulse is the brief burst of RF magnetic field
delivered to the object by the RF transmitter. For RF frequency near the
Larmor frequency, it will result in rotation of the macroscopic magnetization
vector in the rotating frame of reference. The amount of rotation will depend

91
on the strength and duration of the RF pulse; commonly used examples are 90
° and 180° pulses.
26. Relaxation times – after excitation, spins will tend to return to their
equilibrium distribution, in which there is no transverse magnetization and the
longitudinal magnetization is at its maximum value and oriented in the
direction of the static magnetic field. It is observed that in the absence of
applied RF, the transverse magnetization decays toward zero with a
characteristic time-constant T2 and the longitudinal magnetization returns
toward the equilibrium value Mo with a characteristic time-constant T1.
27. Resolution, spatial – although generally referring to the ability of the
imaging process to distinguish adjacent structures in the object, the specific
criterion of resolution to be used depends on the type of test used (e .g., bar
pattern or contrast-detail phantom). Since the ability to separate or detect
objects depends on their contrast, and the different MR parameters of objects
will affect image contrast differently for different imaging techniques, care
must be taken in comparing the results of resolution phantom tests of different
machines and no single simple measure of resolution can be specified.
28. Spin density (N) – the density of resonating spins in a given region; one of
the principal determinants of the strength of the MR signal from the region.
The SI units would be moles/meter. For water, there are about 1 .1 x 10 moles
of hydrogen per meter, or 0.11 mole of hydrogen per centimeter. True spin
density is not imaged directly but must be calculated from signals received
with different interpulse times.
29. Spin-echo – the reappearance of an MR signal ("echo") after the initial signal
(FID) has died away, as the result of the effective reversal of the dephasing of
the spins ("refocusing") by such techniques as reversal of a gradient magnetic
field or by specific RF pulse sequences. Multiple spin echoes or a series of spin
echoes at different times can be used to determine T2 without contamination by
effects of the inhomogeneity of the magnetic field.
30. Stimulated echo – a form of spin echo produced by three-pulse RF sequences,
consisting of two RF pulses following an initial exciting RF pulse. The
stimulated echo appears at a time delay after the third pulse equal to the
interval between the first two pulses. Although classically produced with 90 °
pulses, any RF pulses other than an ideal 180 ° can produce a stimulated echo.
The intensity of the echo depends in part on the T1 relaxation time because the
excitation is"stored" as longitudinal magnetization between the second and
third RF pulses.
31. T1 – the spin-lattice or longitudinal relaxation time; the characteristic time
constant for spins to tend to align themselves with the external magnetic field.
Starting from zero magnetization in the z direction, the z magnetization will
grow to 63% of its final maximum value in a time T1.
32. T2 – the spin-spin or transverse relaxation time; the characteristic time
constant for loss of phase coherence among spins oriented at an angle to the
static magnetic field, due to interactions between the spins, with resulting loss
of transverse magnetization and MR signal. Starling from a non-zero value of

92
the magnetization in the xy plane, the xy magnetization will decay so that it
loses 63% of its initial value in a time T2.
33. TE – the echo time. The time between the middle of the 90° pulse and the
middle of spin-echo production. For multiple echoes, TE1, TE2, and so on are
used.
34. Tesla (T) – the preferred (SI) unit of magnetic flux density (B). One tesla is
equal to 10 ,000 gauss, the CGS unit. The earth's magnetic field is
approximately 0.5 to 1 gauss, depending on location. T1 See inversion time.
35. TR – the repetition time. The period of time between the beginning of a pulse
sequence and the beginning of the succeeding (essentially identical) pulse
sequence.
36. Transverse magnetization (Mxy) – the component of the macroscopic
magnetization vector at right angles to the static magnetic field (Bo).
Precession of the transverse magnetization at the Larmor frequency is
responsible for the detectable MR signal. In the absence of externally applied
RF energy, the transverse magnetization will decay to zero with a characteristic
time constant of T2.

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