MEDICAL IMAGING

NGWA FABRICE AMBE

[BMLS, MSc. MMP,Doctorate fellow)
ngwafabrice12@gmail.com
Tel: 673565456
MEDICAL IMAGING
It’s a branch in medicine or science that uses ionizing and non
ionizing radiation for diagnosis and treatments of abnormalities or it
is the technique and process of creating visual representation of
the internal components of a human body for clinical analysis and
medical intervention.
Types of medical imaging modalities:
1. X-ray radiography
2. Fluoroscopy
3. Computed Tomography scan (CT scan)
4. Magnetic Resonance Imaging (MRI)
5. Ultrasound (US)
6. Nuclear medicine (isotope scan)
7. Positron Emission Tomography scan (PET Scan)
Basics of Ultrasound
 History

The bat use Ultrasound for navigation

 ULTRASOUND: BASIC
DEFINITION
 Ultrasound is acoustic(sound) energy in the form
of waves having a frequency above the human
hearing range(i.e. 20KHz)
 Ultrasound is a way of using sound waves to
look inside the human body.
Pan-Scanner - The transducer rotated in a semicircular arc
around the patient (1957)
Scan converter allowed for the first time to use the
upcoming computer technology to improve US
Ultrasound Parts
The Ultrasound Machine
A basic ultrasound machine has the following parts:
1. Transducer probe - probe that sends and receives the sound
waves
2. Central processing unit (CPU) - computer that does all of the
calculations and contains the electrical power supplies for
itself and the transducer probe
3. Transducer pulse controls - changes the amplitude, frequency
and duration of the pulses emitted from the transducer probe
4. Display - displays the image from the ultrasound data processed
by the CPU
5. Keyboard/cursor - inputs data and takes measurements from
the display
6. Disk storage device (hard, floppy, CD) - stores the acquired
images
7. Printer - prints the image from the displayed data
 ULTRASONOGRAPHY

• Ultrasonography or diagnostic sonography is an

ultrasound based diagnostic imaging technique used
for visualizing internal body structures.
 MAIN IMAGING
MODES

GREY SCALE DOPPLER IMAGING

IMAGING  Continuous wave Doppler
 Power Doppler
 A-Mode
 Color Doppler
 B-Mode  Duplex Doppler
 M-Mode  Pulsed wave Doppler
 A
MODE
Simplest form of ultrasound
imaging which is based
on the pulse-echo
principle.
A scans can be used to
measure distances.
A scans only give one
dimensional information
 Not so useful for imaging
Used for echo-
encephalography and echo-
ophthalmoscopy
 B MODE

 B stands for Brightness

B scans give two dimensional

information about the cross-
section.
Generally used to measure
cardiac
chambers dimensions,
assess valvular structure
and function.
Development of the B-mode Ultrasound image quality
 M MODE

 M stands for motion

This represents
movements of
structures over time.
M Mode is commonly
used for measuring
chamber
dimensions.
This is analogous to
recording a video in
ultrasound.
 DOPPLER IMAGING

It is a general term used to

visualize velocities of moving
tissues.
Doppler ultrasound evaluates
blood velocity as it flows
through a blood vessel.
Blood flow through the heart
and large vessels has certain
characteristics that can be
measured using Doppler
instruments.
 BLOOD FLOW PATTERNS

LAMINAR FLOW TURBULENT

FLOW
• Layers of flow
(normal) • Obstructions
• Slowest at disrupt laminar flow
wall vessel • Disordered
• Fastest within directions of flow
center of vessel
TYPES OF DOPPLER ULTRASOUND

1. CONTINUOUS WAVE DOPPLER (CW)

 Uses different crystals
to send and receive the
signal
 One crystal constantly sends
a sound
frequency wave
the of aother
,single receives the
constantlysignal
reflected
2. PULSED WAVE
DOPPLER
 Produces short
bursts/pulses of
sound
 Uses the same
crystals to send and
receive the signal
 This follows the same
pulse-echo technique
used in 2D image
formation.
3. COLOR
DOPPLER
 Utilizes pulse-echo Doppler flow
principles to generate a color
image.
 Image is superimposed on the
2D image.
 The red and blue display
provides information regarding
DIRECTION and VELOCITY of
flow.
 Used for general assessment of
flow in the region of interest
 Gives only descriptive or semi
quantitative information on blood
flow.
4. POWER
DOPPLER
5 times more sensitive in
detecting blood flow than
color doppler.

It can get those images

that are impossible with
color doppler.

Used to evaluate blood

flow through vessels within
solid organs.
 APPLICATIONS

 Obstetrics and Gynecology

1. Measuring the size of the fetus
2. Determining the sex of the baby
3. Monitoring the baby for various procedures
 Cardiology
1. Seeing the inside of the heart to identify abnormal functions
2.Measuring blood flow through the heart and major
bloo vessels
 Urology
1. Measuring blood flow through the kidney
2. Locating kidney stones
3. Detecting prostate cancer at early stage
 The main use of ultrasonography
are the following areas
1 - Diagnosis and confirmation of early
pregnancy
Gestational sac be visualized as four and
half weeks of gestation, and yolk sac
at about five weeks
US confirm the site of pregnancy
 2 - Vaginal bleeding in early
pregnancy
Viability of the fœtus can be documented in
presence of vaginal bleeding in early
pregnancy
heartbeat could be seen and detectable by
pulse Doppler about 6 weeks (if this is
observed , the probability of a continuing
pregnancy is more than 95%
5% (missed abortion, blighted ovum)
Fetal heart rate tends to vary with
gestational age:
6 weeks 90-110 beats per minute
9 weeks 140-170 beats per minute
5-8 weeks: a bradycardia less than 90
beats per minutes is associated with high
risk of miscarriage
Many women dot not ovulate at around day
14, findings after a single scan should
always be interpreted with caution; the
diagnosis of missed abortion is usually
made by serial US scans (lack of
gestational development)
If US cannot demonstrate a clearcut
heartbeat, it is reasonable to repeat the
US in 7-10 days to avoid error
In the presence of first trimester bleeding,
US is also indispensable in the early
diagnosis of ectopic pregnancies and
molar pregnancies
 3 - Determination of gestational
age and assessment of fetal size
Fetal body measurements reflect the
gestational age of the fetus (this is
particularly true in early pregnancy)
In patient with uncertain last menstrual
period, measurements must be made as
early as possible in pregnancy, to arrive at
a correct dating for a patient
The following measurements are usually
made
a) The crown-rump length (CRL)
7-13 weeks: gives the accurate
estimation of gestational age
dating with the CRL can be within 3-4
days of the menstrual period
b) The biparietal diameter (BPD)
Is measured after 13 weeks between the 2 sides
of the head
it increases from about 2.4 cm at 13 weeks to
about 9.5 cm at term
NB: different babies of the same weight can have
different head size
dating in the later part of pregnancy is generally
considered unreliable
BPD should be done as early as is feasible
c) The femur length (FL)
it reflects the longitudinal growth of the fetus
it increases from about 1.5 cm at 14 weeks
to about 7.8 cm at term
NB: Its usefulness is similar to the BPD
d) The abdominal circumference (AC)
Is the single most important measurement
to make in late pregnancy
d) Weight of the fetus
Use of polynomial equations containing
BPD, LF, AC
Computer software and charts are readily
available
 4 - Diagnosis of fetal malformation
First trimester:
- chromosomal abnormalities: absence of fetal
nasal bone; increased fetal nuchal translucency
(the areas at the back of the neck) to detect
the Down syndrome fetuses
Before 20 weeks: hydrocephalus, anencephaly,
myelomeningocoele, achondroplasia, spina
bifida, gastroschisis, duodenal atresia, fetal
hydrops, cleft lips/palate , cardiac abnormalities
US assists in other diagnosis procedures in
prenatal diagnosis such as:
- amniocentesis
- chorionic villus sampling
- fetal therapy
What can be detected in a pregnancy ultrasound?
A prenatal ultrasound does two things:
 Evaluates the overall health, growth and development of the fetus.
 Detects certain complications and medical conditions related to
pregnancy.
 In most pregnancies, ultrasounds are positive experiences and
pregnancy care providers don’t find any problems.
 However, there are times this isn’t the case and your provider
detects birth disorders or other problems with the pregnancy.
 Ultrasound is also an important tool to help providers screen for
congenital conditions (conditions your baby is born with).
 A screening is a type of test that determines if your baby is more
likely to have a specific health condition. Your provider also uses
ultrasound to guide the needle during certain diagnostic procedures
in pregnancy like amniocentesis or CVS (chorionic villus sampling).
 An ultrasound is also part of a biophysical profile (BPP), a test that
combines ultrasound with a nonstress test to evaluate if your baby
is getting enough oxygen
Reasons why your provider performs a prenatal ultrasound
are to:
 Confirm you’re pregnant.
 Check for ectopic pregnancy, molar pregnancy,
miscarriage or other early pregnancy complications.
 Determine your baby’s gestational age and due date.
 Check your baby’s growth, movement and heart rate.
 Look for multiple babies (twins, triplets or more).
 Examine your pelvic organs like your uterus, ovaries and
cervix.
 Examine how much amniotic fluid you have.
 Check the location of the placenta.
 Check your baby’s position in your uterus.
 Detect problems with your baby’s organs, muscles or
bones.
When do you have your first prenatal ultrasound?
The timing of your first ultrasound varies depending on your
provider. Some people have an early ultrasound (also called a first-
trimester ultrasound or dating ultrasound). This can happen as
early as seven to eight weeks of pregnancy. Providers do an early
ultrasound through your vagina (transvaginal ultrasound). Early
ultrasounds do the following:

 Confirm pregnancy (by detecting a heartbeat).

 Check for multiple fetuses.
 Measure the size of the fetus.
 Help confirm gestational age and due date.
 Some providers perform your first ultrasound closer to 12
weeks of pregnancy.
20-week ultrasound (anatomy scan)

 You can expect an ultrasound around 18 to 20 weeks in

pregnancy. This is known as the anatomy ultrasound or
20-week ultrasound.
 During this ultrasound, your pregnancy care provider can see
your baby’s sex (if your baby is in a good position for viewing their
genitals), detect birth disorders like cleft palate or find serious
conditions related to your baby’s brain, heart, bones or kidneys.
 If your pregnancy is progressing well and with no complications,
your 20-week ultrasound may be your last ultrasound during
pregnancy.
 However, if your provider detects a problem during your 20-week
ultrasound, they may order additional ultrasounds.
What are reasons you need more ultrasounds during pregnancy?
There are several reasons your pregnancy care provider may order
additional ultrasounds during your pregnancy. Some of these reasons
include:

 Problems with your ovaries, uterus, cervix or other pelvic organs.

 Your baby is measuring small for their gestational age or your
provider suspects IUGR (intrauterine growth restriction).
 Problems with the placenta like placenta previa or
placental abruption.
 You’re pregnant with twins, triplets or more.
 Your baby is breech.
 You have too much amniotic fluid (polyhydramnios).
 You have too little amniotic fluid (oligohydramnios).
 You have a condition like gestational diabetes or preeclampsia.
 Your baby has a congenital disorder.
 RISKS

The two major risks involved with Ultrasound are:

 Development of heat:
Tissues or water absorb the ultrasound energy
which
increases their temperature locally.

 Formation of bubbles ( cavitation):

When dissolved gases come out of solution
due
to
 BENEFITS

 Images muscle, soft tissues very well

 Renders “live images” where most
desirable section is selected
 Shows structure of organs
 No long-term side-effects
 Widely available and comparatively flexible
 Highly portable
 Relatively inexpensive
 Spatial resolution is better in high frequency
ultrasound scanners
 LIMITATIONS

 Sonographic devices have trouble penetrating bone

Sonography performs very poorly when there is a gas

between the transducer and organ of interest

Body habitus has large influence on image quality

Method is operator-dependent

No scout image as there is with CT and MRI

X-RAY RADIOGRAPHY
• X-rays are a form of electromagnetic radiation, their frequency and energy being much
greater than visible light. X-rays are produced in an X-ray tube by focusing a beam of
high energy electrons onto a tungsten target. On hitting the target X-rays are produced
which are directed out of the tube through a “window”. They pass through the patient
onto X-ray film.
CONT
• While passing through the patient the X-ray beam is decreased in energy according to the
density & atomic number of the various tissues through which the beam passes. This
process is known as attenuation.
• X-rays turn film black, therefore the less dense parts of the body which allow more X-rays
to pass through, will appear darker on the film e.g. air. The film is enclosed between 2
fluorescent screens within a metal cassette. These screens emit light when exposed to
X-rays. The film records the visible light emitted by the intensifying screens in response
to irradiation by X-rays.
• A high voltage generator supplies the required power to the X-ray tube. A collimator is
placed at the tube exit port to limit the extent of the X-ray field. An electronic timer is
used to keep the X-ray exposure to a precise, finite duration.
THERE ARE 5 PRINCIPLE DENSITIES RECOGNISED ON X-
RAYS:

• air/gas = black (e.g. lung, bowel, stomach)

• fat = dark grey (e.g. subcutaneous tissue layer, retroperitoneal fat)
• soft tissues/water = light grey (e.g. solid organs, heart ,muscle, bladder)
• bone = off white
• contrast material/metal = bright white
RADIO-OPAQUE AND RADIO-LUCENT
STRUCTURES
• Radio-opaque structures: are internal structures of high density. They will absorb the X-
ray beam more than other structures, leading to high attenuation of X-ray beam, (e.g.
bones and metals).
Radio-lucent structures: are internal structures of low density. They will absorb the X-ray
beam less than other structures, leading to low attenuation of X-ray beam, (e.g. soft
tissues and air).
• In x-ray radiography we have conventional radiography and digital radiography.
• Conventional radiography or manual radiography
PROPERTIES OF X-RAY

• X-rays travel in straight lines.

• X-rays cannot be deflected by electric field or magnetic field.
• X-rays have a high penetrating power.
• Photographic film is blackened by X-rays.
• Fluorescent materials glow when X-rays are directed at them.
• Photoelectric emission can be produced by X-rays.
• Ionization of a gas results when an X-ray beam is passed through it.

Note : An object will only be seen on conventional radiography if its borders lie against tissue of
different density, e.g. right heart border is only seen because it lies against aerated lung which is less
dense. If that part of the lung collapses & loses its’ air the R heart border is no longer seen.
RADIOA-ANATOMY
Anatomical Planes:
• A plane is an imaginary two-dimensional surface that passes
through the body. There are three planes commonly referred to in anatomy and medicine:

1. The sagittal plane.

2. The coronal plane.
3. The transverse plane
THE SAGITTAL PLANE:
• is the plane that divides the body or an organ vertically into right and left sides, it is
known as midsagittal plane when it divides the body into two equal right and left sides,
and its known parasagittal plane when it divides the body into unequal right and left sides
THE CORONAL PLANE
• is the plane that divides the body or an organ into an anterior (front) portion and a
posterior (rear) portion. The coronal plane is often referred to as frontal plane
THE TRANSVERSE PLANE:
• also known as axial plane, the transverse plane is the plane that divides the body or
organ horizontally into upper and lower portions. Transverse planes produce images
referred to as cross sections
BODY CAVITIES:
• The body maintains its internal organization by means of membranes, sheaths, and other
structures that separate the body into two main compartments:
1. The dorsal (posterior) cavity.
2. The ventral (anterior) cavity.
These cavities contain and protect delicate internal organs, and allow for significant
changes in the size and shape of the organs as they perform their functions. The lungs,
heart, stomach, and intestines, for example, can expand and contract without distorting
other tissues or disrupting the activity of nearby organs.
• The dorsal (posterior) cavity: this cavity is subdivided into two main cavities:
1. The cranial cavity houses the brain.

2. The spinal cavity (vertebral cavity) encloses the spinal cord.

The cranial and spinal cavities are continuous. The brain and spinal cord are protected by
the bones of the skull and vertebral column and by cerebrospinal fluid.
• The anterior (ventral) cavity: it has two main subdivisions:
1. The thoracic cavity: is the superior subdivision of the anterior cavity
2. The abdominopelvic cavity: is the inferior subdivision of the anterior cavity.
The thoracic cavity is enclosed by the rib cage and contains the lungs and the heart,
which is located in the mediastinum. The diaphragm forms the floor of the thoracic cavity
and separates it from the inferior abdominopelvic cavity.
The abdominopelvic cavity: is the largest cavity in the body, it is divided into two part the
abdominal part houses the digestive organs and the pelvic part houses the organs of
reproduction.
THE SKULL
• The Skull is the skeletal framework of the head; it is the bony structure that forms the
protective cavity for the brain and supports the face. It is comprised of many bones which
are joined by fibrous joints known as sutures.
Skull divisions:
The skull can be divided into two divisions
1. Cranium (Cranial bones): also known as the skullcap, it is the upper part of the skull
represents the brain case, it surrounds the brain and protects its components, and it mainly
houses the meninges, cerebral vasculature and the structures of the middle and inner ear.
2. Facial bones: they underlie the facial structures and supports the soft tissues of the face,
enclose the eyeballs, form the nasal and oral cavities, and support the teeth of the upper and
lower jaws.
• Anatomically, the cranium is subdivided into a roof known as the calvarium and a base.
The cranium of the skull is composed of several bones joined together by sutures, the
base of the cranium has several openings known as foramina, through which blood
vessels and nerves enter and leave the cavity of the cranium.
The cranial bones:
There are 8 cranial bones Figure 5.3):
- The Frontal bone (1)
- The Parietal bones (2)
- The Temporal bones (2)
- The Sphenoid bone (1)
- The Ethmoid bone (1)
- The Occipital bone (1)
THE STANDARD VIEWS FOR SKULL X-RAY

• Lateral
• AP (Towne method)
• or PA (Caldwell method) – usually taken PA unless following trauma.
Note: Since the advent of computed tomography and magnetic resonance the need for plain
X-rays of the skull has almost disappeared. Plain films are of limited value in suspected
intracranial pathology, especially in the absence of neurological signs.
INDICATIONS FOR SKULL X-RAYS

X-ray of the skull may be done to diagnose:

Fracture of the bone of the skull
Birth defect
Infection
Foreign bodies
Pituitary tumors
And certain metabolic and endocrine disorders that causes bone defect
 FRACTURES
• The skull is a tough, resilient, group of bones which provide protection for the brain. A skull
fracture occurs when one of the bones of the skull breaks. It is usually caused by a heavy
blow to the head from a car accident, fall or assault. It may be accompanied by injury to the
brain.

• Fractures are seen as black lines but if the fracture is depressed with overlapping fragments
it will appear as a white line. They can usually be differentiated from vessels by the fact that
vessels branch smoothly, taper peripherally, and are in known anatomical sites. They are less
dark than fractures as one skull table is intact whereas in fractures both skull tables are
broken. They can be differentiated from sutures as the latter have irregular outer margins and
are in specific sites. Sometimes a suture will be widened after skull trauma and this has the
same significance as a fracture. Most fracture will heal by themselves, particularly if they are
simple linear fractures. The healing process can take many months, although any pain will
usually disappear in around 5 to 10 days.
THERE ARE BASICALLY FOUR MAJOR TYPES OF
CRANIAL FRACTURES
• Linear skull fractures
• Depressed skull fracture
• Diastatic skull fracture
• Basilar skull fracture
LINEAR FRACTURE
• This is the most common type of skull fracture and resembles a thin line along the skull
bone similar to a “crack in china”. They usually don’t cause any problems but sometimes
they can cause damage to blood vessels underneath and result in a blood clot on the
surface of the brain. If the fracture extends to the base of the skull or sinuses it can result
in problems
COMPOUND FRACTURE
• This break in the skull involves a tear in the skin and splintering of the bone.
DEPRESSED FRACTURE
• This fracture involves fragments of bone being pushed downwards and can press on the
brain below. This can cause damage to the underlying brain tissue. These types of
fractures can sometimes result in seizures if there is an injury to the brain.
BASE OF SKULL FRACTURE
• This fracture occurs at the bottom of the skull and can involve the bones around the
sinuses and ears. Often the bones in this area are fragile and are attached to layers that
contain fluid that surround the brain. A fracture to these bones can result in leak of fluid
from the nose or ears. There can be a small risk of developing meningitis with these
fractures if a tear occurs.
THE VERTEBRAL COLUMN
• The vertebral column (also known as the backbone) is the part of the axial skeleton that
extends from the base of the skull down to the pelvis, it consists of sequence of 33
separate bony vertebrae, 24 of them are joined by cartilaginous intervertebral discs in
between known as presacral vertebrae, and 9 are fused in two regions: sacral 5 and
coccygeal.
• The vertebral column houses the spinal cord in a cavity known as the spinalcanal.
REGIONS OF VERTEBRAL COLUMN:

• Vertebral column is divided into five regions

• 1. Cervical region at the neck, it is composed of 7 vertebrae.
• 2. Thoracic region at the mid-back, it is composed of 12 vertebrae.
• 3. Lumbar region at the lower-back, it is composed of 5 vertebrae.
• 4. Sacral region at the upper pelvis, it is composed of 5 vertebrae.
• 5. Coccygeal region at the lower pelvis, it is composed of 5 vertebrae.
CURVATURES OF THE VERTEBRAL COLUMN:
• Normal vertebral column does not form a straight line, but instead has four curvatures
• 1. The cervical curve.
• 2. The thoracic curve.
• 3. The lumbar curve.
• 4. The sacrococcygeal curve.
• These curvatures increase the strength and flexibility of the vertebral column, beside they
• increase the ability of the vertebral column to absorb shock.
FUNCTION OF THE VERTEBRAL
COLUMN:

• Protection: The major function of the vertebral column is protection of the

spinal cord.
• Support: It carries the weight of the body above the pelvis.
• Central Axis: it forms the central axis of the body, and provides attachment for
the muscles of pectoral and pelvic girdles.
• Movement: it controls movement and transmits body weight during walking and
standing.
ANATOMICAL STRUCTURE OF VERTEBRA
• Although the anatomical structure of vertebrae varies in size and shape within the
different regions of the vertebral column, all vertebrae follow general similarity in their
structural pattern.
• The basic anatomical structure of a typical vertebra is composed of two main parts
• 1. Vertebral body anteriorly.
• 2. Vertebral arch posteriorly
• Vertebral Body:
• The vertebral body forms the anterior part of vertebra and it is the weight-bearing part,
• this is why lower vertebral bodies are larger than the upper to better support the increased
weight.
• Vertebral Arch:
• The vertebral arch forms the lateral and posterior aspect of each vertebrae, it is formed by
• seven processes
• 1. Single spinous process centered posteriorly.
• 2. Two transverse processes extend laterally and posteriorly from the vertebral body.
• 3. Two pedicles connect the vertebral body to the transverse processes.
• 4. Two laminaeconnect the transverse and spinous processes.
• On each side of vertebrae there are two articular facets:
• 1. Two superior articular facetsfacing superiorly and backward.
• 2. Two inferior articular facets facing inferiorly and forward.
• Each inferior facet articulates with the superior facet of the lower vertebra forming facet
• joint between each two vertebra
 REGIONAL CHARACTERISTICS OF VERTEBRAE
• Cervical Vertebrae
• The seven cervical vertebrae form a flexible framework for the
• neck and support the head. The bone tissue of cervical vertebrae
• is more dense than that found in the other vertebral regions,
• and, except for those in the coccygeal region, the cervical vertebrae
• are smallest. Cervical vertebrae are distinguished by the
• presence of a transverse foramen in each transverse process
• The vertebral arteries and veins pass through this
• opening as they contribute to the blood flow associated with the
• brain. Cervical vertebrae C2–C6 generally have a bifid, or
• notched, spinous process. The bifid spinous processes increase
• the surface area for attachment of the strong nuchal ligament that
• attaches to the back of the skull. The first cervical vertebra has
• no spinous process, and the process of C7 is not bifid and is larger
• than those of the other cervical vertebrae.
THE NECK
THE VERTEBRAL COLUMN AND SPINAL CORD
• Radiography remains an important investigation for the assessment of spinal anatomy,
with all areas adequately assessed by a combination of anteroposterior (AP) and lateral
views.
• These can be supplemented by:
• • AP open mouth view of the odontoid peg and atlanto-axial
• articulation
• • AP view of the lumbosacral junction
• A major advantage of radiography is that it can be obtained in the erect position, allowing
accurate assessment of spinal alignment and overall spinal balance in the coronal and sagittal
planes.
• A major limitation is the inability to assess the soft tissues of the spinal column, which include the
intervertebral discs,
• spinal ligaments, spinal cord and paraspinal musculature:
• • these require the additional techniques of CT and MRI
• It comprises seven cervical, 12 thoracic, five lumbar, five
• sacral and three to five coccygeal vertebrae