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Medicolegal Issues in Diagnostic Imaging

1 Define medical negligence. Negligence is the failure to possess and apply the knowledge that is possessed or applied by reasonable physicians practicing in similar circumstances. 2 What must be proven for a physician to be found liable for malpractice? Establishment of physician-patient relationship. Breach of the duty of care. Adverse outcome with injury or harm. Direct causality between negligence and outcome. 3 Outline the history…

Training Pathways in Diagnostic Imaging

1 Why choose radiology? Radiology is an incredibly dynamic medical specialty in which different imaging modalities are used to both diagnose and treat diseases. It has been said that the radiologist is the “eye” of medicine: each day, radiologists take on the challenge of examining a study and assimilating elements from the clinical history to transform a 2-dimensional image into a living, unfolding narrative. The radiologist…

Imaging of Child Abuse

1 What are key history and physical examination findings that may raise suspicion of the possibility of nonaccidental trauma (NAT)? Red flags from the history that should lead the clinician and radiologist to consider child abuse include injuries that are not commensurate with the development of the child, a delay in seeking care, or vague or changing stories given by caretakers. Physical examination findings that the…

Pediatric Musculoskeletal Radiology

1 How does growing bone respond to trauma, and how is this different from mature bone? The cartilaginous physis separates the epiphysis from the metaphysis. Pediatric ligaments and tendons are relatively stronger than growing bone (in contrast to adults). Given an equivalent force applied to growing versus mature bone, the growing bone has a higher likelihood of fracture. In addition, immature bone has a propensity to…

Pediatric Neuroradiology

1 How does myelinated brain differ from nonmyelinated brain on an infant magnetic resonance imaging (MRI) examination? Where does one expect to see myelinization occur first? Myelinated brain white matter, as in adults, appears hyperintense relative to gray matter on T1-weighted MR images and hypointense on T2-weighted images. In nonmyelinated brain, this pattern is reversed. Myelinization of the infant brain occurs in a predictable pattern, beginning…

Pediatric Genitourinary Radiology

1 What is the role of the radiologist in pediatric urinary tract infection (UTI)? UTI that occurs and recurs in some children is the result of many interrelated factors, most of which the radiologist cannot assess. Generally, UTI results when bacterial virulence outweighs host resistance. One important factor affecting host resistance that the radiologist can assess is whether there is impairment of unidirectional flow of urine…

Pediatric Gastrointestinal Radiology

1 What are the most common causes of small bowel obstruction in a child? AAIIMM is a mnemonic that makes it easy to remember the causes: A = A dhesions, usually post-surgical. A = A ppendicitis. I = I ntussusception. I = I ncarcerated inguinal hernia. M = M alrotation with volvulus or bands. M = M iscellaneous, such as Meckel's diverticulum or intestinal duplication. 2…

Pediatric Cardiovascular Radiology

1 What are some of the most common types of congenital heart disease (CHD) in order of frequency (most common to least common)? Bicuspid aortic valve, ventricular septal defect (VSD), atrial septal defect (ASD), patent ductus arteriosus (PDA), tetralogy of Fallot, coarctation of the aorta, and transposition of the great vessels. 2 How does assessment of pulmonary blood flow aid in the diagnosis of cyanotic disease?…

Pediatric Thoracic Radiology

1 What is the embryologic relationship between the lungs and the gastrointestinal tract? The lung bud is an outpouching of the primitive foregut, appearing during the fourth week of development. 2 Describe the histologic stages of lung development. The lung bud progressively branches during embryologic development, undergoing a pseudoglandular stage (weeks 5 to 17), a canalicular stage (weeks 16 to 25), a terminal sac stage (weeks…

Radiopharmaceutical Therapeutic Intervention

1 What is the purpose of radiopharmaceutical therapy? In sufficient dosages, radiation will kill cells. In many cases, radiation can be delivered directly to sites of disease with external beam techniques. An alternative means of delivering radiation to sites of disease is radiopharmaceutical therapy, wherein a radioactive compound is administered to the patient. Through a combination of the route of administration and the physical and biological…

Brain Scintigraphy

1 What radiotracers are available for functional brain scintigraphy? There are currently two single photon emission computed tomography (SPECT) radiotracers that are available to evaluate general brain function by measuring cerebral blood flow (CBF): technetium-99m ( 99m Tc) ethylcysteinate dimer (ECD) and 99m Tc hexamethylpropyleneamine oxime (HMPAO). These diffuse passively into the brain shortly after injection. Iodine-123 ( 123 I) ioflupane (DaTscan) is now available for…

Cardiac Scintigraphy

1 How do you prepare a patient for stress myocardial perfusion imaging (SMPI)? Patients should be informed that the test takes approximately one half day and consists of two parts: a resting part and a stress part. The placement of an intravenous catheter (usually inserted at the beginning of the study) is required to administer the radiotracer. The order of the study can be either rest-stress…

Gastrointestinal and Genitourinary Scintigraphy

1 What should patients know about renal scintigraphy, and what preparation should they be given? In general, there is little in the way of patient preparation for a renal scan, although patients should be well hydrated. Patients should refrain from taking furosemide, which is sometimes given during the scan to help evaluate for obstruction. Angiotensin converting enzyme (ACE) inhibitors should also be avoided because they can…

Thyroid, Parathyroid, and Salivary Gland Scintigraphy

1 What patient preparation is required before thyroid scintigraphy? Patients should fast after midnight or, at a minimum, for 4 hours before receiving the radioactive iodine-123 ( 123 I) pill to maximize absorption through the gut. Patients should also avoid ingesting foods containing high amounts of iodine because they would saturate the iodine stores in the body and thyroid gland and diminish the uptake of the…

Pulmonary Scintigraphy

1 How would you describe and prepare a patient for a ventilation-perfusion (V/Q) scan? A V/Q scan takes approximately 20 to 30 minutes and consists of two parts. During the ventilation part, the patient will have a face mask placed over his or her mouth and nose and will be asked to inhale oxygen and a radioactive gas that has no smell. The mask will be…

Bone Scintigraphy

1 What should patients know about a bone scan? A bone scan (i.e., bone scintigraphy) requires the intravenous injection of a small amount of a radioactive tracer (e.g., technetium-99m [ 99m Tc] methylene diphosphonate [MDP]) that is adsorbed into the hydroxyapatite structure of bone. Areas of increased radiotracer uptake relate to bone that is actively being remodeled such as with infection or tumor. The radiotracer carries…

Pet of Nononcological Disorders

1 What are some applications of 18 F-fluoro-2-deoxy-2-D-glucose positron emission tomography/computed tomography (FDG PET/CT) in the nononcological setting? For the answer, see Box 77-1 . The applications in nononcological cardiac and brain disorders will be discussed separately in Chapters 82 and 83 , respectively. Box 77-1 Applications of FDG PET/CT in the Nononcological Setting Assessment of patients with brain disorders Refractory seizures Neurocognitive disorders Assessment of…

Pet of Oncological Disorders

1 What is 18 F-fluoro-2-deoxy-2-D-glucose (FDG)? FDG is the most widely used radiotracer for positron emission tomography (PET) imaging and was first tested in humans in 1976. Its utility is based on the Warburg effect (described in the late 1920s by Otto Warburg), in which malignant cancer cells preferentially use glucose compared to other substrates. However, this radiotracer can be used to assess any organ or…

Musculoskeletal Interventional Radiology

1 What are some common image-guided musculoskeletal interventional procedures? Musculoskeletal radiology is a subspecialty that encompasses many diagnostic and therapeutic procedures using image guidance. Some common ultrasonography-guided (US-guided) procedures in musculoskeletal radiology include: joint injections, tendon sheath injections, calcific tendinosis lavage, bursal injections, tendon fenestration, and soft tissue biopsy. Fluoroscopy is often used to guide joint injections as well as joint aspiration and arthrography. Computed tomography…

Neurointerventional Radiology

1 What is the basic normal vascular anatomy of the brain? Arterial The cerebral vasculature is supplied by 4 arterial vessels—the paired internal carotid arteries (ICA) and the vertebral arteries (VA)—and can be divided into anterior and posterior circulations. The anterior circulation consists of the bilateral internal carotid arteries, which bifurcate into the anterior cerebral arteries (ACA) and the middle cerebral arteries (MCA) ( Figure 74-1,…