Magnetic resonance imaging (MRI), nuclear magnetic resonance imaging (NMRI), or magnetic resonance tomography(MRT) is a medical imaging technique

used in radiology to visualize internal structures of the body in detail. MRI makes use of the property of nuclear magnetic resonance (NMR) to image nuclei of atoms inside the body. An MRI scanner is a device in which the patient lies within a large, powerful magnet where the magnetic field is used to align themagnetization of some atomic nuclei in the body, and radio frequency fields to systematically alter the alignment of this magnetization.[1] This causes the nuclei to produce a rotating magnetic field detectable by the scannerand this information is recorded to construct an image of the scanned area of the body.[2]:36 Magnetic field gradients cause nuclei at different locations to rotate at different speeds. By using gradients in different directions 2D images or 3D volumes can be obtained in any arbitrary orientation. MRI provides good contrast between the different soft tissues of the body, which makes it especially useful in imaging the brain,muscles, the heart, and cancers compared with other medical imaging techniques such as computed tomography (CT) or X-rays. Unlike CT scans or traditional Xrays, MRI does not use ionizing radiation.[3][4] The principle behind the use of MRI machines is that they make use of the fact that body tissue contains lots of water (and hence protons) which gets aligned in a large magnetic field.[5] Each water molecule has two hydrogen nuclei or protons. When a person is inside the powerful magnetic field of the scanner, the average magnetic moment of many protons becomes aligned with the direction of the field. A radio frequency current is briefly turned on, producing a varying electromagnetic field. This electromagnetic field has just the right frequency, known as the resonance frequency, to be absorbed and flip the spin of the protons in the magnetic field. After the electromagnetic field is turned off, the spins of the protons return to thermodynamic equilibrium and the bulk magnetization becomes realigned with the static magnetic field. During this relaxation, a radio frequency signal (electromagnetic radiation in the RF range) is generated, which can be measured with receiver coils. MRI is used to visualize the body to assist doctors in their efforts to diagnose certain diseases or conditions and to evaluate injuries. For pediatric imaging, MRI is used for a variety of purposes, including the following: diagnosing diseases of the central nervous system, including the brain and spine detecting musculoskeletal disorders and injuries identifying complications of infectious diseases, such as those associated with Lyme disease or acquired immunodeficiency syndrome (AIDS) imaging the cardiovascular system detecting congenital heart defects in neonates determining the stage of certain types of cancer evaluating bone marrow disease assessing blood vessels in the brain for stroke and other abnormalities assisting in the planning of surgery and cancer treatment evaluating the urinary tract MRI provides images with excellent contrast that allow clinicians to clearly see details of soft tissue, bone, joints, and ligaments. MRI angiography is an imaging technique used to evaluate the blood vessels, for example, to detect aneurysms or cardiovascular problems. Because MRI does not use ionizing radiation to produce images, like x ray and CT, it is often the examination of choice for pediatric imaging and for imaging the male and female reproductive systems, pelvis and hips, and urinary tract and bladder.

MRI can also be used to evaluate brain function for assessing language, senses, neurologic disorders, and pain . This technique, called functional MRI, involves rapid imaging to display changes in the brain's blood flow in response to tasks or visual and auditory stimuli. Functional MRI is being researched to image neurologic disorders, such as attention deficit hyperactivity disorder (ADHD), delayed cognitive development , and epilepsy. MRI spectroscopy is another emerging imaging technique for evaluating pediatric brain disorders. In MRI spectroscopy, chemicals in the brain are measured and brain tissue is imaged. This technique is being investigated to evaluate traumatic brain injury, speech delay, creatine deficiency syndromes, and mood disorders in young children.

Read more: Magnetic Resonance Imaging - Definition, Purpose, Description, Risks http://www.healthofchildren.com/M/Magnetic-Resonance-Imaging.html#b#ixzz22S7k029e Preparation Preparation Prior to any MRI scan, patients are required to remove all metal objects and remove any clothing with metal on them (zippers, snaps). In most cases, parents have to complete a survey regarding their child's past surgical procedures and medical history to indicate whether the child has any metallic implants. Metallic implants include artificial joints, pacemakers, aneurysm clips, metal plates, pins or screws, and surgical staples. Children with metallic implants are likely to undergo a computed tomography (CT) examination instead of an MRI. Unlike CT, no fasting or laxatives are required prior to an MRI scan. Only one type of MRI scan, called a magnetic resonance cholangiopancreatography (MRCP), which scans the bile ducts, requires that the child not eat or drink anything for two to three hours prior to the scan. During the examination, the child must lie still. The MRI scanner does make loud noises throughout the examination, which can be frightening for some children. Before the examination, the procedure should be explained to the child, and it should be emphasized that the examination is painless. Most facilities have specially designed music systems so that patients can wear headsets and listen to music during the scan; some facilities even have special video goggles so children can watch a cartoon or movie during the scan.

return to top How to prepare for the MRI examination. Theres no special preparation necessary for the MRI examination. Unless your doctor specifically requests that you not eat or drink anything before the exam, there are no food or drink restrictions. Continue to take any medication prescribed by your doctor unless otherwise directed. You wont be allowed to wear anything metallic during the MRI examination, so it would be best to leave watches, jewelry or anything made from metal at home. Even some cosmetics contain small amounts of metals, so it is best to not wear make-up. In order to prevent metallic objects from being attracted by the powerful magnet

of the MR system, you will typically receive a gown to wear during your examination. Items that need to be removed by patients before entering the MR system room include: Purse, wallet, money clip, credit cards, cards with magnetic strips Electronic devices such as beepers or cell phones Hearing aids Metal jewelry, watches Pens, paper clips, keys, coins Hair barrettes, hairpins Any article of clothing that has a metal zipper, buttons, snaps, hooks, underwires, or metal threads Shoes, belt buckles, safety pins Before the MRI procedure, you will be asked to fill out a screening form asking about anything that might create a health risk or interfere with imaging. You will also undergo an interview by a member of the MRI facility to ensure that you understand the questions on the form. Even if you have undergone an MRI procedure before at this or another facility, you will still be asked to complete an MRI screening form. Examples of items or things that may create a health hazard or other problem during an MRI exam include: Pacemaker Implantable cardioverter defibrillator (ICD) Neurostimulator Aneurysm clip Metal implant Implanted drug infusion device Foreign metal objects, especially if in or near the eye Shrapnel or bullet wounds Permanent cosmetics or tattoos Dentures/teeth with magnetic keepers Other implants that involve magnets Medication patch (i.e., transdermal patch) that contains metal foil Check with the MRI technologist or radiologist at the MRI center if you have questions or concerns about any implanted object or health condition that could impact the MRI procedure. This is particularly important if you have undergone surgery involving the brain, ear, eye, heart, or blood vessels. Important Note: If you are pregnant or think that you could be pregnant, you must notify your physician and the radiologist or the MRI technologist at the MRI center prior to the MRI procedure. Before entering the examining room, any friend or relative that might be allowed to accompany you will be asked questions to ensure that he or she may safely enter the MR system room and will likewise be instructed to remove all metallic objects. Additionally, this individual will need to fill out a screening form. Post-Procedure Care

Following your MRI, you can resume your normal activities. (Please contact your doctor if you have any questions about your intended activities, or if you have any questions about restricted activities.) If you were given an injection of contrast media as part of your MRI scan today, you should: Drink an extra 24 ounces of water (three extra glasses). Contact your physician immediately if you experience any or the following: Trouble breathing Dizziness or lightheadedness Slow or irregular heartbeat Any other sudden change that concerns you Your injection of contrast media required a puncture through your skin. Even though proper steps were taken to prevent infection as a result of this skin puncture, an infection in this area is possible. Please seek medical care if: The injection site becomes red, painful to the touch, or hot to the touch. A lump that was not present when you finished your scan develops at the injection site, or a small lump that was present becomes larger over time. If you were given (or took) a sedative for this exam, please do not drive or operate machinery until its effects have worn off (please contact your doctor with any questions). Nsg resp Preparing equipment

Gathering and preparing equipment is often done by nurses. Their responsibilities include checking the equipment to assure it is working properly and is ready for use on patients. Cleaning equipment before and after each use to prevent the spread of infection is done by the nursing staff. Another service they provide is assisting technicians who specialize in specific equipment use to make sure the testing is performed on the patient without difficulty. They must also report any broken or damaged equipment and prevent it from being used on patients before it is fixed. Preparing patients Preparing a patient for diagnostic testing is a nurse's responsibility. Drawing blood or administering medication prior to testing is one way nurses help prepare patients. Another way they help is by collecting specimens, such as sputum or urine samples, and sending them to the lab. Patients may need to have an area sterilized or shaved for a surgical procedure or the application of electrodes. Nurses assist with mentally preparing patients for testing by answering questions, explaining the procedure or test and possible outcomes. Sponsored Links OBD 2 Software for OSX Check Engine Light On? Diagnose and Clear yourself. www.yhasi.com Assist with testing

Assisting both patients and other health care providers during diagnostic testing is done by nurses. They provide patient care during the test which may include administering medicines

when needed. Nurses must help position patients properly, like rolling the patient over, in order to complete the necessary diagnostic testing. Transporting patients to and from the test can be part of their job. This helps ensure the patient arrives at the testing site safely and on time. Monitor patients during testing Patients are monitored by nurses during diagnostic testing. This includes monitoring their current medical condition, especially in those patients deemed unstable. They must check a patient's vital signs (blood pressure, pulse, breathing rate), assess physical condition and keep an eye on any monitors that the patient needs to remain hooked up to during the tests, such as a heart monitor or ventilator. Nurses may also be required to connect or disconnect any monitors or devices that can interfere with the testing. Reporting results

Test results are reported to the patient's doctor, specialists and others in need of the information by nurses. Results may be phoned in, faxed or sent electronically via a computer. It may be the nurse's responsibility to check for the results of the tests as well. They may be in charge of entering the results into the patient's medical record. Nurses must also notify the patient's physician when abnormal or critical results that require an immediate response, such as abnormal blood work with critical potassium levels, are found.

Read more: Nursing Responsibilities for Diagnostic Testing | eHow.com http://www.ehow.com/list_7278200_nursing-responsibilities-diagnostictesting.html#ixzz22SA8MRO5 Preparation for the MRI Scan Bring your referral letter or request form and all x-rays taken in the last 2 years with you. Page 2 of 6 Last udpated 4 May 2009 Leave the x-rays with the radiology staff as the doctor may need to look at them. The MRI staff will tell you when these are ready to be picked up. Wear comfortable, loose clothing. Leave all jewellery and valuables at home (metal objects, such as watches, keys, coins and jewellery cannot be taken into the MRI room. Cards with magnetic strips such as bank cards will be erased by most MRI scanners).

If you are having dye: You may be asked not to eat or drink for a few hours before the MRI Scan Important to tell your doctor before the scan If you are or may be pregnant. If you dont like closed in spaces (claustrophobic). Your doctor may then discuss the possibility of you being given something to relax you just before the scan (sedative). If the doctor has decided you need a sedative and written it on the request form, you will need to let the staff know when you book your scan. If you are having dye tell the staff about any medical conditions you have, including kidney disease, allergies and asthma (some conditions such as kidney disease may mean you cannot have an MRI with dye). Just before the MRI Scan: You may be given a gown to wear during the procedure. You will be asked to remove any metal objects. You may be given a sedative if you dont like closed in spaces. (claustrophobic). The sedative will relax you and may make you feel sleepy.

PROCEDURE
What happens during a MRI Scan The staff will ask you to lie on the bed, and will place a receiver around the part of your body being scanned. Straps or pillows may be used to help you keep still during the scan, however you will be able to remain comfortable. If you are having dye or sedative injected, MRI staff will put a needle into a vein in your hand or arm. Page 3 of 6 Last udpated 4 May 2009 Possible side effects of dye: You may feel a slight coolness and a flushing for a few seconds. Part of your body may feel warm - if this bothers you, tell the staff. The MRI machine makes a lot of noise during the scan, which may sound like

thumping or humming. You will be given earplugs or headphones to block out the noise or listen to music. (In most MRI centres you can bring your own CD to listen to). The staff will leave the room where they can control the movement of the bed from behind a screen. They can see, hear and speak to you at all times. You will be able to speak to them at all times. They will tell you what is happening, when to hold still and if you need to take a deep breath and hold it. If you get stiff, need to move or are feeling closed in (claustrophobic), tell the staff. The MRI staff will use a remote control to slowly move you into the tunnel of the MRI scanner. When the scanning is finished you will be asked to wait while the staff check the pictures. The scan, including getting you ready, takes between 30 minutes to one hour. When will I get the results? The amount of time it takes for you to get your results will differ depending on where you get your scans done. The radiology doctor will look at the pictures and write a report. The pictures may be on films or on a CD. Ask whether you should wait to take the pictures and report with you, or whether they will be sent to your doctor. Your doctor will need to discuss the report with you. You will need to make an appointment to do this. After the MRI Scan You will be able to go soon after the MRI is finished and can continue with normal activities. If you had dye: Staff will need to take out the needle if it is still in your arm. Staff will give you any special instructions The dye will pass out of your body in your urine. You will not notice it as it is colourless. Drink plenty of fluid to help get rid of the dye.

If you had a sedative: Staff will need to take out the needle if it is still in your arm. You must not drive a car or take public transport and must have someone with you for 24 hours afterwards.

You must not operate machinery on the day of the scan Ultrasound Ultrasound produces sound waves that are beamed into the body causing return echoes that are recorded to "visualize" structures beneath the skin. The ability to measure different echoes reflected from a variety of tissues allows a shadow picture to be constructed. The technology is especially accurate at seeing the interface between solid and fluid filled spaces. These are actually the same principles that allow SONAR on boats to see the bottom of the ocean. Ultrasonography is body imaging using ultrasound in medical diagnosis. A skilled ultrasound technician is able to see inside the body using ultrasonography to answer questions that may be asked by the medical practitioner caring for the patient. Usually, aradiologist will oversee the ultrasound test and report on the results, but other types of physicians may use ultrasound as a diagnostic tool. For example, obstetricians use ultrasound to assess the fetus duringpregnancy. Surgeons and emergency physicians use ultrasound at the bedside to assess abdominal pain or other concerns. A transducer, or probe, is used to project and receive the sound waves and the return signals. A gel is wiped onto the patient's skin so that the sound waves are not distorted as they cross through the skin. Using their understanding of human anatomy and the machine, the technician can evaluate specific structures and try to answer the question asked by the patient's physician. This may take a fair amount of time and require the probe to be repositioned and pointed in different directions. As well, the technician may need to vary the amount of pressure used to push the probe into the skin. The goal will be to "paint" a shadow picture of the inner organ that the health care practitioner has asked to be visualized. The physics of sound can place limits on the test. The quality of the picture depends on many factors. Sound waves cannot penetrate deeply, and an obese patient may be imaged poorly. Ultrasound does poorly when gas is present between the probe and the target organ. Should the intestine be distended with bowel gas, organs behind it may not be easily seen. Similarly, ultrasound works poorly in the chest, where the lungs are filled with air. Ultrasound does not penetrate bone easily. The accuracy of the test is very much operator dependent. This means that the key to a good test is the ultrasound technician. Ultrasound can be enhanced by using Doppler technology which can measure whether an object is moving towards or away from the probe. This can allow the technician to measure blood flow in organs such as the heartor liver, or within specific blood vessels. Purpose For what purposes are ultrasounds used? Ultrasound is not limited to diagnosis, but can also be used in screening for disease and to aid in treatment of diseases or conditions. Diagnostic uses Obstetrics Ultrasound routinely for assessing the progression of pregnancy. Pelvic ultrasounds can be obtained trans-abdominally where the probe is placed on the abdominal wall, or trans-vaginally, where the probe is placed in the vagina. For example ultrasound in obstetrics is used to diagnose growths or tumors of the ovary,uterus, Fallopian tubes. Cardiology Echocardiography Echocardiography (echo=sound + cardio=heart + graphy=study) evaluates the heart, the heart's valve function, and blood flow through them. It also evaluates the heart wall motion and the amount of blood the heart pumps with each stroke. Echocardiography can be performed in two ways:

trans-thoracic: the probe is place on chest wall to obtain images, and trans-esophageal: where the probe is placed through the mouth into the esophagus. Anatomically, the esophagus sits near the heart and allows clearer images. However, this approach is a little more invasive. Different groups of illnesses can be assessed by echocardiography: Valves in the heart keep blood flowing in one direction when the heart pumps. For example, when the heart beats, blood is pumped from the left ventricle through the aortic valve into the aorta and the rest of the body. The aortic valve prevents blood from back-flowing into the heart as it fills for the next beat. Echocardiography can determine if the valve is narrow or leaking (regurgitating, insufficient). By following how the patient fares clinically, repeated echocardiograms can help determine whether valve replacement or repair is warranted. The same principles apply to the mitral valve which keeps blood flowing from the left atriumto the left ventricle. The heart muscle pumps blood to the body. If the heart weakens, the amount of blood it pumps with each beat can decrease, leading tocongestive heart failure. The echocardiogram can measure the efficiency of the heart beat and how much blood it pumps; which assists in determining whether medications are needed. It also is used to monitor how well medications are working. Echocardiography can visualize the heart chambers to detect blood clots in conditions such as atrial fibrillation (an irregular heart rhythm). In other situations, the test can help diagnose endocarditis (an infection of the heart valves) by visualizing "vegetations" (an infected mass) on the valves themselves. Echocardiography also can detect abnormal fluid collections (pericardial effusions) in the pericardium. Echocardiograms are used to diagnose and monitor pulmonary artery hypertension. Blood vessels Ultrasound can detect blood clots in veins (superficial or deep venous thrombosis) or artery blockage (stenosis) and dilatation (aneurysms). Some examples of ultrasound testing include: Carotid ultrasound is performed in patients with transient ischemic attacks (TIAs) or strokes to determine whether the major arteries in the neck are blocked causing the decreased blood supply to the brain. The aorta is the large blood vessel leaving the heart that supplies blood to the rest of the body. The walls of the aorta are under significant pressure from the force of the heartbeat and over time, may weaken and widen. This is called an aneurysm, and it can be detected in the abdomen by ultrasound (abdominal aortic aneurysm). For those patients with small aneurysm, observation may be recommended and the aneurysm size followed over time by repeated tests. Veins can also be evaluated by ultrasound and it is a common test to assess whether swelling in a leg is due to a blood clot, deep vein thrombosis (DVT) or another cause. Abdominal structures Aside from its use in obstetrics, ultrasound can evaluate most of the solid structures in the abdominal cavity. This includes the liver, gallbladder,pancreas, kidneys, bladder, prostate, testicles, uterus, and ovaries. Ultrasound is the preferred to test to screen for gallstones or an infected gallbladder. The ultrasound can reveal the stones as well as signs of infection, including thickening of the gallbladder wall and fluid surrounding the gallbladder. The ultrasound may find blockage in the bile ducts. For those patients where the radiation of a CT scan (computerized tomography) is a potential risk (pregnant patients or children), ultrasound may be used to look for diseases like appendicitis or kidney stones. Ultrasound is the test of choice to diagnose testicular torsion. Pelvic ultrasound is used in gynecology to help assess non-pregnancy related issues like lower abdominal pain, ovarian cysts, uterine fibroids, uterine growths, and endometriosis. The neck

The thyroid gland can be imaged using ultrasound looking for nodules, growths, or tumors. Knee joint Ultrasound can be used to detect bulging of fluid from a swollen knee joint into the back of the knee, called a Baker's cyst. Ultrasound may be used to screen for blood vessel diseases. By measuring blood flow and blockage in the carotid arteries, the test can predict potential risk for future stroke. Similarly, by measuring the diameter of the aorta in the abdomen, ultrasound can screen for aneurysm (abnormal dilatation) and the risk of rupture. These tests may be indicated for an individual patient or they may be offered as a community wide health screening assessment. What are some common uses of the procedure? Click to play

Ultrasound examinations can help to diagnose a variety of conditions and to assess organ damage following illness. Ultrasound is used to help physicians evaluate symptoms such as: pain swelling infection hematuria (blood in urine) Ultrasound is a useful way of examining many of the body's internal organs, including but not limited to the: heart and blood vessels, including the abdominal aorta and its major branches liver gallbladder spleen pancreas kidneys bladder uterus, ovaries, and unborn child (fetus) in pregnant patients eyes thyroid and parathyroid glands scrotum (testicles) brain in infants hips in infants ltrasound: Liver Ultrasound is also used to: guide procedures such as needle biopsies, in which needles are used to extract sample cells from an abnormal area for laboratory testing. image the breasts and to guide biopsy of breast cancer (see the Ultrasound-Guided Breast Biopsy page (www.RadiologyInfo.org/en/info.cfm?pg=breastbius)). diagnose a variety of heart conditions and to assess damage after a heart attack or diagnose for valvular heart disease.

Doppler ultrasound images can help the physician to see and evaluate: blockages to blood flow (such as clots). narrowing of vessels (which may be caused by plaque). tumors and congenital vascular malformation. With knowledge about the speed and volume of blood flow gained from a Doppler ultrasound image, the physician can often determine whether a patient is a good candidate for a procedure like angioplasty. top of page How should I prepare? You should wear comfortable, loose-fitting clothing for your ultrasound exam. You may need to remove all clothing and jewelry in the area to be examined. You may be asked to wear a gown during the procedure. Other preparation depends on the type of examination you will have. For some scans your doctor may instruct you not to eat or drink for as many as 12 hours before your appointment. For others you may be asked to drink up to six glasses of water two hours prior to your exam and avoid urinating so that your bladder is full when the scan begins. top of page Procedure A clear water-based gel is applied to the area of the body being studied to help the transducer make secure contact with the body and eliminate air pockets between the transducer and the skin that can block the sound waves from passing into your body. The sonographer (ultrasound technologist) or radiologist then presses the transducer firmly against the skin in various locations, sweeping over the area of interest or angling the sound beam from a farther location to better see an area of concern. Doppler sonography is performed using the same transducer. When the examination is complete, the patient may be asked to dress and wait while the ultrasound images are reviewed. In some ultrasound studies, the transducer is attached to a probe and inserted into a natural opening in the body. These exams include: Transesophageal echocardiogram. The transducer is inserted into the esophagus to obtain images of the heart. Transrectal ultrasound. The transducer is inserted into a man's rectum to view the prostate. Transvaginal ultrasound. The transducer is inserted into a woman's vagina to view the uterus and ovaries. Most ultrasound examinations are completed within 30 minutes to an hour. You will be taken into a room where you will be asked to lie down on a couch; the room may be dimmed so that the pictures on the screen can be seen more clearly. A gel will be applied to your skin over the area to be scanned, for example, the abdomen. The gel allows the sensor to slide easily over the skin and helps to produce clearer pictures. You may be asked to take deep breaths and to hold your breath for a few moments. For a scan of the bladder, the bladder may occasionally not be full enough for the examination and you may be asked to drink more fluid, and wait while the bladder

fills up. The doctor/sonographer will slowly move the sensor over your skin while viewing the images on the screen. Records of selected images will be made so that they can be viewed later. Upon completion, the gel will be wiped off and you will be free to get dressed. NURSING RESPONSIBILITIES For best visualization, schedule abdominal ultrasonography before any examinations that usebarium. Drink five to six full glasses of fluid approximately 1 to 2 hours before the test. Explain that the gel is applied over the area where the transducer is place Cerebral angiography
Cerebral angiography is a form of angiography which provides images of blood vessels in and around the brain, thereby allowing detection of abnormalities such as arteriovenous malformations and aneurysms. It was pioneered in 1927 by the Portuguese physicianEgas Moniz at [1] the University of Lisbon, who also helped develop thorotrast for use in the procedure. Typically a catheter is inserted into a large artery (such as the femoral artery) and threaded through the circulatory system to thecarotid artery, where a contrast agent is injected. A series of radiographs are taken as the contrast agent spreads through the brain's arterial system, then a second series as it reaches the venous system. For some applications this method may yield better images than less invasive methods such as computed tomography angiography and magnetic resonance angiography. In addition, cerebral angiography allows certain treatments to be performed immediately, based on the its findings. If, for example, the images reveal an aneurysm, metal coils may be introduced through the catheter already in place and maneuvered to the site of aneurysm; over time these coils encourage formation of connective tissue at the site, strengthening the vessel walls. In some jurisdictions, cerebral angiography is required to confirm brain death.
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What are some common uses of the procedure? Physicians use the procedure to detect or confirm abnormalities within the blood vessels in the brain, including:

an aneurysm, a bulge or sac that develops in an artery due to weakness of the arterial wall. atherosclerosis, a narrowing of the arteries. arteriovenous malformation, a tangle of dilated blood vessels that disrupts normal blood flow in the brain. vasculitis, an inflammation of the blood vessels, generally narrowing them. a tumor. a blood clot. a tear in the lining of the artery, known as a vascular dissection. a stroke.

A cerebral angiogram may be performed:

to evaluate arteries of the head and neck before surgery. to provide additional information on abnormalities seen on MRI or CT of the head, such as the blood supply to a tumor. to prepare for other medical treatment, such as in the surgical removal of a tumor. in preparation for minimally invasive treatment of a vessel abnormality.

The procedure may also be used to help diagnose the cause of symptoms, such as:

severe headaches memory loss slurred speech dizziness blurred or double vision weakness or numbness loss of coordination or balance.

How should I prepare?

You should report to your doctor all medications that you are taking, including herbal supplements, and if you have any allergies, especially to local anesthetic medications, general anesthesia or to contrast materials containing iodine (sometimes referred to as "dye" or "x-ray dye"). Your physician may advise you to stop taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) or blood thinners for a specified period of time before your procedure. Also inform your doctor about recent illnesses or other medical conditions.

If you are going to be given a sedative during the procedure, you may be asked not to eat or drink anything for four to eight hours before your exam. If so, you may want to have a relative or friend accompany you and drive you home afterward. For more information about sedation, visit the Anesthesia page (www.RadiologyInfo.org/en/safety/). You will receive specific instructions on how to prepare, including any changes that need to be made to your regular medication schedule. You will likely be instructed not to eat or drink anything after midnight before your procedure. Your doctor will tell you which medications you may take in the morning. Women should always inform their physician and x-ray technologist if there is any possibility that they are pregnant. Many imaging tests are not performed during pregnancy so as not to expose the fetus to radiation. If an x-ray is necessary, precautions will be taken to minimize radiation exposure to the baby. See the Safety page (www.RadiologyInfo.org/en/safety/) for more information about pregnancy and x-rays. If you are breastfeeding at the time of the exam, you should ask your radiologist how to proceed. It may help to pump breast milk ahead of time and keep it on hand for use after contrast material has cleared from your body, about 24 hours after the test.
What does the equipment look like?

View larger with caption

In this procedure, x-ray equipment and a catheter may be used. The equipment typically used for this examination consists of a radiographic table, an x-ray tube and a television-like monitor that is located in the examining room. Fluoroscopy, which converts x-rays into video images, is used to watch and guide progress of the procedure. The video is produced by the x-ray machine and an image intensifier that is suspended over a table on which the patient lies. A catheter is a long, thin plastic tube, smaller than a pencil.

Other equipment that may be used during the procedure includes an intravenous line (IV) and equipment that monitors your heart beat and blood pressure. top of page
How does the procedure work?

X-rays are a form of radiation like light or radio waves. X-rays pass through most objects, including the body. Once it is carefully aimed at the part of the body being examined, an x-ray machine produces a small burst of radiation that passes through the body, recording an image on photographic film or a special digital image recording plate. Different parts of the body absorb the x-rays in varying degrees. Dense bone absorbs much of the radiation while soft tissue, such as muscle, fat and organs, allow more of the x-rays to pass through them. As a result, bones appear white on the x-ray, soft tissue shows up in shades of gray and air appears black. Until recently, x-ray images were maintained as hard film copy (much like a photographic negative). Today, most images are digital files that are stored electronically. These stored images are easily accessible and are frequently compared to current x-ray images for diagnosis and disease management. Fluoroscopy uses a continuous or pulsed x-ray beam to create a sequence of images that are projected onto a fluorescent screen, or television-like monitor. When used with a contrast material, which clearly defines the area being examined by making it appear bright white, this special x-ray technique makes it possible for the physician to view joints or internal organs in motion. Still images are also captured and stored either on film or electronically on a computer. top of page
How is the procedure performed?

This procedure is often done on an outpatient basis. However, some patients may require admission following the procedure. Please consult with your physician as to whether or not you will be admitted. Prior to your procedure, your blood may be tested to determine how well your liver and kidneys are functioning and whether your blood clots normally.

Because the cerebral angiogram and recovery period may last for several hours, you will be asked to empty your bladder before the procedure begins. A nurse or technologist will insert an intravenous (IV) line into a vein in your hand or arm so that sedative medication can be given intravenously. Alternatively, you may receive general anesthesia. In children up to mid-teens, cerebral angiography is usually performed with the patient under general anesthesia. Devices to monitor your heart rate and blood pressure will be attached to your body. You will be positioned on the examining table. Your head will be held in place using a strap, tape or a foam head holder so you cannot move it during the procedure. The area of your body where the catheter is to be inserted will be shaved, sterilized and covered with a surgical drape. Your physician will numb the area with a local anesthetic. A very small nick is made in the skin at the site. Using x-ray-guidance, a catheter (a long, thin, hollow plastic tube) is inserted through the skin into a blood vessel and navigated to the area to be examined. The contrast material is then injected through the catheter. When it reaches the blood vessels being studied, several sets of x-rays will be taken. At the end of the procedure, the catheter will be removed and pressure will be applied to stop any bleeding. The opening in the skin is then covered with a dressing. No sutures are needed. Your intravenous line will be removed. The procedure is usually completed within one to three hours. Additional time may be required for exam preparation, setup and post-procedure care. top of page

What will I experience during and after the procedure?

You will feel a slight pin prick when the needle is inserted into your vein for the intravenous line (IV) and when the local anesthetic is injected. If the case is done with sedation, the intravenous (IV) sedative will make you feel relaxed and sleepy. You may or may not remain awake, depending on how deeply you are sedated. You may feel slight pressure when the catheter is inserted but no serious discomfort. As the contrast material passes through your body, you may get a warm feeling. You will be asked to remain very still while the x-ray images are taken. The most difficult part of the procedure may be lying flat for several hours. Once the procedure is complete, the catheter will be removed by the radiologist. Pressure is immediately applied to the puncture site to ensure there is no bleeding. The pressure may be either applied by hand or with a special clamp. In either case, it takes about 10 minutes for the tiny hole in the artery to close. You will remain in the recovery room for observation for a few hours following the procedure before you return home. If the catheter was placed in the groin area, you will be given specific instructions regarding how long you may need to keep your leg straight. This will vary based on the technique used to repair the hole created in order to insert the catheter. You may apply ice to the site where the catheter was inserted to relieve pain and swelling. You may resume your normal diet immediately after the exam. You will be able to resume all other normal activities eight to 12 hours after the exam. You should report to your physician immediately if you experience any of the following after your procedure:

weakness or numbness in the muscles of your face, arms or legs slurred speech vision problems signs of infection at the catheter site dizziness chest pain

difficulty breathing rash

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Who interprets the results and how do I get them?

A radiologist, a physician specifically trained to perform, supervise and interpret radiology examinations, will analyze the images and send a signed report to your primary care or referring physician, who will share the results with you. Follow-up examinations are often necessary, and your doctor will explain the exact reason why another exam is requested. Sometimes a follow-up exam is done because a suspicious or questionable finding needs clarification with additional views or a special imaging technique. A follow-up examination may be necessary so that any change in a known abnormality can be detected over time. Follow-up examinations are sometimes the best way to see if treatment is working or if an abnormality is stable over time.
OR/other ref

How the Test is Performed

Cerebral angiography is done in the hospital or large radiology center. You will be asked to lie on an x-ray table. Your head is positioned and held still using a strap, tape, or sandbags, so you do not move during the procedure. The health care provider will attach electrocardiogram(ECG) leads to your arms and legs, which monitor your heart activity during the test. Before the test starts, you will be given a mild sedative to help you relax. An area of your body, usually the groin, is cleaned and numbed with a local numbing medicine (anesthetic). A thin, hollow tube called a catheter is placed through an artery and carefully moved up through the main blood vessels in the belly area and chest and into an artery in the neck. Moving xray images help the doctor position the catheter. Once the catheter is in place, a special dye (contrast material) is injected into catheter. X-ray images are taken to see how the dye moves through the artery and blood vessels of the brain. The dye helps highlight any blockages in blood flow. After the x-rays are taken, the needle and catheter are withdrawn. Pressure is immediately applied on the leg at the site of insertion for 10 - 15 minutes to stop the bleeding. After that time, the area is checked and a tight bandage is applied. Your leg should be kept straight for 4 - 6 hours after the procedure. Watch the area for bleeding for at least the next 12 hours.

Digital subtraction angiography (DSI) uses a computer to "subtract" or take out the bones and tissues in the area viewed, so that only the blood vessels filled with the contrast dye are seen.

How to Prepare for the Test

You must sign a consent form. Your health care provider will explain the procedure and its risks. Routine blood tests and examination of the nervous system will be done before the procedure. Tell the health care provider if you:

Are allergic to shellfish or iodine substances Have a history of bleeding problems Have had an allergic reaction to x-ray contrast dye or any iodine substance May be pregnant You may be told not to eat or drink anything for 4 to 8 hours before the test. When you arrive at the testing site, you will be given a hospital gown to wear. You must remove all jewelry.

How the Test Will Feel

The x-ray table may feel hard and cold. You may wish to ask for a blanket or pillow. Some people feel a sting when the numbing medicine (anesthetic) is given. You will feel a brief, sharp pain as the catheter is inserted. There is a feeling of pressure as the catheter is moved into the body. Some people feel a warm or burning sensation of the skin of the face or head when the contrast dye is injected. You may have slight tenderness and bruising at the site of the injection after the test.

Why the Test is Performed

Cerebral angiography is most frequently used to identify or confirm problems with the blood vessels in the brain. Your doctor may order this test if you have symptoms or signs of:

Abnormal blood vessels (vascular malformation) Aneurysm Narrowing of the arteries in the brain Vasculitis

It is sometimes used to:

Confirm a brain tumor Evaluate the arteries of the head and neck before surgery Find a clot that may have caused a stroke In some cases, this procedure may be used to get more detailed information after something abnormal has been detected by an MRI or CT scan of the head. This test may also be done in preparation for medical treatment (interventional radiology procedures) by way of certain blood vessels.

What Abnormal Results Mean

Contrast dye flowing out of the blood vessel may be a sign of internal bleeding. Narrowed arteries may suggest cholesterol deposits, a spasm, or inherited disorders. Out of place blood vessels may be due to brain tumors, bleeding within the skull, aneurysm (bulging of the artery walls), or arteriovenous malformation. Abnormal results may also be due to:

Intracerebral hemorrhage Metastatic brain tumor Neurosyphilis Optic glioma Pituitary tumor Primary brain tumors

Risks
There is the possibility of significant complications, including:

Allergic reaction to the contrast dye Blood clot or bleeding at the needle stick site, which could partly block blood flow to the leg Damage to an artery or artery wall from the catheter, which can block blood flow and cause a stroke (rare)

Considerations
Tell your health care provider immediately if you have:

Facial weakness Numbness in your leg during or after the procedure Slurred speech

Vision problems

TEACHING

During your Angiogram: You will be sedated and comfortable. After cleansing and numbing your groin area, a small incision will be made and a catheter will be inserted into your femoral artery. The neurosurgeon will pass this catheter slowly through the arteries and vessels to the neck, by visualizing the path on a TV like monitor, where contrast dye will be injected. The contrast dye allows the blood vessels to be visible while x-ray pictures are being taken. During the procedure a registered nurse will monitor your blood pressure, heart rate, and oxygen level. You may communicate to your doctor or nurse if you feel anxious or uncomfortable at anytime throughout the procedure and medication will be given to help you feel more comfortable. When the contrast dye is being injected some patients report feeling a warm flushing sensation to their face or a salty taste in their mouth. These sensations are brief and a normal response to the contrast dye. Will I be in pain? The procedure is generally not painful. You are sedated so that you are still and comfortable, but you will be able to communicate with the surgeon if needed. You will receive a local anesthetic prior to the incision and insertion of the catheter. You may feel a burning sensation briefly. You may also experience a hot or flushed feeling when the dye is injected. Please do not hesitate to communicate any discomfort during the procedure. What happens after the angiogram is completed? DISCHARGE!!!! When the study is completed, the catheter will be removed from your artery and pressure will be applied at the point of entry. If needed, the doctor may choose to close the artery puncture with a closure device. You then will be transported to the Day Care Unit for observation. You must stay in bed for the next 2 to 6 hours. Your doctor will determine how long you should stay in bed. If a closure device is used,

the period that you lie flat is shorter. During your stay, your vital signs will be monitored regularly. The registered nurse will also check the incision site and pedal pulses regularly. You will be instructed to keep your leg straight to prevent any bleeding from the incision site. You will be given IV fluids and will be encouraged to drink plenty of fluids. You will be able to eat a light snack. You should not drive or operate heavy machinery 24 hours after the procedure. You may shower the day after your angiogram. No baths or swimming until incision is completely healed (10-14 days). You should NOT lift, push, pull, or strain your abdominal muscles for at least 7 days after your procedure. Do not lift anything heavier than 10 lbs. Do not engage in any strenuous activities. You may resume your normal activities 7 days after your procedure. You may resume your normal medication regimen. Please talk to the doctor prior to restarting Coumadin, Lovenox, or Metformin. It is normal to have some discomfort to the incision site after the angiogram. You may take Tylenol if appropriate. Some bruising at the incision site is normal. A follow-up appointment with Dr. Thomas will be scheduled to review your results. Nsg resp ZZZZZZZZZ
c. N u r s i n g implications. ( 1 ) R e v i e w t h e patient's clinical r eco rd to d etermine t h e r ea s o n (p urp o se) fo r t h e specific patient's s c h e d u l e d cerebral an gio gr ap h y a n d w h a t t h e patient h a s b e e n to ld a b o u t t h e p r o ced ur e. ( 2 ) C h e c k t h e patient's medication hi s to r y f o r hyp ersensitivity to iodine, seafoods, or t h e d y e s u s e d f o r o t h e r lo cal tests, a n d report significant findings to t h e Professio nal N u r s e . (3) Ap p ro ach a n d identify t h e patient. ( 4 ) I n t e r v i e w t h e p atient to d eter mi ne h i s/ h er k n o wl e d g e of t h e p urp o s e of t h e cerebral antio gr ap h y p r o ced ur e. ( 5 ) As indicated, e xp l ai n to t h e patient t h e specific p urp o se of t h e cerebral an g io grap h y in hi s/ h er situatio n. E xp l ai n p urp o se in a m a n n e r co nsistent w i t h t h a t o ffered by t h e p hysicia n to avo id co n f u s i n g t h e patient. ( 6 ) Exp lai n to t h e patient e v e n t s t h a t wi l l o c c u r prior to t h e cerebral an g io grap h y p r o ced ur e. ( a ) Patient wil l be required to fas t 8 -1 0 h o u r s b efore test.

( b ) A l l j e we l r y , d e n t u r e s , a n d hair p i n s wi l l be r e m o v e d a n d p laced in safekeeping. (c) Patient wil l w e a r a hospital g o w n . ( d ) Patient wil l be asked to e m p t y hi s / her b lad der prior to t h e proced ure. (e) Patient ( o r responsible f a mi l y m e m b e r ) m u s t s i g n a c o n s e n t f o r m . (f) The test wi ll ta ke ap p r o ximatel y t w o h o u r s . ( g ) If ordered, medication s u c h as a sedative may be ad ministered prior to t h e test. ( 7 ) Exp lai n to t h e patient e v e n t s t h a t wi l l o c c u r d u r i n g t h e cerebral an g io grap h y p r o ced ur e. ( a ) Patient wil l be tr anspor ted to t h e x - r a y d ep ar t me n t. ( b ) The p atient wi ll be p laced in a s u p i n e position on t h e x - r a y tab le a n d asked to r e ma i n still

Lumbar puncture

A lumbar puncture (or LP, and colloquially known as a spinal tap) is a diagnostic and at times therapeutic procedure that is performed in order to collect a sample of cerebrospinal fluid (CSF) for biochemical, microbiological, and cytological analysis, or very rarely as a treatment ("therapeutic lumbar puncture") to relieve increased intracranial pressure.
Contents
[hide]

1 Indications 2 Contraindications 3 Procedure 4 Risks 5 Diagnostics 6 History 7 References 8 External links

[edit]Indications The most common purpose for a lumbar puncture is to collect cerebrospinal fluid in a case of suspected meningitis, since there is no other reliable tool with which meningitis, a life-threatening but highly treatable condition, can be excluded. Young infants commonly require lumbar puncture as a part of the routine workup for fever without a source, as they have a much higher risk of meningitis than older persons and do not reliably show signs of meningeal irritation (meningismus). In any age

group, subarachnoid hemorrhage, hydrocephalus, benign intracranial hypertensionand many other diagnoses may be supported or excluded with this test. Lumbar punctures may also be done to inject medications into the cerebrospinal fluid ("intrathecally"), particularly for spinal anesthesia or chemotherapy. It may also be used to detect the presence of malignant cells in the CSF, as in carcinomatous meningitis or medulloblastoma. [edit]Contraindications Lumbar puncture should not be performed in the following situations Idiopathic (unidentified cause) increased intracranial pressure (ICP) Rationale: lumbar puncture in the presence of increased ICP may cause uncal herniation Exception: therapeutic use of lumbar puncture to reduce ICP Precaution CT brain is advocated by some, especially in the following situations Age >65 Reduced GCS or conscious state Recent history of seizure Focal neurological signs

Ophthalmoscopy for papilledema

Bleeding diathesis Coagulopathy Decreased platelet count (<50 x 10 /L)

[1] 9

Infections

Skin infection at puncture site Sepsis

Abnormal respiratory pattern Hypertension with bradycardia and deteriorating consciousness Vertebral deformities (scoliosis or kyphosis), in hands of an inexperienced physician.
[2][3]

[edit]Procedure

Spinal needles used in lumbar puncture.

In performing a lumbar puncture, first the patient is usually placed in a left (or right) lateral position with his/her neck bent in full flexionand knees bent in full flexion up to his/her chest, approximating a fetal position as much as possible. It is also possible to have the patient sit on a stool and bend his/her head and shoulders forward. The area around the lower back is prepared using aseptic technique. Once the appropriate location is palpated, local anaesthetic is infiltrated under the skin and then injected along the intended path of the spinal needle. A spinal needle is inserted between the lumbar vertebrae L3/L4 or L4/L5 and pushed in until there is a "give" that indicates the needle is past the ligamentum flavum. The needle is again pushed until there is a second 'give' that indicates the needle is now past the dura mater. Since the arachnoid membrane and the dura mater exist in flush contact with one another in the living person's spine (due to fluid pressure from CSF in the subarachnoid space pushing the arachnoid membrane out towards the dura), once the needle has pierced the dura mater it has also traversed the thinner arachnoid membrane and is now in the subarachnoid space. The stylet from the spinal needle is then withdrawn and drops of cerebrospinal fluid are collected. The opening pressure of the cerebrospinal fluid may be taken during this collection by using a simple column manometer. The procedure is ended by withdrawing the needle while placing pressure on the puncture site. In the past, the patient would often be asked to lie on his/her back for at least six hours and be monitored for signs of neurological problems, though there is no scientific evidence that this provides any benefit. The technique described is almost identical to that used in spinal anesthesia, except that spinal anesthesia is more often done with the patient in a seated position. The upright seated position is advantageous in that there is less distortion of spinal anatomy which allows for easier withdrawal of fluid. It is preferred by some practitioners when a lumbar puncture is performed on an obese patient where having them lie on their side would cause a scoliosis and unreliable anatomical landmarks. On the other hand, opening pressures are notoriously unreliable when measured on a seated patient and therefore the left or right lateral (lying down) position is preferred if an opening pressure needs to be measured. Patient anxiety during the procedure can lead to increased CSF pressure, especially if the person holds their breath, tenses their muscles or flexes their knees too tightly against their chest. Diagnostic analysis of changes in fluid pressure during lumbar puncture procedures requires attention both to the patient's [citation needed] condition during the procedure and to theirmedical history. Reinsertion of the stylet may decrease the rate of post lumbar puncture headaches. [edit]Risks Post spinal headache with nausea is the most common complication; it often responds to analgesics and infusion of fluids. It was long taught that this complication can often be prevented by strict maintenance of a supine posture for two hours after the successful puncture; this has not been borne out in modern studies involving large numbers of patients.Merritt's Neurology (10th edition), in the section on lumbar puncture, notes that intravenous caffeine injection is often quite effective in aborting these so-called "spinal headaches." Contact between the side of the lumbar puncture needle and a spinal nerve root can result in anomalous sensations (paresthesia) in a leg during the procedure; this is harmless and patients
[3]

can be warned about it in advance to minimize their anxiety if it should occur. A headache that is persistent despite a long period of bedrest and occurs only when sitting up may be indicative of a CSF leak from the lumbar puncture site. It can be treated by more bedrest, or by an epidural blood patch, where the patient's own blood is injected back into the site of leakage to cause a clot to form and seal off the leak. Serious complications of a properly performed lumbar puncture are extremely rare. They include spinal or epidural bleeding, adhesive arachnoiditis and trauma to thespinal cord or spinal nerve roots resulting in weakness or loss of sensation, or even paraplegia. The latter is exceedingly rare, since the level at which the spinal cord ends (normally the inferior border of L1, although it is slightly lower in infants) is several vertebral spaces above the proper location for a lumbar puncture (L3/L4). There are case reports of lumbar puncture resulting in perforation of abnormal dural arterio-venous malformations, resulting in catastrophic epidural hemorrhage; this is exceedingly rare. The procedure is not recommended when epidural infection is present or suspected, when topical infections or dermatological conditions pose a risk of infection at the puncture site or in patients with severe psychosis or neurosis with back pain. Some authorities believe that withdrawal of fluid when initial pressures are abnormal could result in spinal cord compression or cerebral herniation; others believe that such events are merely coincidental in time, occurring independently as a result of the same pathology that the lumbar puncture was performed to diagnose. In any case, computed tomography of the brain is often performed prior to lumbar puncture if an intracranial mass is suspected. Removal of cerebrospinal fluid resulting in reduced fluid pressure has been shown to correlate with greater reduction of cerebral blood flow among patients with Alzheimer's disease. Its clinical significance is uncertain. [edit]Diagnostics
[citation needed]

Lumbar puncture in a child suspected of having meningitis.

Increased CSF pressure can indicate congestive heart failure, cerebral edema, subarachnoid hemorrhage, hypo-osmolality resulting fromhemodialysis, meningeal inflammation, purulent meningitis or tuberculous meningitis, hydrocephalus, or pseudotumor cerebri. Decreased CSF pressure can indicate complete subarachnoid blockage, leakage of spinal fluid, severe dehydration, hyperosmolality, orcirculatory collapse. Significant changes in pressure during the procedure can indicate tumors or spinal blockage resulting in a large pool of CSF, or hydrocephalus

associated with large volumes of CSF. Lumbar puncture for the purpose of reducing pressure is performed in some patients with idiopathic intracranial hypertension (also called pseudotumor cerebri.) The presence of white blood cells in cerebrospinal fluid is called pleocytosis. A small number of monocytes can be normal; the presence ofgranulocytes is always an abnormal finding. A large number of granulocytes often heralds bacterial meningitis. White cells can also indicate reaction to repeated lumbar punctures, reactions to prior injections of medicines or dyes, central nervous system hemorrhage, leukemia, recent epileptic seizure, or a metastatic tumor. When peripheral blood contaminates the withdrawn CSF, a common procedural complication,white blood cells will be present along with erythrocytes, and their ratio will be the same as that in the peripheral blood. The finding of erythrophagocytosis, where phagocytosed erythrocytes is observed, signifies haemorrhage into the CSF that preceded the lumbar puncture. Therefore, when erythrocytes are detected in the CSF sample, erythrophagocytosis suggests causes other than a traumatic tap, such as intracranial haemorrhage and haemorrhagic herpetic encephalitis. In which case, further investigations are warranted, including imaging and viral culture. Several substances found in cerebrospinal fluid are available for diagnostic measurement. Measurement of chloride levels may aid in detecting the presence of tuberculous meningitis. Glucose is usually present in the CSF; the level is usually about 60% that in the peripheral circulation. A fingerstick or venipuncture at the time of lumbar puncture may therefore be performed to assess peripheral glucose levels in order to determine a predicted CSF glucose value. Decreased glucose levels can indicate fungal, tuberculous or pyogenic infections; lymphomas; leukemia spreading to the meninges; meningoencephalitic mumps; or hypoglycemia. A glucose level of less than one third of blood glucose levels in association with low CSF lactate levels is typical in hereditary CSF glucose transporter deficiency also known as De Vivo disease. Increased glucose levels in the fluid can indicate diabetes, although the 60% rule still applies. Increased levels of glutamine are often involved with hepatic encephalopathies, Reye's syndrome, hepatic coma, cirrhosis and hypercapnia. Increased levels of lactate can occur the presence of cancer of the CNS, multiple sclerosis, heritable mitochondrial disease, low blood pressure, low serum phosphorus, respiratory alkalosis, idiopathic seizures, traumatic brain injury, cerebral ischemia, brain abscess, hydrocephalus, hypocapnia or bacterial meningitis. The enzyme lactate dehydrogenase can be measured to help distinguish meningitides of bacterial origin, which are often associated with high levels of the enzyme, from those of viral origin in which the enzyme is low or absent. Changes in total protein content of cerebrospinal fluid can result from pathologically increased permeability of the blood-cerebrospinal fluid barrier, obstructions of CSF circulation, meningitis, neurosyphilis, brain abscesses, subarachnoid hemorrhage, polio, collagen disease or Guillain-Barr syndrome, leakage of CSF, increases in intracranial pressure or hyperthyroidism. Very high levels of protein may indicate tuberculous meningitis or spinal block. IgG synthetic rate is calculated from measured IgG and total protein levels; it is elevated in immune disorders such as multiple sclerosis, transverse myelitis, and neuromyelitis optica of Devic.
[4]

Numerous antibody-mediated tests for CSF are available in some countries: these include rapid tests for antigens of common bacterial pathogens, treponemal titers for the diagnosis of neurosyphilis and Lyme disease, Coccidioides antibody, and others. The India ink test is still used for detection of meningitis caused by Cryptococcus neoformans, but the cryptococcal antigen (CrAg) test has a higher sensitivity. CSF can be sent to the microbiology lab for various types of smears and cultures to diagnose infections. Polymerase chain reaction (PCR) has been a great advance in the diagnosis of some types of meningitis. It has high sensitivity and specificity for many infections of the CNS, is fast, and can be done with small volumes of CSF. Even though testing is expensive, it saves cost of hospitalization.

Patient teaching\

Before Arriving for Your Procedure

You will be contacted by a member of our team the day before your exam (between 4 and 6 p.m.) and given instructions on how you should prepare and what time you should arrive. If you are not contacted, please call (310) 423-4125 early in the morning of your procedure (such as 6 a.m.) You should have your doctor's office fax all orders and lab results to Cedars-Sinai the day before your procedure: (310) 423-0108. You should plan to arrive two hours before your scheduled procedure (three hours if you have not had all your pre-op lab work done). You should not eat anything from the midnight before your procedure. You should consult with your physician about taking your regular medications prior to your exam. Some medications(such as Coumadin or Plavix) should not be taken before your procedure. You will not be allowed to drive after the procedure, so you should arrange for someone to help you get home. We want to make your waiting time as pleasant as possible. Consider bringing your favorite magazine, book or music player to help you pass the time. Please leave your jewelry and valuables at home and please wear comfortable clothing.

After Arriving
A physician specialist in interventional radiology will discuss your procedure with you and answer any questions you might have. After this discussion, you will be asked to sign a consent form, giving us permission to perform the test.

You must tell the technologist, nurse, or physician of any allergies you may have, and whether you are or might be pregnant.

During Your Procedure

You will be asked to change into a hospital gown. You will be asked to either lay on your side or sit leaning forward in a chair. Your back will be cleaned. A local anesthetic will be used to numb the skin on your back. A needle will be inserted into the space between two of the bones in your back, and some fluid will be removed. A special gauge might be attached to the needle to test the pressure of your spinal fluid. The needle will remain in place for a couple of minutes. The lumbar puncture procedure usually takes 15 to 30 minutes.

After Your Procedure

You will be asked to lay flat for a few hours, and might experience a headache after the procedure. You should avoid strenuous activity for 24 hours. If a sample of fluid was taken it will be tested and a report written. The report will be sent to your physician who will discuss the results with you.

Discharge instruction LUMBAR PUNCTURE

Discharge Instructions

1. Lie flat for the rest of today. This will help prevent you from developing a headache. Try not to use a pillow, but if you have to, make if a small one. If you are using a small pillow and begin to get a headache, remove the pillow and lie completely flat.

2. Get up to go to the bathroom only.

3. Have someone bring your meals to you.

4. Drink as much as you can today. Fluids like Gatorade or K-10 help to replace the fluids in your body lost. (Be careful not to drink so much that you make yourself sick.)

5. You may take your regular medications.

6. If you develop a headache when you get up, go to bed, lie completely flat for 24 hours. NO pillows. Do NOT get out of bed to eat or to go to the bathroom. Use a bedpan or urinal. If you get up during this 24-hour period, you must lie flat for another 24 hours beginning from the time you got up.

7. If the headaches last for more than 24 hours, you should call your doctor or X-Ray Department as Mission Radiology, , or St. Josephs Radiology .NSG RESPONSIBILITIES

AFTER YOU LEAVE: Medicines:

Keep a current list of your medicines: Include the amounts, and when, how, and why you take them. Take the list or the pill bottles to follow-up visits. Carry your medicine list with you in case of an emergency. Throw away old medicine lists. Use vitamins, herbs, or food supplements only as directed. Take your medicine as directed: Call your primary healthcare provider if you think your medicine is not working as expected. Tell him about any medicine allergies, and if you want to quit taking or change your medicine.

Ask for information about where and when to go for follow-up visits:
For continuing care, treatments, or home services, ask for more information.

Ask your caregiver when the results of your procedure will be available.

Post-lumbar puncture headache:

You may develop a headache during the first few hours after your LP, which may last up to several days. This happens when the amount of CSF and the CSF pressure are decreased, such as with a CSF leak. The headache may range from mild to severe (very bad) and may get worse when you sit or stand. You may have neck or back pain as well. The following may help ease or prevent a postlumbar puncture headache:

Drinking liquids: You may be asked to drink more liquid than usual after your LP. For most people, good liquids to drink include water, milk, and juices. Do not drink alcohol. Tell your caregiver if you cannot drink a lot of liquid because of another medical condition, such as a heart or kidney condition. Lying down: You may need to lie flat for some time after your LP. Ask your caregiver how long you need to lie down. Treatment options: You may have any of the following:
o o

Medicines: Caffeine: Caffeine may be used to treat a LP headache. As CSF pressure decreases, such as with a leak, blood vessels in the brain will dilate (get bigger) to get more fluid to the brain. Headache pain is caused by the blood vessels getting bigger. Caffeine causes the blood vessels in the brain to narrow (get smaller), which will decrease your headache pain. Drink caffeinated drinks, such as coffee or soda, every 4 to 6 hours. If this does not relieve your headache, call your caregiver. You may need to be given caffeine intravenously (IV) through a tube placed in your vein. Pain medicine: You may need medicine to relieve or decrease your headache pain. These medicines may include NSAIDS (non-steroidal anti-inflammatory medicine), such as ibuprofen, acetaminophen, or medicine that your caregiver orders (prescription) for you. Your caregiver will decide which medicine is best for you to take for your headache. Follow your caregiver's instructions on how to take your medicine. Tell your caregiver if the pain medicine does not help or if you have any questions about your medicine. Procedures: You may need to have any of the following if your headache is not relieved by the treatments above:
o

Blood patch: If your headache is caused by a leakage of CSF from the LP site, a blood patch procedure may be needed. This procedure uses a small amount of your blood, that is taken from a vein, to patch (seal) the LP leak. The blood is put through a needle into your spinal canal in the same way that the LP was done. You will need to lie in bed for 1 to 2 hours after this procedure. This procedure may need to be repeated if your headache is not relieved.

Saline epidural: A saline epidural may be given if your headache is caused by low CSF pressure due to a leak. This procedure puts saline (an IV fluid) back into your spinal canal to increase CSF pressure. The increased pressure may help to seal the leak. The saline is put through a needle into your spinal canal in the same way that the LP was done.

CONTACT A CAREGIVER IF:

You have severe (bad) pain in your back or neck. You have bleeding or a discharge coming from the area where the needle was put into your back. You have questions or concerns about your procedure or medicine.

SEEK CARE IMMEDIATELY IF:

You have a headache that is very bad and does not get better after lying down. You have a fever. You have a stiff neck or have trouble thinking clearly. Your legs, feet, or other parts below the waist feel numb, tingly, or weak.

CT Scan Ventriculogram
X-ray computed tomography, also computed tomography (CT scan) or computed axial tomography (CAT scan), is a medical imaging procedure that utilizes computer-processed X-rays to produce tomographic images or 'slices' of specific areas of the body. These cross-sectional images are [1] used for diagnostic and therapeutic purposes in various medical disciplines. Digital geometry processing is used to generate a three-dimensional image of the inside of an object from a large series of [2] two-dimensional X-ray images taken around a single axis of rotation. CT produces a volume of data that can be manipulated, through a process known as "windowing", in order to demonstrate various bodily structures based on their ability to block the X-ray beam. Although historically the images generated were in the axial or transverse plane, perpendicular to the long axis of the body, modern scanners allow this volume of data to be reformatted in various planes or even as volumetric (3D) representations of structures. Although most common in medicine, CT is also used in other fields, such as nondestructive materials testing. Another example is archaeological uses such as imaging the contents of sarcophagi. Usage of CT has increased dramatically over the last two decades in many countries. An estimated 72 [4] million scans were performed in the United States in 2007. It is estimated that 0.4% of current cancers in the United States are due to CTs performed in the past and that this may increase to as high as 1.5-2% [5] [6] with 2007 rates of CT usage; however, this estimate is disputed. Kidney problems following intravenous contrast agents may also be a concern in some types of studies.
[3]

Purpose

Diagnostic use

Typical CT Scout view as used for planning an exam

Since its introduction in the 1970s, CT has become an important tool in medical imaging to supplement Xrays and medical ultrasonography. It has more recently been used for preventive medicine or screening for disease, for example CT colonography for patients with a high risk of colon cancer, or full-motion heart scans for patients with high risk of heart disease. A number of institutions offer full-body scans for the general population. [edit]Head Main article: CT head

Computed tomography of human brain, from base of the skull to top. Taken with intravenous contrast medium.

Bone reconstructed in 3D

CT scanning of the head is typically used to detect infarction, tumours, calcifications, haemorrhage and bone trauma. Of the above, hypodense (dark) structures indicate infarction or tumours, hyperdense (bright) structures indicate calcifications and haemorrhage and bone trauma can be seen as disjunction in bone windows. Ambulances equipped with small bore multi-sliced CT scanners respond to cases involving stroke or head trauma. [edit]Lungs CT can be used for detecting both acute and chronic changes in the lung parenchyma, that is, the internals of the lungs. It is particularly relevant here because normal two-dimensional X-rays do not show such defects. A variety of techniques are used, depending on the suspected abnormality. For evaluation of chronic interstitial processes (emphysema, fibrosis, and so forth), thin sections with high spatial frequency reconstructions are used; often scans are performed both in inspiration and expiration. This special technique is called high resolution CT. Therefore, it produces a sampling of the lung and not continuous images. [edit]Pulmonary

angiogram

Example of a CTPA, demonstrating a saddle embolus (dark horizontal line) occluding the pulmonary arteries (bright white triangle)

CT pulmonary angiogram (CTPA) is a medical diagnostic test used to diagnose pulmonary embolism (PE). It employs computed tomography and an iodine based contrast agent to obtain an image of the pulmonary arteries. [edit]Cardiac Main article: Cardiac CT With the advent of subsecond rotation combined with multi-slice CT (up to 320-slices), high resolution and high speed can be obtained at the same time, allowing excellent imaging of the coronary arteries (cardiac CT angiography). [edit]Abdominal

and pelvic

CT Scan of 11 cm Wilms' tumor of right kidney in 13 month old patient.

CT is a sensitive method for diagnosis of abdominal diseases. It is used frequently to determine stage of cancer and to follow progress. It is also a useful test to investigate acute abdominal pain. [edit]Extremities CT is often used to image complex fractures, especially ones around joints, because of its ability to reconstruct the area of interest in multiple planes. Fractures, ligamentous injuries and dislocations can [ easily be recognised with a 0.2 mm resolution.

Advantages
There are several advantages that CT has over traditional 2D medical radiography. First, CT completely eliminates the superimposition of images of structures outside the area of interest. Second, because of the inherent high-contrast resolution of CT, differences between tissues that differ in physical density by less than 1% can be distinguished. Finally, data from a single CT imaging procedure consisting of either multiple contiguous or one helical scan can be viewed as images in the axial, coronal, or sagittal planes, depending on the diagnostic task. This is referred to as multiplanar reformatted imaging. CT is regarded as a moderate- to high-radiation diagnostic technique. The improved resolution of CT has permitted the development of new investigations, which may have advantages; compared to conventional radiography, for example, CT angiography avoids the invasive insertion of a catheter. CT Colonography (also known as Virtual Colonoscopy or VC for short) may be as useful as a barium enema for detection of tumors, but may use a lower radiation dose. CT VC is increasingly being used in the UK as a diagnostic test for bowel cancer and can negate the need for a colonoscopy. The radiation dose for a particular study depends on multiple factors: volume scanned, patient build, number and type of scan sequences, and desired resolution and image quality. In addition, two helical CT scanning parameters that can be adjusted easily and that have a profound effect on radiation dose are

tube current and pitch. Computed tomography (CT) scan has been shown to be more accurate than [9] radiographs in evaluating anterior interbody fusion but may still over-read the extent of fusion. [edit]Adverse [edit]Cancer The ionizing radiation in the form of x-rays used in CT scans are energetic enough to directly or indirectly damage DNA. This and othertypes of DNA damage are occasionally not corrected properly by cellular repair mechanisms. Such damage to the DNA occasionally lead to cancer. The estimates of harm from CT are partly based on similar radiation exposures experienced by those present during theatomic [5] bomb explosions in Japan during the second world war and those of nuclear industry works. There is a small increased risk of cancer with CT scans. It is estimated that 0.4% of current cancers in the United States are due to CTs performed in the past and that this may increase to as high as 1.5-2% with [5] [10] 2007 rates of CT usage; however, this estimate is disputed. This would be equivalent to one in 1000 [11] to one in 2000 increased risk of developing a fatal cancer per 10mSv CT scan. Or 29,000 new cancer [12] cases in the United States due to the number of scans done in 2007 and 2100 new cancers in the [13] United Kingdom. This additional risk is still low compared to the background risk of dying from cancer [14] of ~20%. The most common cancers caused by radiation exposure are thought to be lung [11] cancer, breast cancer, thyroid cancer, stomach cancer and leukemia. A person's age plays a significant role in the subsequent risk of cancer. Estimated lifetime cancer [14] mortality risks from an abdominal CT of a 1-year-old is 0.1% or 1:1000 scans. The risk for someone who is 40 years old is half that of someone who is 20 years old with substantially less risk in the [14] elderly. The International Commission on Radiological Protection estimates that the risk to a fetus being exposure to 10 mGy increases the rate of cancer before 20 years of age from 0.03% to 0.04% (for [13] reference a CT pulmonary angiogram exposes a fetus to 4 mGy). A 2012 review did not find an association between medical radiation and cancer risk in children noting however the existence of [15] limitations in the evidences over which the review is based. CT scans can be performed with different settings for lower exposure in children with most manufacturers [11] of CT scans as of 2007 having this function built in. Furthermore, certain conditions can require [5] children to be exposed to multiple CT scans. Studies support informing parents of the risks of pediatric [16] CT scanning.
[14]

effects

Reason for Procedure

CT scans are indicated to detect or confirm the characteristics, size, and involvement of abnormal structural changes. Wherever the location, a tumor can be evaluated before definitive treatment is begun. A head CT can provide direct information about bruises (contusions) or blood clots (hematomas) within or outside (epidural or subdural hematomas) the brain. CT of the spine is indicated in cases of suspected disc herniation, spinal infection, trauma, or intraspinal tumor. A face or neck CT is indicated for inflammation or infection, fractures of the facial structures, or for assessing foreign bodies within the eye socket (orbit). Chest CTs are most commonly used to detect suspected cancers (malignancies) and to determine the extent to which the cancer has spread (metastasis). CT is used to define the presence and extent of the ballooning of a vessel due to weakness of the vessel wall (traumatic aneurysms) and the splitting of an aortic vessel wall (aortic dissections). High-resolution CT can help evaluate lung diseases

and, when used with dye (intravenous contrast), can be used to confirm an inflammation of the pancreas (acute pancreatitis). CT may also be useful in differentiating a kidney tumor from a faintly calcified stone that may not be visible on plain x-ray. It can also help in the classification of kidney injuries by defining the extent of lacerations, hematomas, or urine leaking into the abdominal cavity. In the pelvis, CT can provide information regarding the extent of tumors in the lymphatic system and their relationship to normal structures. While bone fractures are usually evaluated by standard x-ray, CT scan provides more precise information about the presence, location, orientation, and relationship of fracture fragments in complex anatomic regions such as the pelvis, shoulder, foot, and ankle. CT can provide precise locations and help guide the needle to sample of cells withdrawn through a needle for microscopic examination (aspirationbiopsies), to withdraw a core of tissue withdrawn through a large-bore needle, for microscopic examination (core biopsy), for through the skin (percutaneous) drainage of abdominal abscesses, or for other fluid collections. CT can also be used to guide the placement of various catheters or surgical instruments. The CT may not be diagnostically helpful for people who cannot lie still (due to some neurological diseases), for the extremely obese, or for those who have a fear of being surrounded by or contained within a machine (this later would be unusual because of the openness of the scanner). It's important to note that MRI scanning also creates an image of body structures by combining a series of pictures taken at different levels and angles. However, MRI uses a different technology to create the images. MRIs have replaced CT scans for many soft tissue conditions, but CT continues to be the best imaging test in select situations.

Source: Medical Disability Advisor

How Procedure is Performed

The individual being scanned must lie still on a padded metal couch that is encircled by the CT scanner. The individual is positioned in the scanner so that the correct part of the body is located in the center of the scanner. Scans are painless, and most take between 10 to 30 minutes. If an intravenous contrast medium is required, a temporary catheter or needle is placed into a vein for injection of that medium. There is usually no need for specific pre-procedure preparation, although some abdominal scans may require that the individual fast for a short period of time. Scans that focus on the bladder require the bladder to be full prior to scanning.

What are some common uses of the procedure?

CT imaging is: View larger with caption

one of the best and fastest tools for examining the chest, abdomen and pelvis because it provides detailed, cross-sectional views of all types of tissue. used to examine patients with severe injuries from incidents such as a motor vehicle accident. performed on patients with acute symptoms such as abdominal pain or difficulty breathing. often the best method for detecting many different cancers, including lung, liver, kidney and pancreatic cancer, since the image allows a physician to confirm the presence of a tumor and measure its size, precise location and the extent of the tumor's involvement with other nearby tissue. an examination that plays a significant role in the detection, diagnosis and treatment of vascular diseases that can lead to stroke, kidney failure or even death. CT is commonly used to assess for pulmonary embolism (a blood clot in the lung vessels) as well as for abdominal aortic aneurysms (AAA). invaluable in diagnosing and treating spinal problems and injuries to the hands, feet and other skeletal structures because it can clearly show even very small bones as well as surrounding tissues such as muscle and blood vessels.

In pediatric patients, CT is rarely used to diagnose tumors of the lung or pancreas as well as abdominal aortic aneurysms. For children, CT imaging is more often used to evaluate:

lymphoma neuroblastoma kidney tumors congenital malformations of the heart, kidneys and blood vessels cystic fibrosis complications of acute appendicitis

complications of pneumonia inflammatory bowel disease severe injuries

Physicians often use the CT examination to:

quickly identify injuries to the lungs, heart and vessels, liver, spleen, kidneys, bowel or other internal organs in cases of trauma. guide biopsies and other procedures such as abscess drainages and minimally invasive tumor treatments. plan for and assess the results of surgery, such as organ transplants or gastric bypass. stage, plan and properly administer radiation treatments for tumors as well as monitor response to chemotherapy. measure bone mineral density for the detection of osteoporosis.

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How should I prepare?

You should wear comfortable, loose-fitting clothing to your exam. You may be given a gown to wear during the procedure. Metal objects including jewelry, eyeglasses, dentures and hairpins may affect the CT images and should be left at home or removed prior to your exam. You may also be asked to remove hearing aids and removable dental work. You may be asked not to eat or drink anything for several hours beforehand, especially if a contrast material will be used in your exam. You should inform your physician of all medications you are taking and if you have any allergies. If you have a known allergy to contrast material, or "dye," your doctor may prescribe medications to reduce the risk of an allergic reaction. Also inform your doctor of any recent illnesses or other medical conditions and whether you have a history of heart disease, asthma, diabetes, kidney disease or thyroid problems. Any of these conditions may increase the risk of an unusual adverse effect. Women should always inform their physician and the CT technologist if there is any possibility that they are pregnant. See the Safety

page (www.RadiologyInfo.org/en/safety/) for more information about pregnancy and

x-rays.
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What does the equipment look like?

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The CT scanner is typically a large, box-like machine with a hole, or short tunnel, in the center. You will lie on a narrow examination table that slides into and out of this tunnel. Rotating around you, the x-ray tube and electronic x-ray detectors are located opposite each other in a ring, called a gantry. The computer workstation that processes the imaging information is located in a separate control room, where the technologist operates the scanner and monitors your examination.
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How does the procedure work?

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CT scan showing the liver View larger with caption

CT slice through mid abdomen

In many ways CT scanning works very much like other x-ray examinations. X-rays are a form of radiationlike light or radio wavesthat can be directed at the body. Different body parts absorb the x-rays in varying degrees. In a conventional x-ray exam, a small amount of radiation is aimed at and passes through the body, recording an image on photographic film or a special image recording plate. Bones appear white on the x-ray; soft tissue, such as organs like the heart or liver, shows up in shades of gray and air appears black. With CT scanning, numerous x-ray beams and a set of electronic x-ray detectors rotate around you, measuring the amount of radiation being absorbed throughout your body. At the same time, the examination table is moving through the scanner, so that the x-ray beam follows a spiral path. A special computer program processes this large volume of data to create two-dimensional cross-sectional images of your body, which are then displayed on a monitor. This technique is called helical or spiral CT. CT imaging is sometimes compared to looking into a loaf of bread by cutting the loaf into thin slices. When the image slices are reassembled by computer software, the result is a very detailed multidimensional view of the body's interior. Refinements in detector technology allow new CT scanners to obtain multiple slices in a single rotation. These scanners, called multislice CT or multidetector CT, allow thinner slices to be obtained in a shorter period of time, resulting in more detail and additional view capabilities. Modern CT scanners are so fast that they can scan through large sections of the body in just a few seconds, and even faster in small children. Such speed is beneficial for all patients but especially children, the elderly and critically ill.

For children, the CT scanner technique will be adjusted to their size and the area of interest to reduce the radiation dose. For some CT exams, a contrast material is used to enhance visibility in the area of the body being studied.
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How is the CAT scan performed?

Click to play

The technologist begins by positioning you on the CT examination table, usually lying flat on your back or less commonly, on your side or on your stomach. Straps and pillows may be used to help you maintain the correct position and to hold still during the exam. Depending on the part of the body being scanned, you may be asked to keep your hands over your head. Many scanners are fast enough that children can be scanned without sedation. In special cases, sedation may be needed for children who cannot hold still. Motion will degrade the quality of the examination the same way that it affects photographs. If contrast material is used, it will be swallowed, injected through an intravenous line (IV) or administered by enema, depending on the type of examination. Next, the table will move quickly through the scanner to determine the correct starting position for the scans. Then, the table will move slowly through the machine as the actual CT scanning is performed. Depending on the type of CT scan, the machine may make several passes. You may be asked to hold your breath during the scanning. Any motion, whether breathing or body movements, can lead to artifacts on the images. This is similar to the blurring seen on a photograph taken of a moving object. When the examination is completed, you will be asked to wait until the technologist verifies that the images are of high enough quality for accurate interpretation. The CT examination is usually completed within 30 minutes. The portion requiring intravenous contrast injection usually lasts only 10 to 30 seconds.
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What will I experience during and after the procedure?

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CT scan: appendicitis View larger with caption

CT scan: normal appendix CT exams are generally painless, fast and easy. With helical CT, the amount of time that the patient needs to lie still is reduced. Though the scanning itself causes no pain, there may be some discomfort from having to remain still for several minutes. If you have a hard time staying still, are claustrophobic or have chronic pain, you may find a CT exam to be stressful. The technologist or nurse, under the direction of a physician, may offer you some medication to help you tolerate the CT scanning procedure. If an intravenous contrast material is used, you will feel a pin prick when the needle is inserted into your vein. You may have a warm, flushed sensation during the injection of the contrast materials and a metallic taste in your mouth that lasts for a few minutes. Some patients may experience a sensation like they have to urinate but this subsides quickly. If the contrast material is swallowed, you may find the taste mildly unpleasant; however, most patients can easily tolerate it. You can expect to experience a sense of abdominal fullness and an increasing need to expel the liquid if your contrast material is given by enema. In this case, be patient, as the mild discomfort will not last long. When you enter the CT scanner, special light lines may be seen on your body and are used to ensure that you are properly positioned. With modern CT scanners, you will hear only slight buzzing, clicking and whirring sounds as the CT scanner revolves around you during the imaging process.

You will be alone in the exam room during the CT scan, unless there are special circumstances. However, the technologist will always be able to see, hear and speak with you at all times. With pediatric patients, a parent may be allowed in the room but will be required to wear a lead apron to minimize radiation exposure. After a CT exam, you can return to your normal activities. If you received contrast material, you may be given special instructions.
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Who interprets the results and how do I get them?

A physician, usually a radiologist with expertise in supervising and interpreting radiology examinations, will analyze the images and send a signed report to your primary care physician or the physician who referred you for the exam, who will discuss the results with you. Follow-up examinations are often necessary, and your doctor will explain the exact reason why another exam is requested. Sometimes a follow-up exam is done because a suspicious or questionable finding needs clarification with additional views or a special imaging technique. A follow-up examination may be necessary so that any change in a known abnormality can be detected over time. Follow-up examinations are sometimes the best way to see if treatment is working or if an abnormality is stable over time.
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What are the benefits vs. risks?

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Benefits

CT scanning is painless, noninvasive and accurate.

A major advantage of CT is its ability to image bone, soft tissue and blood vessels all at the same time. Unlike conventional x-rays, CT scanning provides very detailed images of many types of tissue as well as the lungs, bones, and blood vessels. CT examinations are fast and simple; in emergency cases, they can reveal internal injuries and bleeding quickly enough to help save lives. CT has been shown to be a cost-effective imaging tool for a wide range of clinical problems. CT is less sensitive to patient movement than MRI. CT can be performed if you have an implanted medical device of any kind, unlike MRI. CT imaging provides real-time imaging, making it a good tool for guiding minimally invasive procedures such as needle biopsies and needle aspirations of many areas of the body, particularly the lungs, abdomen, pelvis and bones. A diagnosis determined by CT scanning may eliminate the need for exploratory surgery and surgical biopsy. No radiation remains in a patient's body after a CT examination. X-rays used in CT scans usually have no immediate side effects.

Risks There is no conclusive evidence that radiation at amounts delivered by a CT scan causes cancer. Large population studies have shown a slight increase in cancer from larger amounts of radiation, such as from radiation therapy. Thus, there is always concern that this risk may also apply to the lower amounts of radiation delivered by a CT exam. When a CT scan is recommended by your doctor, the expected benefit of this test outweighs the potential risk from radiation. You are encouraged to discuss the risks versus the benefits of your CT scan with your doctor, and to explore whether alternative imaging tests may be available to diagnose your condition.

The effective radiation dose for this procedure varies. See the Safety page (www.RadiologyInfo.org/en/safety/) for more information about radiation dose. Women should always inform their physician and x-ray or CT technologist if there is any possibility that they are pregnant. See the Safety page (www.RadiologyInfo.org/en/safety/) for more information about pregnancy and x-rays. CT scanning is, in general, not recommended for pregnant women unless medically necessary because of potential risk to the baby.

Manufacturers of intravenous contrast indicate mothers should not breastfeed their babies for 24-48 hours after contrast medium is given. However, both the American College of Radiology (ACR) and the European Society of Urogenital Radiology note that the available data suggest that it is safe to continue breastfeeding after receiving intravenous contrast. For further information please consult the ACR Manual on Contrast Media and its references. (www.acr.org/Quality-Safety/Resources/Contrast-Manual) The risk of serious allergic reaction to contrast materials that contain iodine is extremely rare, and radiology departments are well-equipped to deal with them.

Because children are more sensitive to radiation, they should have a CT exam only if it is essential for making a diagnosis and should not have repeated CT exams unless absolutely necessary. CT scans in children should always be done with low-dose technique.

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What are the limitations of CT Scanning of the Body?

Soft-tissue details in areas such as the brain, internal pelvic organs, and joints (such as knees and shoulders) can often be better evaluated with magnetic resonance imaging (MRI). In pregnant women, while CT can be performed safely, other imaging exams not involving radiation, such as ultrasound or MRI, is preferred if they are likely to be as good as CT in diagnosing your condition. A person who is very large may not fit into the opening of a conventional CT scanner or may be over the weight limitusually 450 poundsfor the moving tabl
Computed Tomography, Brain

General
Synonym/Acronym: Computed axial tomography (CAT) of the head, computed transaxial tomography (CTT) of the head, brain CT, helical/spiral CT. Common Use: To visualize and assess the brain to assist in diagnosing tumor, bleeding, infarct, infection, structural changes, and edema. Also valuable in evaluation of medical, radiation, and surgical interventions. Area of Application: Brain.

Contrast: With or without IV iodinated contrast medium.

Description
Computed tomography (CT) of the brain is a noninvasive procedure used to assist in diagnosing abnormalities of the head, brain tissue, cerebrospinal fluid, and blood circulation. It becomes invasive if contrast medium is used. The patient lies on a table and is moved in and out of a doughnut-like device called a gantry, which houses the x-ray tube and associated electronics. The scanner uses multiple x-ray beams and a series of detectors that rotate around the patient to produce cross-sectional views in a threedimensional fashion. Differences in tissue density are detected and recorded and are viewable as computerized digital images for the health-care provider (HCP) to look at. Slices or thin sections of certain anatomic views of the brain and associated vascular system are viewed to allow differentiations of solid, cystic, inflammatory, or vascular lesions, as well as identification of suspected hematomas or aneurysms. The procedure is repeated after intravenous injection of iodinated contrast medium for vascular evaluation. Images can be recorded on photographic or x-ray film or stored in digital format as digitized computer data. Cine scanning is used to produce a series of moving images of the area scanned. Tumor progression, before and after therapy, and effectiveness of medical interventions may be monitored by CT scanning.

Indications
Detect brain infection, abscess, or necrosis, as evidenced by decreased density on the image Detect ventricular enlargement or displacement by increased cerebrospinal fluid Determine benign and cancerous intracranial tumors and cyst formation, as evidenced by changes in tissue densities Determine cause of increased intracranial pressure Determine presence and type of hemorrhage in infants and children experiencing signs and symptoms of intracranial trauma or congenital conditions such as hydrocephalus and arteriovenous malformations (AVMs) Determine presence of multiple sclerosis, as evidenced by sclerotic plaques Determine lesion size and location causing infarct or hemorrhage Differentiate hematoma location after trauma (e.g., subdural, epidural, cerebral) and determine extent of edema, as evidenced by higher blood densities Differentiate between cerebral infarction and hemorrhage Evaluate abnormalities of the middle ear ossicles, auditory nerve, and optic nerve Monitor and evaluate the effectiveness of medical, radiation, or surgical therapies

Potential Diagnosis
Normal Findings:

Normal size, position, and shape of intracranial structures and vascular system

Abnormal Findings:

Abscess Aneurysm AVMs Cerebral atrophy Cerebral edema Cerebral infarction Congenital abnormalities Craniopharyngioma Cysts Hematomas (e.g., epidural, subdural, intracerebral) Hemorrhage

Hydrocephaly Increased intracranial pressure or trauma Infection Sclerotic plaques suggesting multiple sclerosis Tumor Ventricular or tissue displacement or enlargement

Critical Findings
Abscess Acute hemorrhage Aneurysm Infarction Infection Tumor with significant mass effect It is essential that critical diagnoses be communicated immediately to the appropriate HCP. A listing of these diagnoses varies among facilities. Note and immediately report to the HCP abnormal results and related symptoms.

Interfering Factors
This procedure is contraindicated for:

Patients with allergies to shellfish or iodinated dye. The contrast medium used may cause a life-threatening allergic reaction. Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids or the use of nonionic contrast medium. Patients who are claustrophobic. Patients who are pregnant or suspected of being pregnant, unless the potential benefits of the procedure far outweigh the risks to the fetus and mother. Elderly and other patients who are chronically dehydrated before the test, because of their risk of contrast-induced renal failure. Patients who are in renal failure. Young patients (17 yr and younger), unless the benefits of the x-ray diagnosis outweigh the risks of exposure to high levels of radiation.

Factors that may impair clear imaging:

Metallic objects (e.g., jewelry, dentures, body rings) within the examination field, which may inhibit organ visualization and cause unclear images. Patients who are very obese or who may exceed the weight limit for the equipment. Patients with extreme claustrophobia unless sedation is given before the study. Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status.

Other considerations:

Complications of the procedure may include hemorrhage, infection at the IV needle insertion site, and cardiac arrhythmias. The procedure may be terminated if chest pain or severe cardiac arrhythmias occur.

Failure to follow dietary restrictions and other pretesting preparations may cause the procedure to be canceled or repeated. Consultation with the HCP should occur before the procedure for radiation safety concerns regarding younger patients or patients who are lactating. Risks associated with radiation overexposure can result from frequent x-ray procedures. Personnel in the room with the patient should wear a protective lead apron, stand behind a shield, or leave the area while the examination is being done. Personnel working in the examination area should wear badges to record their level of radiation exposure.

Nursing Implications and Procedures

Pretest:

Positively identify the patient using at least two unique identifiers before providing care, treatment, or services. Patient Teaching: Inform the patient this procedure can assist in assessing the brain.

Obtain a history of the patient's complaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex, iodine, seafood, anesthetics, or contrast medium. Obtain a history of the patient's musculoskeletal system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures. Ensure results of coagulation testing are obtained and recorded prior to the procedure; BUN and creatinine results are also needed if contrast medium is to be used. Note any recent procedures that can interfere with test results, including examinations using barium- or iodine-based contrast medium. Ensure that barium studies were performed more than 4 days before the CT scan. Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women. Obtain a list of the patient's current medications including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals (see Appendix F). Note the last time and dose of medication taken. If contrast media is scheduled to be used, patients receiving metformin (Glucophage) for non-insulin-dependent (type 2) diabetes should discontinue the drug on the day of the test and continue to withhold it for 48 hr after the test. Failure to do so may result in lactic acidosis. Review the procedure with the patient. Address concerns about pain and explain that there may be moments of discomfort and some pain experienced during the test. Inform the patient the procedure is usually performed in a radiology suite by an HCP specializing in this procedure, with support staff, and takes approximately 15 to 30 min. Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure. Explain that an IV line may be inserted to allow infusion of IV fluids, contrast medium, dye, or sedatives. Usually contrast medium and normal saline are infused. Inform the patient that he or she may experience nausea, a feeling of warmth, a salty or metallic taste, or a transient headache after injection of contrast medium. Instruct the patient to remove dentures and jewelry and other metallic objects from the area to be examined. There are no food or fluid restrictions unless by medical direction. Instruct the patient to avoid taking anticoagulant medication or to reduce dosage as ordered prior to the procedure. Protocols may vary among facilities. Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest:

Ensure the patient has complied with medication restrictions and pretesting preparations.

Ensure the patient has removed dentures and all external metallic objects from the area to be examined prior to the procedure. If the patient has a history of allergic reactions to any substance or drug, administer ordered prophylactic steroids or antihistamines before the procedure. Use nonionic contrast medium for the procedure. Have emergency equipment readily available. Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still throughout the procedure because movement produces unreliable results. Observe standard precautions, and follow the general guidelines in Appendix A. Establish an IV fluid line for the injection of contrast medium, emergency drugs, and sedatives. Administer an antianxiety agent, as ordered, if the patient has claustrophobia. Administer a sedative to a child or to an uncooperative adult, as ordered. Place the patient in the supine position on an examination table. If contrast media is used, a rapid series of images is taken during and after injection. Instruct the patient to take slow, deep breaths if nausea occurs during the procedure. Monitor the patient for complications related to the procedure (e.g., allergic reaction, anaphylaxis, bronchospasm) if contrast is used. The needle is removed, and a pressure dressing is applied over the puncture site. Observe/assess the needle insertion site for bleeding, inflammation, or hematoma formation.

Post-test:

A report of the examination will be sent to the requesting HCP, who will discuss the results with the patient. Instruct the patient to resume medications and activity, as directed by the HCP. Renal function should be assessed before metformin is resumed, if contrast was used. Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and then as ordered by the HCP. Monitor temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Protocols may vary from facility to facility. If contrast was used, observe for delayed allergic reactions, such as rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting. Instruct the patient to immediately report symptoms such as fast heart rate, difficulty breathing, skin rash, itching, chest pain, persistent right shoulder pain, or abdominal pain. Immediately report symptoms to the appropriate HCP. Observe/assess the needle insertion site for bleeding, inflammation, or hematoma formation. Instruct the patient in the care and assessment of the site. Instruct the patient to apply cold compresses to the puncture site as needed, to reduce discomfort or edema. Instruct the patient to increase fluid intake to help eliminate the contrast medium, if used. Inform the patient that diarrhea may occur after ingestion of oral contrast medium. Recognize anxiety related to test results. Discuss the implications of abnormal test results on the patient's lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Reinforce information given by the patient's HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family. Depending on the results of this procedure, additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient's symptoms and other tests performed.

Related Monographs

Related tests include angiography carotid, audiometry hearing loss, BUN, CSF analysis, CBC, CBC hematocrit, CBC hemoglobin, CT angiography, creatinine, EEG, EMG, evoked brain potentials, MR angiography, MRI brain, nerve fiber analysis, otoscopy, PET brain, PT/INR, spondee speech reception threshold, and tuning fork tests. Refer to the Musculoskeletal System table at the end of the book for related tests by body system.

Preparation of Client
Ensure a signed consent form. Check hospital policy on withholding food and fluids. Clients are usually on NPO status (except for the medications ordered as part of the test) for 8 hours before the test if it is done in the morning. If the test is done in the afternoon, the client may have a liquid breakfast. Give medications up to 2 hours before test. Assess for possible reaction to iodine dye (by asking about allergy to seafood). Document any allergy and inform the physician and radiology department. Remove metal hairpins, clips, and earrings.

Client and Family Teaching

(If applicable) Do not drink or eat anything before the test except for the ordered medications. You may be given an intravenous infusion. When the contrast dye is injected, you may feel warm and have a metallic taste in the mouth. The exam lasts from 30 to 90 minutes. Your head will be positioned in a cradle, and a wide rubber strap will be applied snugly across the forehead during the test (to keep your head immobilized). The CT scanner is circular with a round opening. You are strapped to a special table, and the scanner revolves around the body part to be examined. The scanner makes a clicking noise. The test is painless. Someone is always immediately available during the test.

SKULL XRAY

X-rays of the Skull

(Skull X-ray Studies)
Procedure overview

What are X-rays of the skull? X-rays use invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs on film. Standard X-rays are performed for many reasons, including diagnosing tumors or bone injuries. X-rays are made by using external radiation to produce images of the body, its organs, and other internal structures for diagnostic purposes. X-rays pass through body tissues onto specially treated plates (similar to camera film) and a "negative" type picture is made (the more solid a structure is, the whiter it appears on the film). When the body undergoes X-rays, different parts of the body allow varying amounts of the X-ray beams to pass through. Images are produced in degrees of light and dark, depending on the amount of X-rays that penetrate the tissues. The soft tissues in the body (such as blood, skin, fat, and muscle) allow most of the X-ray to pass through and appear dark gray on the film. A bone or a tumor, which is denser than the soft tissues, allows few of the X-rays to pass through and appears white on the X-ray. At a break in a bone, the X-ray beam passes through the broken area and appears as a dark line in the white bone. While X-rays of the skull are not used as often as in the past, due to the use of newer technologies such as computed tomography (CT scans) and magnetic resonance imaging (MRI), they remain valuable for evaluating the bones of the skull for fractures and detecting other conditions of the skull and brain. In addition to CT scans and MRI, other related procedures that may be used to diagnose problems involving the skull and/or brain include positron emission tomography (PET) and bone scan. Please see these procedures for additional information. Bones of the skull

Click Image to Enlarge

The skull, also called the cranium, is the bony structure of the head. Two sets of bones comprise the skull:

Cranial bones. Bones that protect and enclose the brain. Facial bones. Bones that provide the framework for the face and mouth.

All bones comprising the skull are attached to each other via immovable joints, except for the mandible, which is attached via a movable joint. The cranium, which holds and protects the brain, consists of eight bones (frontal bone, parietal bones, temporal bones, ethmoid bone, sphenoid bone, and occipital bone). The skeleton of the face has 14 bones, which include those that make up the jaws, cheeks, and nasal area.
Reasons for the procedure

X-rays of the skull may be performed to diagnose fractures of the bones of the skull, congenital anomalies (birth defects), pituitary tumors, and certain metabolic and endocrine disorders that cause bone defects of the skull. Skull X-rays may also be used to detect tumors, evaluate the nasal sinuses, and detect cerebral calcification (calcifications within the brain). There may be other reasons for your physician to recommend an X-ray of the skull.
Risks of the procedure

You may want to ask your physician about the amount of radiation used during the procedure and the risks related to your particular situation. It is a good idea to keep a record of your past history of radiation exposure, such as previous scans and other

types of X-rays, so that you can inform your physician. Risks associated with radiation exposure may be related to the cumulative number of X-ray examinations and/or treatments over a long period of time. If you are pregnant or suspect that you may be pregnant, you should notify your physician. Radiation exposure during pregnancy may lead to birth defects. If it is necessary for you to have a skull X-ray, special precautions will be made to minimize the radiation exposure to the fetus. There may be other risks depending upon your specific medical condition. Be sure to discuss any concerns with your physician prior to the procedure.
Before the procedure

Your physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure. Generally, no prior preparation, such as fasting or sedation, is required. Notify the radiologic technologist if you are pregnant or suspect you may be pregnant. Notify the radiologic technologist if you have a prosthetic (artificial) eye, because the prosthesis can create a confusing shadow on an X-ray of the skull. Based upon your medical condition, your physician may request other specific preparation.

During the procedure

An X-ray may be performed on an outpatient basis or as part of your stay in a hospital. Procedures may vary depending on your condition and your physician's practices. Generally, an X-ray procedure of the skull follows this process:

1. You will be asked to remove any clothing, jewelry, hairpins, eyeglasses, hearing aids, or other metal objects that might interfere with the procedure. 2. If you are asked to remove clothing, you will be given a gown to wear. 3. You will be positioned on an X-ray table that carefully places the part of the skull that is to be x-rayed between the X-ray machine and a cassette containing the X-ray film. 4. Body parts not being imaged may be covered with a lead apron (shield) to avoid exposure to the X-rays. 5. The radiologic technologist will ask you to hold still in a certain position for a few moments while the X-ray exposure is made. 6. If the X-ray is being performed to determine an injury, special care will be taken to prevent further injury. For example, a neck brace may be applied if a cervical spine fracture is suspected. 7. Some skull X-ray studies may require several different positions. It is extremely important to remain completely still while the exposure is made, as any movement may distort the image and even require another X-ray to be done to obtain a clear image of the body part in question. 8. The X-ray beam will be focused on the area to be photographed. 9. The radiologic technologist will step behind a protective window while the image is taken. While the X-ray procedure itself causes no pain, the manipulation of the body part being examined may cause some discomfort or pain, particularly in the case of a recent injury or invasive procedure such as surgery. The radiologic technologist will use all possible comfort measures and complete the procedure as quickly as possible to minimize any discomfort or pain.
After the procedure

Generally, there is no special type of care following an X-ray of the skull. However, your physician may give you additional or alternate instructions after the procedure, depending on your particular situation.

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2-17. SKULL X-RAYS a. Skull X-rays are the oldest, non-invasive neurological test used to evaluate the bones, which make up the skull. Because of complex anatomy of the skull, a series of films is usually required for a complete evaluation. b. Diagnostic uses for skull X-rays: (1) To detect fractures in patient's with head trauma.

(2) To help detect and assess increased intracranial pressure, tumors, bleeding, and infection. (3) To aid diagnosis of pituitary tumors. (4) To detect congenital anomalies. c. Nursing implications. (1) Review the patient's clinical record to determine the reason (purpose) for the specific scheduled skull x-rays. (2) Approach and identify the patient. (3) Interview the patient to determine his/her knowledge of the purpose of the skull x-rays. (4) As indicated, explain to the patient the specific purpose of the skull x-rays in his/her situation. Explain purpose in a manner consistent with that offered by the physician to avoid confusing the patient. (5) Explain to the patient the events which will occur prior to the skull x-rays. (a) Patient is not required to restrict food and fluids before x-rays. (b) All jewelry and other metal objects must be removed from patient's head and neck and placed in safekeeping. (c) Tell the patient where and when the x-rays will be performed. (6) Explain to the patient events which will occur during the skull x-ray procedure. (a) Patient will be placed in a supine position on a radiographic table, or seated in a chair, and instructed to remain still.

(b) A headband, foam pads, or sandbags may be used to immobilize the patient's head and increase patient comfort. (c) Tell the patient that several (usually five) x-ray films of the skull will be taken from various angles. (d) Reassure patient that the procedure will cause no discomfort. (e) Films will be developed and checked before patient leaves the x-ray department. (7) Explain to the patient events, which will occur after the procedure. (a) Patient will be returned to his/her room. (b) Physician will report the results of the x-rays to the patient when they are available.