Radiological interpretation

Elizabeth Stokell MA VetMB CertVR MRCVS

Department of Clinical Veterinary Medicine
University of Cambridge
Madingley Road
Cambridge

1. Introduction

Radiographic interpretation is based on the visualisation and analysis of opacities

on a radiograph. These opacities are formed by the following processes:

1. X-Ray photons have the potential to penetrate tissue

2. X-Ray photons will be attenuated in part by the tissue, and in part will pass
through the tissue to interact with and expose the radiographic film
3. Absorption of X-Rays is a function of the atomic number and thickness of
the tissues/objects
o Tissues/objects with a higher atomic number will absorb more
radiation than tissues with a lower atomic number
o Thicker tissue/objects will absorb more X-Rays than thinner tissue
of similar composition
4. The greater the amount of tissue absorption, the fewer X-Ray photons
reach the film, and the whiter the image on the film
5. The radiograph will display a range of densities from white, through
various shades of grey, to black
o Radiopaque tissues/objects appear more white
o Radiolucent tissues/objects appear more black
6. The resultant pattern of opacities forms an image on the radiograph, which
is recognisable in form, and which can be interpreted

2. Radiopacity

The radiopacity of various objects and tissues results in radiographs showing

different radiopacities, and hence they can be differentiated. Radiopaque
tissues/objects result in a whiter image; less radiopaque objects result in a
blacker image. The radiopacity depends on:

1. Atomic number
o The higher the atomic number, the more radiopaque the
tissue/object:
2. Physical opacity
o Air, fluid and soft tissue have approximately the same atomic
number, but the specific gravity of air is only 0.001, whereas that of
fluid and soft tissue is 1
 o Therefore air will appear black on a radiograph, compared with fluid
and soft tissue, which appear more grey
3. Thickness
o The thicker the tissue/object, the greater the attenuation of X-Rays
and the more white the image will be
o When two tissues/objects are superimposed, the composite
shadow formed by these will appear more opaque than either of the
two separate tissues/objects (e.g. the area where the two kidneys
overlap appears more radiopaque than either kidney itself)

Effective
Specific
Tissue/Object Atomic
Gravity
Number
gas 1-2 0.001
fat 6-7 0.9
soft tissue/fluid 7-8 1
bone 14 1.8
metal (lead) 82 11.3

3. Basic tissue radiographic opacities

1. Mineral opacity
o Bone is composed primarily of calcium and phosphorus
o There is a normal variation in radiopacity within the same bone and
between bones because of the difference in radiopacity of:
 Compact vs spongy bone
 Trabecular bone vs intertrabecular spaces
 Cortical bone vs medullary canal
o Diseased bone may be more (sclerotic) or less (porotic) opaque
than normal bone
2. Soft tissue/fluid opacity
o Both soft tissues and fluids have the same radiopacity
o This is the radiopacity of normal soft tissue and fluid-filled organs
(heart, liver, spleen, urinary bladder)
o Variation in volume, thickness and degree of compactness of soft
tissue creates a pattern of various densities on the radiograph
3. Fat opacity
o Fat is more lucent than bone or soft tissue, but is more opaque than
gas
o Fat produces radiographic contrast for differentiation and
visualisation of many organs and structures, in that fat surrounding
an organ or structure will allow it to be delineated
o In immature and thin animals, the lack of fat results in poorer
contrast in the radiograph
4. Gas opacity
o Gas is the most radiolucent material visible on a film
o This lucency provides contrast to allow visualisation of various
structures, e.g. the heart and great vessels outlined against the air-
filled lungs in the chest.
 5. Metal opacity
o This is the most opaque shadow seen on radiographs, and may be
seen as:
 Contrast media: barium, water-soluble iodine media
 Orthopaedic implants
 Metallic foreign bodies
 Artefacts, e.g. metal on collar and lead chain
6. Only these five radiographic opacities are visible on a radiograph
o However, there is some variation in opacity within each group
o The appearance of these opacities is relative
 For instance, a small cystic calculus (mineral opacity) may
be difficult to identify in a bladder full of urine (soft tissue
opacity), but will be more readily apparent in a
pneumocystogram since it contrasts with the air (gas
opacity) in the bladder
 In a positive contrast cystogram the calculus will appear
relatively radiolucent as it is less opaque than the iodine-
containing contrast medium (metal opacity)

4. Radiologic interpretation

1. Viewing the radiograph

o This should be done in a quiet, darkened room
o At least two good, evenly-lit viewing boxes are required
o A bright light illuminator is required for relatively over-exposed
areas
o The bright edges around the film should be masked
2. Three-dimensional concept
o The radiographic image is simply a two-dimensional shadowgram
of the patient
o The third dimension must be reconstructed mentally, preferably
from two radiographic projections made at right angles (orthogonal
projections) to each other
o Oblique projections may be required to assess anatomically
complicated areas
o Reference to normal should be made through the use of anatomic
specimens, radiographs of normal animals and textbooks.
3. Routine assessment of radiographs
o Ensure that the radiograph is the one of the patient being
examined, and check the date
o Ensure two orthogonal projections are available
o The radiographic views are named according to the direction the
primary beam enters and leaves the tissue and the body part being
examined (e.g. mediolateral view of stifle joint, dorsopalmar view of
carpus)
o The position of the patient during exposure should be known, and
left/right markers should be identified
o The radiograph should be of high technical quality with respect to
positioning, centring, collimation, exposure and development, and
should be free from artefacts
 4. Every shadow visible must be evaluated to determine whether it is:
o A feature of normal anatomy
o A composite structure formed by superimposition of structures
o An artefact produced by inaccurate positioning
o A pathologic lesion: a)-c) must be ruled out first

5. Evaluating the radiographs

1. Determine whether an abnormality exists:

o This is often the most difficult part
 There is a wide range of normal anatomic variants
 It is impossible to remember, or even see, in a lifetime all the
normal variations
o Reference should be made to textbooks, normal radiographs,
tissue specimens or the contralateral limb
o This decision making improves with experience
2. Define the anatomic location of the abnormality
o A minimum of two orthogonal projections are required
o More views may be required in certain areas
3. Classify the abnormality according to its roentgen signs
o The roentgen signs are defined below
4. Make a list of differential diagnoses (gamuts) by considering what
diseases could cause the observed roentgen signs
o For example, if the roentgen sign is the presence of an enlarged
kidney, then possible differentials (gamuts) are:
 neoplasia
 hydronephrosis
 cyst
 abscess
 subcapsular urine/haemorrhage
5. If a number of abnormal roentgen signs are identified, then those gamuts
common to all lists are more likely (assuming only one problem is present)

6. Description of radiologic abnormalities of tissues/organs/objects

(roentgen signs)

1. Changes in size of an organ or structure

o Increase in size e.g. diffuse neoplasia within the spleen
o Decrease in size e.g. poor development of the liver with a
portosystemic shunt
2. Variation in contour or shape
o This may be local or diffuse e.g. hypertrophy of chambers of the
heart in cardiomyopathy
o Irregularity of mucosal border seen on positive contrast study with
intestinal lymphosarcoma
3. Variation in number of organs
o Many organs or structures may be present in increased or
decreased number or absent completely (e.g. supernumerary teeth
and ribs, absence of a kidney)
4. Change in position of an organ or structure
 o Presence of abdominal organs in chest in diaphragmatic rupture
o Ventral deviation of descending colon by enlarged sub-lumbar
lymph nodes
5. Alteration in opacity of an organ or structure
o Increased radiopacity
 increased opacity in air-filled space e.g. fluid-filled tympanic
bulla
 calcification within soft tissues
 radiopaque foreign body
o Increased lucency
 gas in abnormal sites e.g. subcutaneous emphysema
 bone may appear more lucent with osteoporosis,
osteomyelitis and neoplasia
6. Alteration in the architectural pattern of an organ or structure
o Change in normal bone trabeculation, or bronchovascular markings
in the lungs
7. Alteration in the normal function of an organ
o Secretory contrast studies e.g. excretory intravenous urogram
o Transit contrast studies e.g. Barium series
o Physiologic phases e.g. inspiratory and expiratory chest films
o Moving picture image intensification contrast studies of pharynx
and oesophagus

7. Other clues

1. Summation shadows
o This results when parts of a patient or an object in different planes
are superimposed
o The result is a summation image representing the degree of X-Ray
absorption by all the superimposed objects
o Radiolucent summation shadows are formed in the 'Swiss cheese '
effect
 When a radiograph is made of, for example, a block of Swiss
cheese, fewer X-rays are absorbed by the cheese in areas
where the cavities overlap.
 The more cavities that overlap, the greater the number of X-
Rays that reach the film.
o Radiopaque summation shadows are involved in the 'bunch of
grapes' effect
 A radiograph of a single small object, for instance a grape,
may not be readily visible
 If a radiograph is made of a bunch of grapes, the areas
where many grapes overlap will absorb more X-Rays
 This feature accounts for the visibility of miliary pulmonary
metastases, where the individual size of the metastases is
very small
2. The silhouette effect
o This principle is based on the fact that when two structures of the
same radiopacity are in contact, their individual margins at the point
of contact cannot be distinguished.
  For instance, the liver and stomach are generally in close
contact and a composite shadow representing both
structures is formed on a radiograph
 A coronary artery and a small pulmonary artery of the same
size are not equally visible on a thoracic radiograph
 The coronary artery is not visible since it has the
same radiopacity as the heart, and there is no
intervening tissue of a different radiopacity
 The pulmonary artery is visible because it is not in
contact with the heart, and it is surrounded by the
more radiolucent lung
o Conversely, if two objects are not in contact, and are separated by
a substance of different radiopacity, their borders can be
distinguished
 If the two objects are separated along the axis of the primary
beam, then a summation shadow will be formed
 For example, overlap of the renal shadows is often
identified on a lateral abdominal radiograph
 If the two objects are separated along a plane perpendicular
to the axis of the primary beam then an obvious space is
seen between them
 For example, a lucent space is identified between the
borders of the heart and diaphragm on an inspiratory
thoracic radiograph
o If two structures of the same radiopacity are in contact, one is said
to silhouette with the other, or to form a positive silhouette sign.
This terminology is confusing, and the term 'border effacement' has
been suggested when their is a loss of the clear margins of a
structure
3. Importance of a contrasting substance
o Just as the lack of a contrasting material prevents distinguishing
between two structures of the same radiopacity, the presence of a
contrasting substance allows some structures to become
exquisitely visible
o This principle is particularly important when the contrasting
substance is air, and the object in question is on the surface of the
body
 For example, in many patients, nipples and the prepuce are
clearly visible in ventrodorsal projections of the abdomen
 These structures are not particularly large or radiopaque, but
cast a disproportionately opaque shadow
o The explanation lies in the fact that these structures are surrounded
by air, and their margins are parallel to the axis of the central ray,
providing optimum geometry for visualisation
4. Perception
o When evaluating radiographs, the eyes are used to detect
abnormalities which are interpreted by the brain
o However, the eyes and brain do not always perceive appearances
accurately, and optical illusions may occur
o What appears as concrete visual evidence is not always such, and
perception is an important part of radiographic interpretation
 o What appears to be an obvious finding to inexperienced
radiologists may be an incorrect assessment because of perception

8. Pitfalls in interpretation

1. The presence of an obvious abnormality that distracts the evaluator from

systematic evaluation of the rest of the radiograph
2. Discovery of a lesion that answers the clinical question that prompted the
radiographic examination, thereby distracting the evaluator
3. Tunnel vision, which is a preconception of what will be found, so that when
the preconception is confirmed, viewing of the radiograph ends
4. Failure to adopt a systematic approach, and using the error-prone 'Aunt
Minny' approach;
o Aunt Minny represents an abnormality which looks like one that the
evaluator has seen before, or been told about (e.g. distal radial
metaphyseal osteosarcoma)
o Uncle Fred represents a boring abnormality which is often present
(e.g. ventral lumbar spondylosis)
o Cousin Harry represents an abnormality which the evaluator has
not seen for a long time, but would like to see (e.g.
peritoneopericardiac diaphragmatic hernia)
5. The 'Aunt Minny' approach has its devotees, and those who use it often
appear to have a supernatural ability to make a diagnosis
o However, there is more than one possible cause for most
abnormalities seen
o It would be impossible to remember the appearance of every
disease
o It would be difficult to recognise new findings using this approach

X rays pass easily through air and soft tissue of the body. When they encounter more
dense material, such as a tumor, bone, or a metal fragment, they are stopped. Diagnostic x
rays are performed by positioning the part of the body to be examined between a focused
beam of x rays and a plate containing film. This process is painless. The greater the
density of the material that the x rays pass through, the more rays are absorbed. Thus
bone absorbs more x rays than muscle or fat, and tumors may absorb more x rays than
surrounding tissue. The x rays that pass through the body strike the photographic plate
and interact with silver molecules on the surface of the film.

Once the film plates have been processed, dense material such as bone shows up as
white, while softer tissue shows up as shades of gray, and airspaces look black. A
radiologist, who is a physician trained to interpret diagnostic x rays, examines the
pictures and reports to the doctor who ordered the tests. Plain film x rays normally take
only a few minutes to perform and can be done in a hospital, radiological center, clinic,
doctor's or dentist's office, or at bedside with a portable x-ray machine.
 Ultrasonography

Diagnostic applications
This section does not cite any references or sources.
Please help improve this article by adding citations to reliable sources. Unsourced material may
be challenged and removed. (April 2010)

Orthogonal planes of a 3 dimensional sonographic volume with transverse and coronal

measurements for estimating foetal cranial volume.[1],[2]

Typical diagnostic sonographic scanners operate in the frequency range of 2 to 18

megahertz, though frequencies up to 50-100 megahertz has been used experimentally in a
technique known as biomicroscopy in special regions, such as the anterior chamber of
eye.[citation needed] The above frequencies are hundreds of times greater than the limit of
human hearing, which is typically accepted as 20 kilohertz. The choice of frequency is a
trade-off between spatial resolution of the image and imaging depth: lower frequencies
produce less resolution but image deeper into the body.

Sonography (ultrasonography) is widely used in medicine. It is possible to perform both

diagnosis and therapeutic procedures, using ultrasound to guide interventional procedures
(for instance biopsies or drainage of fluid collections). Sonographers are medical
professionals who perform scans for diagnostic purposes. Sonographers typically use a
hand-held probe (called a transducer) that is placed directly on and moved over the
patient.

Sonography

Sonography is effective for imaging soft tissues of the body. Superficial structures such
as muscles, tendons, testes, breast and the neonatal brain are imaged at a higher
frequency (7-18 MHz), which provides better axial and lateral resolution. Deeper
structures such as liver and kidney are imaged at a lower frequency 1-6 MHz with lower
axial and lateral resolution but greater penetration

Other types of uses include:

• Intervenional; biopsy, emptying fluids, intrauterine transfusion [disambiguation needed]

(Hemolytic disease of the newborn)
• Contrast-enhanced ultrasound

A general-purpose sonographic machine may be used for most imaging purposes. Usually
specialty applications may be served only by use of a specialty transducer. Most
ultrasound procedures are done using a transducer on the surface of the body, but
improved diagnostic confidence is often possible if a transducer can be placed inside the
body. For this purpose, specialty transducers, including endovaginal, endorectal, and
transesophageal transducers are commonly employed. At the extreme of this, very small
transducers can be mounted on small diameter catheters and placed into blood vessels to
image the walls and disease of those vessels.

[edit] Therapeutic applications

Therapeutic applications use ultrasound to bring heat or agitation into the body.
Therefore much higher energies are used than in diagnostic ultrasound. In many cases the
range of frequencies used are also very different.

• Ultrasound is sometimes used to clean teeth in dental hygiene.

• Ultrasound sources may be used to generate regional heating and mechanical
changes in biological tissue, e.g. in occupational therapy, physical therapy and
cancer treatment. However the use of ultrasound in the treatment of
musculoskeletal conditions has fallen out of favor.[4][5]
• Focused ultrasound may be used to generate highly localized heating to treat cysts
and tumors (benign or malignant), This is known as Focused Ultrasound Surgery
(FUS) or High Intensity Focused Ultrasound (HIFU). These procedures generally
use lower frequencies than medical diagnostic ultrasound (from 250 kHz to
2000 kHz), but significantly higher energies. HIFU treatment is often guided by
MRI.
• Focused ultrasound may be used to break up kidney stones by lithotripsy.
• Ultrasound may be used for cataract treatment by phacoemulsification.
• Additional physiological effects of low-intensity ultrasound have recently been
discovered, e.g. its ability to stimulate bone-growth and its potential to disrupt the
blood-brain barrier for drug delivery.
• Procoagulant at 5-12 MHz,

[edit] From sound to image

The creation of an image from sound is done in three steps - producing a sound wave,
receiving echoes, and interpreting those echoes.
[edit] Producing a sound wave

Medical sonographic instrument

A sound wave is typically produced by a piezoelectric transducer encased in a housing which can
take a number of forms. Strong, short electrical pulses from the ultrasound machine make the
transducer ring at the desired frequency. The frequencies can be anywhere between 2 and 18
MHz. The sound is focused either by the shape of the transducer, a lens in front of the transducer,
or a complex set of control pulses from the ultrasound scanner machine (Beamforming). This
focusing produces an arc-shaped sound wave from the face of the transducer. The wave travels
into the body and comes into focus at a desired depth.

Older technology transducers focus their beam with physical lenses. Newer technology
transducers use phased array techniques to enable the sonographic machine to change the
direction and depth of focus. Almost all piezoelectric transducers are made of ceramic.

Materials on the face of the transducer enable the sound to be transmitted efficiently into the body
(usually seeming to be a rubbery coating, a form of impedance matching). In addition, a water-
based gel is placed between the patient's skin and the probe.

The sound wave is partially reflected from the layers between different tissues. Specifically,
sound is reflected anywhere there are density changes in the body: e.g. blood cells in blood
plasma, small structures in organs, etc. Some of the reflections return to the transducer.

[edit] Receiving the echoes

The return of the sound wave to the transducer results in the same process that it took to send the
sound wave, except in reverse. The return sound wave vibrates the transducer, the transducer
turns the vibrations into electrical pulses that travel to the ultrasonic scanner where they are
processed and transformed into a digital image.

[edit] Forming the image

The sonographic scanner must determine three things from each received echo:

1. How long it took the echo to be received from when the sound was transmitted.
2. From this the focal length for the phased array is deduced, enabling a sharp image of that
echo at that depth (this is not possible while producing a sound wave).
3. How strong the echo was. It could be noted that sound wave is not a click, but a pulse
with a specific carrier frequency. Moving objects change this frequency on reflection, so
that it is only a matter of electronics to have simultaneous Doppler sonography.

Once the ultrasonic scanner determines these three things, it can locate which pixel in the image
to light up and to what intensity and at what hue if frequency is processed (see redshift for a
natural mapping to hue).

Transforming the received signal into a digital image may be explained by using a blank
spreadsheet as an analogy. First picture a long, flat transducer at the top of the sheet. Send pulses
down the 'columns' of the spreadsheet (A, B, C, etc.). Listen at each column for any return
echoes. When an echo is heard, note how long it took for the echo to return. The longer the wait,
the deeper the row (1,2,3, etc.). The strength of the echo determines the brightness setting for that
cell (white for a strong echo, black for a weak echo, and varying shades of grey for everything in
between.) When all the echoes are recorded on the sheet, we have a greyscale image.
[edit] Displaying the image

Images from the sonographic scanner can be displayed, captured, and broadcast through a
computer using a frame grabber to capture and digitize the analog video signal. The captured
signal can then be post-processed on the computer itself.[6]

For computational details see also: Confocal laser scanning microscopy, Radar,

[edit] Sound in the body

Linear Array Transducer

Ultrasonography (sonography) uses a probe containing one or more acoustic transducers
to send pulses of sound into a material. Whenever a sound wave encounters a material
with a different density (acoustical impedance), part of the sound wave is reflected back
to the probe and is detected as an echo. The time it takes for the echo to travel back to the
probe is measured and used to calculate the depth of the tissue interface causing the echo.
The greater the difference between acoustic impedances, the larger the echo is. If the
pulse hits gases or solids, the density difference is so great that most of the acoustic
energy is reflected and it becomes impossible to see deeper.

The frequencies used for medical imaging are generally in the range of 1 to 18 MHz.
Higher frequencies have a correspondingly smaller wavelength, and can be used to make
sonograms with smaller details. However, the attenuation of the sound wave is increased
at higher frequencies, so in order to have better penetration of deeper tissues, a lower
frequency (3-5 MHz) is used.

Seeing deep into the body with sonography is very difficult. Some acoustic energy is lost

every time an echo is formed, but most of it (approximately ) is

lost from acoustic absorption.

The speed of sound is varies as it travels through different materials, and is dependent on
the acoustical impedance of the material. However, the sonographic instrument assumes
that the acoustic velocity is constant at 1540 m/s. An effect of this assumption is that in a
real body with non-uniform tissues, the beam becomes somewhat de-focused and image
resolution is reduced.

To generate a 2D-image, the ultrasonic beam is swept. A transducer may be swept

mechanically by rotating or swinging. Or a 1D phased array transducer may be use to
sweep the beam electronically. The received data is processed and used to construct the
image. The image is then a 2D representation of the slice into the body.

3D images can be generated by acquiring a series of adjacent 2D images. Commonly a

specialised probe that mechanically scans a conventional 2D-image transducer is used.
However, since the mechanical scanning is slow, it is difficult to make 3D images of
moving tissues. Recently, 2D phased array transducers that can sweep the beam in 3D
have been developed. These can image faster and can even be used to make live 3D
images of a beating heart.

Doppler ultrasonography is used to study blood flow and muscle motion. The different
detected speeds are represented in color for ease of interpretation, for example leaky heart
valves: the leak shows up as a flash of unique color. Colors may alternatively be used to
represent the amplitudes of the received echoes.
[edit] Modes of sonography
Several different modes of ultrasound are used in medical imaging.[7] These are:

• A-mode: A-mode is the simplest type of ultrasound. A single transducer scans a

line through the body with the echoes plotted on screen as a function of depth.
Therapeutic ultrasound aimed at a specific tumor or calculus is also A-mode, to
allow for pinpoint accurate focus of the destructive wave energy.
• B-mode: In B-mode ultrasound, a linear array of transducers simultaneously
scans a plane through the body that can be viewed as a two-dimensional image on
screen.
• M-mode: M stands for motion. In m-mode a rapid sequence of B-mode scans
whose images follow each other in sequence on screen enables doctors to see and
measure range of motion, as the organ boundaries that produce reflections move
relative to the probe.
• Doppler mode: This mode makes use of the Doppler effect in measuring and
visualizing blood flow
o Color doppler: Velocity information is presented as a color coded overlay
on top of a B-mode image
o Continuous doppler: Doppler information is sampled along a line
through the body, and all velocities detected at each time point is
presented (on a time line)
o Pulsed wave (PW) doppler: Doppler information is sampled from only a
small sample volume (defined in 2D image), and presented on a timeline
o Duplex: a common name for the simultaneous presentation of 2D and
(usually) PW doppler information. (Using modern ultrasound machines
color doppler is almost always also used, hence the alternative name
Triplex.)

Midwives generally use this type of system.

[edit] Doppler sonography
See also: Doppler echocardiography

Spectral Doppler of Common Carotid Artery

Colour Doppler of Common Carotid Artery

Computer-enhanced transcranial doppler.

 Doppler usg

Sonography can be enhanced with Doppler measurements, which employ the Doppler
effect to assess whether structures (usually blood) are moving towards or away from the
probe, and its relative velocity. By calculating the frequency shift of a particular sample
volume, for example flow in an artery or a jet of blood flow over a heart valve, its speed
and direction can be determined and visualised. This is particularly useful in
cardiovascular studies (sonography of the vascular system and heart) and essential in
many areas such as determining reverse blood flow in the liver vasculature in portal
hypertension. The Doppler information is displayed graphically using spectral Doppler,
or as an image using color Doppler (directional Doppler) or power Doppler (non
directional Doppler). This Doppler shift falls in the audible range and is often presented
audibly using stereo speakers: this produces a very distinctive, although synthetic,
pulsating sound.

Most modern sonographic machines use pulsed Doppler to measure velocity. Pulsed
wave machines transmit and receive series of pulses. The frequency shift of each pulse is
ignored, however the relative phase changes of the pulses are used to obtain the
frequency shift (since frequency is the rate of change of phase). The major advantages of
pulsed Doppler over continuous wave is that distance information is obtained (the time
between the transmitted and received pulses can be converted into a distance with
knowledge of the speed of sound) and gain correction is applied. The disadvantage of
pulsed Doppler is that the measurements can suffer from aliasing. The terminology
"Doppler ultrasound" or "Doppler sonography", has been accepted to apply to both
pulsed and continuous Doppler systems despite the different mechanisms by which the
velocity is measured.

It should be noted here that there are no standards for the display of color Doppler. Some
laboratories insist on showing arteries as red and veins as blue, as medical illustrators
usually show them, even though, as a result, a tortuous vessel may have portions with
flow toward and away relative to the transducer. This can result in the illogical
appearance of blood flow that appears to be in both directions in the same vessel. Other
laboratories use red to indicate flow toward the transducer and blue away from the
transducer which is the reverse of 150 years of astronomical literature on the Doppler
effect. Still other laboratories prefer to display the sonographic Doppler color map more
in accord with the prior published physics with the red shift representing longer waves of
echoes (scattered) from blood flowing away from the transducer; and with blue
representing the shorter waves of echoes reflecting from blood flowing toward the
transducer. Because of this confusion and lack of standards in the various laboratories,
the sonographer must understand the underlying acoustic physics of color Doppler and
the physiology of normal and abnormal blood flow in the human body.[8][9][10][11]
[edit] Contrast media

The use of microbubble contrast media in medical sonography to improve ultrasound signal
backscatter is known as contrast-enhanced ultrasound. This technique is currently used in
echocardiography, and may have future applications in molecular imaging and drug delivery.

[edit] Compression ultrasonography

Compression ultrasonography is a technique used for diagnosing deep vein thrombosis and
combines ultrasonography of the deep veins with venous compression.[12] The technique can be
used on deep veins of the upper and lower extremities, with some laboratories limiting the
examination to the common femoral vein and the popliteal vein, whereas other laboratories
examine the deep veins from the inguinal region to the calf, including the calf veins.[12]

Compression ultrasonography in B-mode has both high sensitivity and specificity for detecting
proximal deep vein thrombosis in symptomatic patients. The sensitivity lies somewhere between
90 to 100% for the diagnosis of symptomatic deep vein thrombosis, and the specificity ranges
between 95 to 100%.[12]

A-mode: This display mode is the simplest; signals are recorded as spikes on a graph.
The vertical (Y) axis of the display shows the echo amplitude, and the horizontal (X) axis
shows depth or distance into the patient. This type of ultrasonography is used for
ophthalmologic scanning.

B-mode (gray-scale): This mode is most often used in diagnostic imaging; signals are
displayed as a 2-dimensional anatomic image. B-mode is commonly used to evaluate
the developing fetus and to evaluate organs, including the liver, spleen, kidneys, thyroid
gland, testes, breasts, and prostate gland. B-mode ultrasonography is fast enough to
show real-time motion, such as the motion of the beating heart or pulsating blood
vessels. Real-time imaging provides anatomic and functional information.

M-mode: This mode is used to image moving structures; signals reflected by the moving
structures are converted into waves that are displayed continuously across a vertical
axis. M-mode is used primarily for assessment of fetal heartbeat and in cardiac imaging,
most notably to evaluate valvular disorders.

Doppler: This type of ultrasonography is used to assess blood flow. Doppler

ultrasonography uses the Doppler effect (alteration of sound frequency by reflection off a
moving object). The moving objects are RBCs in blood.

Direction and velocity of blood flow can be determined by analyzing changes in the
frequency of sound waves:

• If a reflected sound wave is lower in frequency than the transmitted sound wave,
blood flow is away from the transducer.
 • If a reflected sound wave is higher in frequency than the transmitted sound wave,
blood flow is toward the transducer.
• The magnitude of the change in frequency is proportional to blood flow velocity.
Changes in frequency of the reflected sound waves are converted into images showing
blood flow direction and velocity.

Duplex Doppler ultrasonography combines the graphic display of spectral

ultrasonography with the images of B-mode. For color Doppler ultrasonography, color is
superimposed on a gray-scale anatomic image. The color indicates direction of blood
flow. By convention, red indicates flow toward and blue indicates flow away from the
transducer.

Doppler ultrasonography is also used to evaluate vascularity of tumors and organs, to

evaluate heart function (eg, as for echocardiography), to detect occlusion and stenosis
of blood vessels, and to detect blood clots in blood vessels (eg, in deep venous
thrombosis

Image construction
The probe contains a large number of transmitters set in a line along its length. Typically
up to five of these firing simultaneously generate a short pulse of ultrasound that travels
in a narrow column away from the probe. The transmitters then act as receivers and
record the intensity of the reflected sound.

The process is repeated sequentially along the length of the probe. The time taken for an
echo to return is used determine the distance from the probe and is calculated assuming
that sound has a constant speed (1540m/s). The strength of the echoes returning from any
point is represented by the brightness of that point on the screen.

Figure 1 Time take for the transmitted pulse to be reflected back is used to calculated the
distance of the reflecting boundary from the probe

The path that a single pulse passes along is described as the beam. The width of the beam
determines the lateral resolution. The length of the pulse determines the axial resolution.
Shorter pulses can be achieved using higher frequency, so the highest frequency
practicable is generally used.

Different Types of Reflection

Two distinct patterns of reflection give rise to the echoes that make up an ultrasound
image – specular reflection and scattering.

Specular reflection
 Specular reflection is responsible for the bright appearance of fibrous structures such as
tendons and of boundaries between different tissues. It occurs when the sound wave
meets a distinct surface (significantly larger than the wavelength of the ultrasound).

The process that occurs is similar to when light passes from air to water on the surface of
a lake. Some of the light travels in to the water, while some is reflected back.

The amount of sound that is reflected at the boundary between two different tissues, such
as fat and muscle, depends on how marked the difference is in their acoustic properties.
Acoustic impedance, which is the measure of this, varies with the density and
compressibility of the tissue.

Scattering

Scattering gives rise to the characteristic texture (echo texture) of the image seen within
soft tissue. This occurs at the small (relative to the wave length of the ultrasound) subtle
boundaries that exist within tissue. At these, small amounts of energy are absorbed and
retransmitted in all directions as if from a point source, in a manor that loosely resembles
a pebble dropped into a pond.

Enhancement and Attenuation

One drawback of ultrasound is that each layer of tissue that is passed through reflects
and absorbs the pulse to some extent, reducing the strength of the signal that reaches
deeper tissue.

As less sound returns from deeper tissues than more superficial ones, the image is
processed to compensate for this by applying a standard correction in proportion to the
depth.

Some structures however allow sound to pass through them more easily than others. The
most dramatic example is watery fluid, such as in an effusion, or in a cyst. These are
described as being translucent. Because only a minimal amount of energy is absorbed by
the fluid, the region that lies behind will receive more sound than the processor expects
for that depth. This area will therefore appear uniformly brighter. This effect is called
Enhancement.

Attenuation or Shadowing is the reverse effect, where some tissues absorb relatively
more of the sound. The area of the image deep to this will appear darker. In the extreme
almost no sound is transmitted, leaving a dark shadow behind the structure.

This effect is used as a diagnostic tool in identifying calculi, which if they are larger than
the beam width cast a strong acoustic shadow.

Anisotropy

This is the effect that makes a tendon appear bright when it runs at 90 Degrees to the
ultrasound beam, but dark when the angle is changed.
The reason for this is that at particularly smooth boundaries, the angle of reflection and
incidence are the same, just as they are with a conventional mirror. Thus the probe will
only receive the reflected sound if the beam strikes the surface at a right angle

It's All About Artifacts

Ultrasound is the only imaging modality that uses artifacts to help determine the consistency
of certain tissues. In X-ray, CT, MRI, artifacts just get in the way, and obscure the image in
many cases. With ultrasound we can determine if an object is cystic or solid, if it is desnse of
stiff. But with the help of the artifacts we can determine the structure, but some also get in
our way. If you understand physics all artifacts make sense (well at least for the most part).

The best angle of incidence of the sound beam is 90 degrees. THe most information
received by the transducer would be at this angle. If you scan a tissue at a lesser degree of
incidence the sound will refract causing the sound beam to bend. The image will become
unreliable, also if the impedance or resistance of adjacent tissues are not similar, the sound
wil also refract. Try to image at 90 degree as much as possible.

Anechoic mean there are no echoes (a black area). With an acounstical enhancement distal
to the black area, this may mean a solid object or a cystic object the area becomes a cystic
structure due to the increased inensity distal to no resistance through the cystic structure. An
acoustical enhancement occurs distal to the black structure. This works well until you use a
10 MHZ trasnducer or higher, then there may not be sufficient intensity to produce an
enhancement. Without an accoustical enhancement distal to the black area, this means that
the structure is solid due to attenuation of the sound, but if the resistance within the structure
is smaller then the sound beam, the echoes would scatter, and will not return to the
transducer to be received. Further investigation is necessary by scanning from a different
angle. You can also increase the intensity levels and try to produce enhancement. An
example of an accoustical enhancement would be distal to the gallbladder, or the urinary
bladder. An example of an anechoic area would occur from an adenocarcinoma at the head
of the pancrease.

Edge shadows occur from a refractino of the sound beam off an irregular structure. As the
sound beam hits at an irregular angle it bends, sending it to the right or left but not straight
down. Therefore there is no intensity distal to the edge, this causes a "shadow" distal. An
example on an edge shadow would be from the round edges of a cystic structure.

A shadow can also occur from the intensity of the sound beam reflecting of a calcification.
The echo reflects back to the transducer leaving no trasmitted intensity to continue on the
pathway. This creates a "shadow". Bones or stones such as gallstones or renal calculi would
be a good example of a shadow.

A strong interface meets with resistance creating a white area. The greater the resistance
the whiter the area. Dense tissue causes great reisistance. An example of a great resistance
would be the diaphram. Dense livers caused from cirrhosis or fatty streaks would cause the
liver to be bright.

Gas or air will cause the sound to attenuate and absorb as it propagates through the tissues.
Gas or air is a "closed doot" as sound will not penetrate gas filled areas. Try to establish
another angle of incidence to avoid the gas or air.

Bone also is a "closed door". The sound beam travels faster through bone than it does
through soft tissue, but it also absorbs the sound due to gas being a compressable median.
Because bone reflects and absorbs the sound beam, a "shadow" appears distal to the bone.
There is no transmitted intensity of the sound beam distal to the bone.

Reverberation can be caused by the sound beam "bouncing" from the anterior wall to the
posterior wall from two strong reflectors, creating the image from the anterior wall to be
written again. Lowering the power, or intensity of the sound beam, may help eliminate the
reverberation artifact. An object such as gas or metal can also cause a reverberation artifact
distal to the object. This can help to determine that two strong reflectores exist, such as an
IUD in the uterus, metal clips from a gallbladder surgery, or a gas pocket in a solid organ.

Mirror image is a propagation speed artifact. Since time and distance are synonymous the
computer places the resistant echo on the screen according to how long it took for the echo
to return to the transducer. As the echo returns and bounces into a strong reflector, it slows
down causing the time to increase from the time it left the transducer. This places the echoes
further from the actual place and rewrites the anterior tissue distal to the strong reflector. The
diaphram is a classic example of a strong reflector, causing the liver to be placed distal to the
diaphram in the lung region.
Magnetic resonance imaging (MRI), or nuclear magnetic resonance imaging
(NMRI), is primarily a noninvasive medical imaging technique used in radiology to
visualize detailed internal structure and limited function of the body. MRI provides much
greater contrast between the different soft tissues of the body than computed tomography
(CT) does, making it especially useful in neurological (brain), musculoskeletal,
cardiovascular, and oncological (cancer) imaging.

Unlike CT, MRI uses no ionizing radiation. Rather, it uses a powerful magnetic field to
align the nuclear magnetization of (usually) hydrogen atoms in water in the body. Radio
frequency (RF) fields are used to systematically alter the alignment of this magnetization.
This causes the hydrogen nuclei to produce a rotating magnetic field detectable by the
scanner. This signal can be manipulated by additional magnetic fields to build up enough
information to construct an image of the body.[1]:36

Magnetic resonance imaging is a relatively new technology. The first MR image was
published in 1973[2][3] and the first cross-sectional image of a living mouse was published
in January 1974.[4] The first studies performed on humans were published in 1977.[5][6] By
comparison, the first human X-ray image was taken in 1895.

Magnetic resonance imaging is a development of nuclear magnetic resonance. Originally,

the technique was referred to as nuclear magnetic resonance imaging (NMRI). However,
because the word nuclear was associated in the public mind with ionizing radiation
exposure, it is generally now referred to simply as MRI. Scientists still use the term
NMRI when discussing non-medical devices operating on the same principles. The term
magnetic resonance tomography (MRT) is also sometimes used.

The body is largely composed of water molecules. Each water molecule has two
hydrogen nuclei or protons. When a person goes inside the powerful magnetic field of the
scanner, the magnetic moments of some of these protons changes, and aligns with the
direction of the field.

In an MRI machine a radio frequency transmitter is briefly turned on, producing an

electromagnetic field. The photons of this field have just the right energy, known as the
resonance frequency, to flip the spin of the aligned protons in the body. As the intensity
and duration of application of the field increase, more aligned spins are affected. After
the field is turned off, the protons decay to the original spin-down state and the difference
in energy between the two states is released as a photon. It is these photons that produce
the electromagnetic signal that the scanner detects. The frequency the protons resonate at
depends on the strength of the magnetic field. As a result of conservation of energy, this
also dictates the frequency of the released photons. The photons released when the field
is removed have an energy — and therefore a frequency — due to the amount of energy
the protons absorbed while the field was active.

It is this relationship between field-strength and frequency that allows the use of nuclear
magnetic resonance for imaging. Additional magnetic fields are applied during the scan
to make the magnetic field strength depend on the position within the patient, in turn
making the frequency of the released photons dependent on position in a predictable
manner. Position information can then be recovered from the resulting signal by the use
of a Fourier transform. These fields are created by passing electric currents through
specially-wound solenoids, known as gradient coils. Since these coils are within the bore
of the scanner, there are large forces between them and the main field coils, producing
most of the noise that is heard during operation. Without efforts to dampen this noise, it
can approach 130 decibels (dB) with strong fields [7] (see also the subsection on acoustic
noise).

An image can be constructed because the protons in different tissues return to their
equilibrium state at different rates, which is a difference that can be detected. By
changing the parameters on the scanner, this effect is used to create contrast between
different types of body tissue or between other properties, as in fMRI and diffusion MRI.

Contrast agents may be injected intravenously to enhance the appearance of blood

vessels, tumors or inflammation. Contrast agents may also be directly injected into a joint
in the case of arthrograms, MRI images of joints. Unlike CT, MRI uses no ionizing
radiation and is generally a very safe procedure. Nonetheless the strong magnetic fields
and radio pulses can affect metal implants, including cochlear implants and cardiac
pacemakers. In the case of cardiac pacemakers, the results can sometimes be lethal,[8] so
patients with such implants are generally not eligible for MRI.
MRI is used to image every part of the body, and is particularly useful for tissues with
many hydrogen nuclei and little density contrast, such as the brain, muscle, connective
tissue and most tumors.

In clinical practice, MRI is used to distinguish pathologic tissue (such as a brain tumor)
from normal tissue. One advantage of an MRI scan is that it is believed to be harmless to
the patient. It uses strong magnetic fields and non-ionizing radiation in the radio
frequency range, unlike CT scans and traditional X-rays, which both use ionizing
radiation.

While CT provides good spatial resolution (the ability to distinguish two separate
structures an arbitrarily small distance from each other), MRI provides comparable
resolution with far better contrast resolution (the ability to distinguish the differences
between two arbitrarily similar but not identical tissues). The basis of this ability is the
complex library of pulse sequences that the modern medical MRI scanner includes, each
of which is optimized to provide image contrast based on the chemical sensitivity of
MRI.

For example, with particular values of the echo time (TE) and the repetition time (TR),
which are basic parameters of image acquisition, a sequence takes on the property of T2-
weighting. On a T2-weighted scan, water- and fluid-containing tissues are bright (most
modern T2 sequences are actually fast T2 sequences) and fat-containing tissues are dark.
The reverse is true for T1-weighted images. Damaged tissue tends to develop edema,
which makes a T2-weighted sequence sensitive for pathology, and generally able to
distinguish pathologic tissue from normal tissue. With the addition of an additional radio
frequency pulse and additional manipulation of the magnetic gradients, a T2-weighted
sequence can be converted to a FLAIR sequence, in which free water is now dark, but
edematous tissues remain bright. This sequence in particular is currently the most
sensitive way to evaluate the brain for demyelinating diseases, such as multiple sclerosis.

The typical MRI examination consists of 5–20 sequences, each of which are chosen to
provide a particular type of information about the subject tissues. This information is then
synthesized by the interpreting physician.

[edit] Basic MRI scans

[edit] T1-weighted MRI

Main article: Spin-lattice relaxation time

T1-weighted scans use a gradient echo (GRE) sequence, with short TE and short TR. This
is one of the basic types of MR contrast and is a commonly run clinical scan. The T1
weighting can be increased (improving contrast) with the use of an inversion pulse as in
an MP-RAGE sequence. Due to the short repetition time (TR) this scan can be run very
fast allowing the collection of high resolution 3D datasets. A T1 reducing gadolinium
contrast agent is also commonly used, with a T1 scan being collected before and after
administration of contrast agent to compare the difference. In the brain T1-weighted scans
provide good gray matter/white matter contrast; in other words, T1-weighted images
highlights fat deposition.
[edit] T2-weighted MRI
Main article: Spin-spin relaxation time

T2-weighted scans use a spin echo (SE) sequence, with long TE and long TR. They have
long been the clinical workhorse as the spin echo sequence is less susceptible to
inhomogeneities in the magnetic field. They are particularly well suited to edema as they
are sensitive to water content (edema is characterized by increased water content). In
other words, put more simply, T2 weighted images light up liquid on the images being
visualized.

[edit] T*2-weighted MRI

T*2 (pronounced "T 2 star") weighted scans use a gradient echo (GRE) sequence, with
long TE and long TR. The gradient echo sequence used does not have the extra refocusing
pulse used in spin echo so it is subject to additional losses above the normal T2 decay
(referred to as T2′), these taken together are called T*2. This also makes it more prone to
susceptibility losses at air/tissue boundaries, but can increase contrast for certain types of
tissue, such as venous blood.

[edit] Spin density weighted MRI

Spin density, also called proton density, weighted scans try to have no contrast from
either T2 or T1 decay, the only signal change coming from differences in the amount of
available spins (hydrogen nuclei in water). It uses a spin echo or sometimes a gradient
echo sequence, with short TE and long TR.

[edit] Specialized MRI scans

[edit] Diffusion MRI

Main article: Diffusion MRI

DTI image

Diffusion MRI measures the diffusion of water molecules in biological tissues.[9] In an

isotropic medium (inside a glass of water for example) water molecules naturally move
randomly according to turbulence and Brownian motion. In biological tissues however,
where the Reynold's number is low enough for flows to be laminar, the diffusion may be
anisotropic. For example a molecule inside the axon of a neuron has a low probability of
crossing the myelin membrane. Therefore the molecule moves principally along the axis
of the neural fiber. If we know that molecules in a particular voxel diffuse principally in
one direction we can make the assumption that the majority of the fibers in this area are
going parallel to that direction.

The recent development of diffusion tensor imaging (DTI)[3] enables diffusion to be

measured in multiple directions and the fractional anisotropy in each direction to be
calculated for each voxel. This enables researchers to make brain maps of fiber directions
to examine the connectivity of different regions in the brain (using tractography) or to
examine areas of neural degeneration and demyelination in diseases like Multiple
Sclerosis.

Another application of diffusion MRI is diffusion-weighted imaging (DWI). Following

an ischemic stroke, DWI is highly sensitive to the changes occurring in the lesion.[10] It is
speculated that increases in restriction (barriers) to water diffusion, as a result of
cytotoxic edema (cellular swelling), is responsible for the increase in signal on a DWI
scan. The DWI enhancement appears within 5–10 minutes of the onset of stroke
symptoms (as compared with computed tomography, which often does not detect changes
of acute infarct for up to 4–6 hours) and remains for up to two weeks. Coupled with
imaging of cerebral perfusion, researchers can highlight regions of "perfusion/diffusion
mismatch" that may indicate regions capable of salvage by reperfusion therapy.

Like many other specialized applications, this technique is usually coupled with a fast
image acquisition sequence, such as echo planar imaging sequence.

[edit] Magnetization Transfer MRI

Main article: Magnetization transfer

Magnetization transfer (MT) refers to the transfer of longitudinal magnetization from free
water protons to hydration water protons in NMR and MRI.

In magnetic resonance imaging of molecular solutions, such as protein solutions, two

types of water molecules, free (bulk) and hydration (bound), are found. Free water
protons have faster average rotational frequency and hence less fixed water molecules
that may cause local field inhomogeneity. Because of this uniformity, most free water
protons have resonance frequency lying narrowly around the normal proton resonance
frequency of 63 MHz (at 1.5 teslas). This also results in slower transverse magnetization
dephasing and hence longer T2. Conversely, hydration water molecules are slowed down
by interaction with solute molecules and hence create field inhomogeneities that lead to
wider resonance frequency spectrum.

[edit] Fluid attenuated inversion recovery (FLAIR)

Main article: Fluid attenuated inversion recovery

Fluid Attenuated Inversion Recovery (FLAIR)[11] is an inversion-recovery pulse sequence

used to null signal from fluids. For example, it can be used in brain imaging to suppress
cerebrospinal fluid (CSF) so as to bring out the periventricular hyperintense lesions, such
as multiple sclerosis (MS) plaques. By carefully choosing the inversion time TI (the time
between the inversion and excitation pulses), the signal from any particular tissue can be
suppressed.
[edit] Magnetic resonance angiography

Magnetic Resonance Angiography

Main article: Magnetic resonance angiography

Magnetic resonance angiography (MRA) generates pictures of the arteries to evaluate

them for stenosis (abnormal narrowing) or aneurysms (vessel wall dilatations, at risk of
rupture). MRA is often used to evaluate the arteries of the neck and brain, the thoracic
and abdominal aorta, the renal arteries, and the legs (called a "run-off"). A variety of
techniques can be used to generate the pictures, such as administration of a paramagnetic
contrast agent (gadolinium) or using a technique known as "flow-related enhancement"
(e.g. 2D and 3D time-of-flight sequences), where most of the signal on an image is due to
blood that recently moved into that plane, see also FLASH MRI. Techniques involving
phase accumulation (known as phase contrast angiography) can also be used to generate
flow velocity maps easily and accurately. Magnetic resonance venography (MRV) is a
similar procedure that is used to image veins. In this method, the tissue is now excited
inferiorly, while signal is gathered in the plane immediately superior to the excitation
plane—thus imaging the venous blood that recently moved from the excited plane.[12]

[edit] Magnetic resonance gated intracranial CSF dynamics (MR-

GILD)

Magnetic resonance gated intracranial cerebrospinal fluid (CSF) or liquor dynamics (MR-
GILD) technique is an MR sequence based on bipolar gradient pulse used to demonstrate
CSF pulsatile flow in ventricles, cisterns, aqueduct of Sylvius and entire intracranial CSF
pathway. It is a method for analyzing CSF circulatory system dynamics in patients with
CSF obstructive lesions such as normal pressure hydrocephalus. It also allows
visualization of both arterial and venous pulsatile blood flow in vessels without use of
contrast agents.[13][14]

Diastolic time data acquisition (DTDA). Systolic time data acquisition (STDA).
[edit] Magnetic resonance spectroscopy
Main article: In vivo magnetic resonance spectroscopy
Main article: Nuclear magnetic resonance spectroscopy

Magnetic resonance spectroscopy (MRS) is used to measure the levels of different

metabolites in body tissues. The MR signal produces a spectrum of resonances that
correspond to different molecular arrangements of the isotope being "excited". This
signature is used to diagnose certain metabolic disorders, especially those affecting the
brain,[15] and to provide information on tumor metabolism.[16]

Magnetic resonance spectroscopic imaging (MRSI) combines both spectroscopic and

imaging methods to produce spatially localized spectra from within the sample or patient.
The spatial resolution is much lower (limited by the available SNR), but the spectra in
each voxel contains information about many metabolites. Because the available signal is
used to encode spatial and spectral information, MRSI requires high SNR achievable
only at higher field strengths (3 T and above).

[edit] Functional MRI

Main article: Functional magnetic resonance imaging

A fMRI scan showing regions of activation in orange, including the primary visual cortex
(V1, BA17).
Functional MRI (fMRI) measures signal changes in the brain that are due to changing
neural activity. The brain is scanned at low resolution but at a rapid rate (typically once
every 2–3 seconds). Increases in neural activity cause changes in the MR signal via T*2
changes;[17] this mechanism is referred to as the BOLD (blood-oxygen-level dependent)
effect. Increased neural activity causes an increased demand for oxygen, and the vascular
system actually overcompensates for this, increasing the amount of oxygenated
hemoglobin relative to deoxygenated hemoglobin. Because deoxygenated hemoglobin
attenuates the MR signal, the vascular response leads to a signal increase that is related to
the neural activity. The precise nature of the relationship between neural activity and the
BOLD signal is a subject of current research. The BOLD effect also allows for the
generation of high resolution 3D maps of the venous vasculature within neural tissue.

While BOLD signal is the most common method employed for neuroscience studies in
human subjects, the flexible nature of MR imaging provides means to sensitize the signal
to other aspects of the blood supply. Alternative techniques employ arterial spin labeling
(ASL) or weight the MRI signal by cerebral blood flow (CBF) and cerebral blood volume
(CBV). The CBV method requires injection of a class of MRI contrast agents that are
now in human clinical trials. Because this method has been shown to be far more
sensitive than the BOLD technique in preclinical studies, it may potentially expand the
role of fMRI in clinical applications. The CBF method provides more quantitative
information than the BOLD signal, albeit at a significant loss of detection sensitivity.

[edit] Real-time MRI

Main article: Real-time MRI

Real-time MRI refers to the continuous monitoring (“filming”) of moving objects in real
time. While many different strategies have been developed over the past two decades, a
recent development reported a real-time MRI technique based on radial FLASH that
yields a temporal resolution of 20 to 30 milliseconds for images with an in-plane
resolution of 1.5 to 2.0 mm. The new method promises to add important information
about diseases of the joints and the heart. In many cases MRI examinations may become
easier and more comfortable for patients.

[edit] Interventional MRI

Main article: Interventional MRI

The lack of harmful effects on the patient and the operator make MRI well-suited for
"interventional radiology", where the images produced by a MRI scanner are used to
guide minimally invasive procedures. Of course, such procedures must be done without
any ferromagnetic instruments.

A specialized growing subset of interventional MRI is that of intraoperative MRI in

which the MRI is used in the surgical process. Some specialized MRI systems have been
developed that allow imaging concurrent with the surgical procedure. More typical,
however, is that the surgical procedure is temporarily interrupted so that MR images can
be acquired to verify the success of the procedure or guide subsequent surgical work.

[edit] Radiation therapy simulation

Because of MRI's superior imaging of soft tissues, it is now being utilized to specifically
locate tumors within the body in preparation for radiation therapy treatments. For therapy
simulation, a patient is placed in specific, reproducible, body position and scanned. The
MRI system then computes the precise location, shape and orientation of the tumor mass,
correcting for any spatial distortion inherent in the system. The patient is then marked or
tattooed with points that, when combined with the specific body position, permits precise
triangulation for radiation therapy.

[edit] Current density imaging

Current density imaging (CDI) endeavors to use the phase information from images to
reconstruct current densities within a subject. Current density imaging works because
electrical currents generate magnetic fields, which in turn affect the phase of the magnetic
dipoles during an imaging sequence. To date no successful CDI has been performed
using biological currents, but several studies have been published that involve currents
applied through a pair of electrodes.
[edit] Magnetic resonance guided focused ultrasound

In MRgFUS therapy, ultrasound beams are focused on a tissue—guided and controlled

using MR thermal imaging—and due to the significant energy deposition at the focus,
temperature within the tissue rises to more than 65 °C (150 °F), completely destroying it.
This technology can achieve precise ablation of diseased tissue. MR imaging provides a
three-dimensional view of the target tissue, allowing for precise focusing of ultrasound
energy. The MR imaging provides quantitative, real-time, thermal images of the treated
area. This allows the physician to ensure that the temperature generated during each cycle
of ultrasound energy is sufficient to cause thermal ablation within the desired tissue and if
not, to adapt the parameters to ensure effective treatment.

[edit] Multinuclear imaging

Hydrogen is the most frequently imaged nucleus in MRI because it is present in

biological tissues in great abundance. However, any nucleus with a net nuclear spin could
potentially be imaged with MRI. Such nuclei include helium-3, carbon-13, fluorine-19,
oxygen-17, sodium-23, phosphorus-31 and xenon-129. 23Na, 31P and 17O are naturally
abundant in the body, so can be imaged directly. Gaseous isotopes such as 3He or 129Xe
must be hyperpolarized and then inhaled as their nuclear density is too low to yield a
useful signal under normal conditions. 17O, 13C and 19F can be administered in sufficient
quantities in liquid form (e.g. 17O-water, 13C-glucose solutions or perfluorocarbons) that
hyperpolarization is not a necessity.

Multinuclear imaging is primarily a research technique at present. However, potential

applications include functional imaging and imaging of organs poorly seen on 1H MRI
(e.g. lungs and bones) or as alternative contrast agents. Inhaled hyperpolarized 3He can be
used to image the distribution of air spaces within the lungs. Injectable solutions
containing 13C or stabilized bubbles of hyperpolarized 129Xe have been studied as contrast
agents for angiography and perfusion imaging. 31P can potentially provide information on
bone density and structure, as well as functional imaging of the brain.

[edit] Susceptibility weighted imaging (SWI)

Main article: Susceptibility weighted imaging

Susceptibility weighted imaging (SWI), is a new type of contrast in MRI different from
spin density, T1, or T2 imaging. This method exploits the susceptibility differences
between tissues and uses a fully velocity compensated, three dimensional, RF spoiled,
high-resolution, 3D gradient echo scan. This special data acquisition and image
processing produces an enhanced contrast magnitude image very sensitive to venous
blood, hemorrhage and iron storage. It is used to enhance the detection and diagnosis of
tumors, vascular and neurovascular diseases (stroke and hemorrhage, multiple sclerosis,
Alzheimer's), and also detects traumatic brain injuries that may not be diagnosed using
other methods[18]

[edit] Other specialized MRI techniques

MRI is a new and active field of research and new methods and variants are often
published when they are able to get better results in specific fields. Examples of these
recent improvements are T*2-weighted turbo spin-echo (T2 TSE MRI), double inversion
recovery MRI (DIR-MRI) or phase-sensitive inversion recovery MRI (PSIR-MRI), all of
them able to improve imaging of the brain lesions.[19][20] Another example is MP-RAGE
(magnetization-prepared rapid acquisition with gradient echo),[21] which improves images
of multiple sclerosis cortical lesions

MRI versus CT

A computed tomography (CT) scanner uses X-rays, a type of ionizing radiation, to

acquire its images, making it a good tool for examining tissue composed of elements of a
higher atomic number than the tissue surrounding them, such as bone and calcifications
(calcium based) within the body (carbon based flesh), or of structures (vessels, bowel).
MRI, on the other hand, uses non-ionizing radio frequency (RF) signals to acquire its
images and is best suited for non-calcified tissue, though MR images can also be acquired
from bones and teeth[26] as well as fossils.[27]

CT may be enhanced by use of contrast agents containing elements of a higher atomic

number than the surrounding flesh such as iodine or barium. Contrast agents for MRI
have paramagnetic properties, e.g., gadolinium and manganese.

Both CT and MRI scanners are able to generate multiple two-dimensional cross-sections
(slices) of tissue and three-dimensional reconstructions. Unlike CT, which uses only X-
ray attenuation to generate image contrast, MRI has a long list of properties that may be
used to generate image contrast. By variation of scanning parameters, tissue contrast can
be altered and enhanced in various ways to detect different features. (See Applications
above.)

MRI can generate cross-sectional images in any plane (including oblique planes). In the
past, CT was limited to acquiring images in the axial (or near axial) plane. The scans used
to be called Computed Axial Tomography scans (CAT scans). However, the development
of multi-detector CT scanners with near-isotropic resolution, allows the CT scanner to
produce data that can be retrospectively reconstructed in any plane with minimal loss of
image quality.

For purposes of tumor detection and identification in the brain, MRI is generally superior.
[28][29][30]
However, in the case of solid tumors of the abdomen and chest, CT is often
preferred due to less motion artifact. Furthermore, CT usually is more widely available,
faster, less expensive, and may be less likely to require the person to be sedated or
anesthetized.

MRI is also best suited for cases when a patient is to undergo the exam several times
successively in the short term, because, unlike CT, it does not expose the patient to the
hazards of ionizing radiation