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Diagnostic Imaging StudiesRadiology for the Primary Care Provider
Anis Frayha M.D.NPAM Spring Conference
April 18, 2013
Objectives
• Understand the types of diagnostic imaging studies that are available and the information they can provide.
• Determine the clinical indications for obtaining studies and the relative risk/benefit of radiologic procedures
• Explain the diagnostic limitations of imaging studies and how these parameters affect patient care.
Overview
• Modality overview
• X‐ray, Ultrasound, CT, and MRI
• Fluoroscopy, Mammography, Nuclear Medicine
• Contrast Overview
• Imaging by body part
• Neuro
• Chest
• Abdomen/Pelvis
X‐ray
• Pros
• Low cost
• Access
• Cons
• Radiation
• Low sensitivity
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Ultrasound
• Pros
• Low cost
• No radiation
• Soft tissue
• Cons
• User dependent
• Limitations: • Body habitus
• Bone and air
CT
• Pros
• Cost
• Availability
• Resolution
• Cons
• Cost
• Radiation
MRI
• Pros
• No Radiation
• Soft Tissue
• Cons
• High Cost
• Limitations
• Availability
• Time
• Motion
• Bone and air
•
Contrast Enhanced Imaging
• Ultrasound
• X‐ray/CT
• MRI
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When do I use contrast?
• Inflammatory Process
• Neoplastic Process• Endovascular Imaging
Ultrasound
• Contrast‐enhanced ultrasound (CEUS)
• Microbubbles
Radiology: Volume 257: Number 1—October 2010
X‐ray and CT Contrast
• Intravenous vs oral contrast
• Intravenous contrast• Iodinated contrast media – CT, IVP
• Oral Contrast• Barium vs iodinated water soluble contrast
Iodinated ContrastContrast Induced Nephrotoxicity
• Etiology
• Renal hemodynamic changes (vasoconstriction) vs direct tubular toxicity.
• Diagnosis• Serum creatinine > .3mg/dL
• Percent increase in creatinine > 50%
• Urine output reduced to <.5mL/kg/hr for 6 hrs
• Avoid contrast if creatinine > 1.5 to 2.0
• Hydration most effective prevention
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CT Contrast
CT Contrast
CT Contrast
MRI Contrast
• Gadolinium based agents
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MRI Contrast Nephrogenic Systemic Fibrosis
• Fibrosing disease involving the skin, subcutaneous tissues, and organs.
• Gadolinium based agents and chronic kidney disease.
• Dissociation of gadolinium from chelate.
• Avoid contrast if GFR < 30.
MRI Contrast
MRI Contrast
Neuro Imaging Available Studies
• Brain
• CT Brain
• CT Brain w/wo
• CTA Head/Neck
• MRI Brain
• MRI Brain w/wo• Routine, IAC, Pituitary, Seizure
• MRA Head/Neck
• Spine
• CT Spine
• CT Spine w/wo
• CT Myelogram
• MRI Spine
• MRI Spine w/wo
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History: 78 year old female s/p fall with head trauma.
History: 56 yo M with 6 days of constant headache.
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History: 75 yo female presenting with aphasia and right sided weakness. History: 63 yo man with HTN, DM, PVD,
ESRD s/p kidney transplant presenting with dizziness and right facial droop.
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History: 70 yo Female brought in by family, nonverbal with r sided paralysis.
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Day 1
Day 2
Day 2
Day 8
History: 76 yo female with unsteady gait, remote hx of lung cancer.
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History: 44 yo male with history of IVDA presenting with low back pain.
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History: 37 yo female with back pain.Chest Imaging Available Studies
• CT Chest• CT Chest w • CTA Chest
• PE
• Dissection
• MRI Chest
• MRI w/wo
• MRA w or wo
History: 57 yo female with ESRD on peritoneal dialysis presenting with
back pain.
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Noncontrast Contrast
History: 63 yo with chest pain and abdominal pain.
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54 year old admitted for colloid cyst resection.
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Abd Imaging Available Studies
• CT Abd/Pel wo
• CT Abd/Pel w
• CT Abd/Pel w/wo
• CTA
• MRI wo
• MRI w/wo
• MRA
History: RLQ pain and nausea
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History: 22 yr old F, 15 wk pregnant with RLQ abdominal pain.
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History: 54 yo female with LLQ pain. History: Another patient with LLQ pain.
Normal Diverticulosis Diverticulitis w/Perforation
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History: 55 yo male with HIV presenting with left flank pain.
History: Acute onset LLQ pain.
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History: Epigastric pain, nausea.
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History: 55 yo female presenting with RUQ and RLQ abdominal pain.
History: 77 yo male with an ileus with an increasing white count.
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History: 34 yo presenting with fever 103 and LLQ pain. R/O abscess or TOA.
Is anyone still awake?
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ACR Appropriateness Criteria
ACR.org
References
• ACR Appropriateness Criteria. http://www.acr.org/Quality‐Safety/Appropriateness‐Criteria
• Contrast Induced Nephrotoxicity. http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/Contrast%20Manual/Contrast%20Nephrotoxicity.pdf
• Nephrogenic Sytemic Fibrosis (NSF). http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/Contrast%20Manual/Nephrogenic%20Systemic%20Fibrosis.pdf
• Microbubble‐enhanced US Body Imaging. Radiology: Volume 257: Number 1—October 2010
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