Radiology Team

Lecture 1
Introduction to Radiology

Done and edited by:

● Nouf Alharbi
● Ahmed Alsaleh

★ Before starting, please check our Radiology editing file

 Objectives
•

•
 Imaging
modalities

Non-ionizi
Ionizing
ng
radiation
radiation

X-rays Ultrasound MRI

Radiographs/ Fluoroscopy/ Nuclear
CT Angiography
mammograms
medicine

The line between ionized and non ionized is the visible light so the frequency of the
waves determined which ionization and non-ionized radiation so any thing higher
than the visible light considered as ionizing radiation and any thing less will be
non-ionized.

Radiographic Terminology:
Radiology: Medical specialty in which x-rays, radium, and radioactive
substances are applied in the diagnosis and treatment of the patient.
Diagnostic Imaging: Medical specialty in which x-rays, radium,
radioactive substances, sound waves, and radio frequencies are applied
in the diagnosis and treatment of the patient
Radiologist: Physician who applies any form of radiation in the diagnosis
and treatment of disease.
Radiographer: Skilled person qualified by education to provide patient
services using imaging modalities as directed by a physician qualified to
order and/or perform radiographic procedures (X-ray Technologist).
Radiograph: a photographic record produced by x-rays through an
object
 How we make radiographs ?
In old conventional cameras Light rays bounce
off my hand and into my camera. We call the
image:
• “Light-Ray”
• “Photograph” : Is the image of the light
photons that bounce off my hand and
into my image capture device.

And now take a deep breath… ☺

Imagine that you are in a dark room and you are holding a light source and
this source is directed toward your hand, what you will see in the wall?
Correct! it is your hand’s shadow and they call it “shadow graph”

1)“shadow-graph” 2)“Negative-graph”

Everywhere hand blocks the light is Everywhere hand blocks light the film
dark… is not exposed and stays white...
Everywhere hand doesn’t block the
light is illuminated. Everywhere hand doesn’t block the
Now, if we hang photographic film on light the film gets exposed and turns
wall we get… “Negative-graph” dark.

X-ray
Tube

X-rays”:
←Rays that pass
thru the patient
The image→
X-ray Detector
is called a ”Radiograph”
 20th Century: Images = Film
In 20th century they first scan the patient and then → they
process the film in the dark → allow the film to dry → then
they call radiologist or other specialist to see the radiograph
→ and then send the film to the doctor → and the patient
might take the film and it might get lost or damaged. And this
process caused a “headache” to the radiology department
because they must keep it in a special dry room and it take
huge room in the hospitals

21st Century: Digital Imaging

And now we have computer servers and these servers can
save huge number of images and it just needs small room in
the hospitals so we save very big space a lot of effort and
people and the images will not be missed of damaged. The
images will be in the computer and the radiologist can see the
images online and even the doctor can see it too and if the
patient want a copy we can give it to him in a CD and we still
have a copy of that image. And now we have a backup server
if any incident happen like fire and earthquake there will be a
backup copy of these images so we will not loose the
information

In x-ray : black coloration (Radio-lucent) is called (Lucency),

white coloration (Radio-opaque) is called (opacity)
How do x-rays create an image of internal body
?structures
Lower atomic number
Higher atomic
X-rays pass through structures allow
number structures
the body to varying x-rays to pass
block x-rays better,
degrees through, example: air
example bone
in the lungs

:Radiographs are Limited can detect only four densities of tissue

All soft tissues look the same on

radiographs:
• Muscles/Tendons Metal (white)
• Vessels/Nerves
Bones (light gray)
• Organs/Blood
Soft Tissues (dark
gray)

Air (black)

X-rays as Diagnostic Tool:

NOTE:
Can see: Can’t see: From the most black to
-Bones -Inside skull the most white:
・Fractures ・Can’t see the brain 1-Air
-Joint width, surfaces -Inside joints 2- Fat
・Arthritis ・Can’t see tears
3- Soft tissue
・Osteophytes ・Ligaments, Tendons
・Menisci, Cartilage
4- Bone
・Erosions

Radiographs: 2D projection of 3D patient

Radiographs flatten everything
Can’t tell what’s in front, what’s behind
With radiographs: NEED MULTIPLE VIEWS!
“One view = No views” one is not enough and
it’s useless.

In this image if you look at it think that somebody who is stab himself with knife but when you take another
view which we call it lateral in x-ray you can see that the he is holding the knife in front but because in
x-ray you can’t differentiate between front you and back so that’s why one image never enough
Continue Need Multiple Views…
Sometimes you can’t see fracture in one
view, you have to have multiple views
with multiple directions to see the
fracture it wasn’t showing in this PA
PA Obl Lat
direction so when we ask patient to
change position we could see fracture • Small finger
clearly . Not a subtle fracture
Fragment overlap each other so
perfectly on PA view, are
undetectable.

• Sometimes P
dislocation can’t be P I
PI P
seen in one P I
direction P

Lat

P Obl
A
This pic Showing how different tissues or different substances and how it shows in
different modalities (x-ray,CT,MR,US..) this is for your knowledge ☺
X-ray not very helpful in soft tissues so in this images you see lots of things
look the same and the worse is sometimes can be covered behind ribs so
you can’t see behind the bones that’s why sometimes we use contrast
which material has very high density so the patient swallow this contrast
and then we can see inside the bowel and we can see the stomach

In PA position beam comes from posterior and the film will be in the
anterior, It depends where is the bone for example you want to see a
specific tissue try to make it in front the bone to get the images better.
 Tomography

To overcome flat 2D nature of T

radiographs… u
b
• Structures in the Focal Plane → are e
in focus.(where focus the structure
of interest)
• Structures out of focal plane are
blurred out. Focal Plane→
• At best, we got blurry pictures.(we
will get most of the pic blurry except
the structure in the focal plane)
Fil
• Long exposures = high radiation. m
• Can’t use this to see the brain ☹

Computed Tomography

This handsome mathematician proved

that we can get an image of 3D object by
taking an infinite number of 2D projection
images of the object and reconstruct
(rebuild) them.
Johann Radon BUT at that time there was no main-frame
computers ☹

❖ 2 years after computer invention, Godfrey Hounsfield

a British electrical engineer developed EMI brain
scanner. And by using this scanner we can see
through the skull into the brain. “Hounsfield Units” is
the scale we use to measure CT density
 How CT works ?
By rotating X-ray tube with the X-ray
detector and the patient will go through
these rays then we will have something like
“slices” so each one is an image and we
reconstruct these images to have other
images from different views, Which are 3D
images.

How it looks like ?

Inside CT Scanner Outside CT Scanner

X-ray
Tube

X-ray
Tube

Computed AXIAL Tomography

Axial Plane: The axial plane passes through the body from
anterior to posterior and divides it into superior and inferior
sections.
• Base of skull
Arch of C1
Body of C2
Computed VOLUME Tomography

Thin, continuous slices = Solid volume of data

Can reformat data:
Any 2-D plane (Coronal, Sagittal, Oblique)* Even
in 3-D!

Multi-Planar Reformat
Fx easy to
Dens Fx see on CT Fx hard to
(Odontoid) see on
radiographs

•Coronal Plane •Sagittal Plane

–Front to Back –Left to Right
–Like AP view –Like a Lateral view

Multi-Planar Reconstruction
can be used to reconstruct images in orthogonal planes (coronal, sagittal, axial or
oblique, depending on what the base image plane is). This can help to create a
visualization of the anatomy which was not possible using base images alone.
NOTE:
In CT we use the word
( Dense ):
1- Hyper –dense.
2- Iso-dense (iso =in between).
3- Hypo-dense.
Why CT is so great ?
• Can see fractures otherwise missed
Cervical spine, pelvis
• Can see the brain!
Strokes, bleeds, tumors “Hemorrhage always hyper dense"
• Can see organs (lungs, liver, bowel)
Tumors, trauma, acute/chronic diseases
• And now with ultra-fast, multi-slice…
• Can scan the heart in a single beat!
• Can see coronary arteries, pulmonary emboli
• Some hospitals have CT scanners in the ER

*coronal= view from front , Sagittal= view from side, axial= view through patient
Because of the possible side 1% patients are allergic to
effects, e.g. allergic reactions Usually requires IV contrast CT contrast
and extravasation: leakage Can affect renal function
of contrast into surrounding
tissues

Knee: •Menisci, •Ligaments,

Problems with •Cartilage

CT Can’t see structures inside

Shoulder: •Rotator Cuff,
•Labrum
joints
Spine: •Disks, •Spinal Cord
(We can’t see spinal cord
unless if there is calcification)

Costs more than

radiographs

High Radiation Dose

Normally we are exposed to low level of radiation every day, which is
called ”background radiation”
• Ave background dose ≈ 2.4mSv/year.
• When we use chest radiograph we will expose the patient ≈
0.06mSv ≈ 1 week of background radiation.
• When we use chest CT we will expose the patient ≈ 7.0mSv ≈3
YEARS of background radiation. in one exposure of CT as you are
having 3 background radiation “ ‫”اﻻﺷﻌﺎع اﻟﻲ ﺑﺎﻟﺟو‬.
*What is radionuclides ? An unstable form of a chemical element that
radioactively decays, resulting in the emission of nuclear radiation
• In earth: naturally occurring radionuclides is Uranium-238,
potassium-40
• In atmosphere: Radon-222 (from U-238)
• 2nd leading cause of lung cancer after smoking
• In space: cosmic rays
• Airline crews are more exposed to cosmic rays,
doubling their background exposure

• •
• •
• •
•
•
 Radionuclide imaging
(Nuclear Medicine)
Why nuclear medicine ?!
Because it is not only a radiological diagnostic method, we can use it for
treatment !
• Developed after World War II
• Research on nuclear bomb byproducts
Fission Uranium-235 → Iodine-131
They found that there is weaker isotopes (agents) then the ones used in
nuclear bomb that can help us in medicine
What are the agents that can be used in radionuclide imaging ?

1- Iodine 2-Technetium

•Naturally occurring element

•Rare on Earth (47th abundant) • Radiopharmaceuticals
•Rare in Humans (<0.05%) • Not naturally occurring
•Taken up by Thyroid Gland • 1936: First element to be
•Made into Thyroid Hormone artificially produced
•Used in X-ray contrast dye
•Naturally occurring Iodine not radioactive Technetium-99m
BUT Iodine-131 is HIGHLY radioactive • Ideal Imaging Agent Short
•Emits β-particles which is Much more half-life (6 hours)
damaging than γ-rays • After 24 hours 94% gone
• Accumulate in and destroys • Emits γ-rays
Thyroid tissue • γ-rays pass out of the
• Nuclear Reactor Fallout → patient without
Hypothyroid accumulating
• Take Iodine pills to block I-131 •
from Thyroid Good energy for gamma-camera
• Useful for treating Thyroid detection
Cancer • Dual-head cameras:
• Image γ-rays emitted
Now they developed more agents to front & back
accumulate in specific tissues, emit
low-energy γ-rays.

❖ Nuclear medicine: (Bone scan)

❖ Was used a lot before CT & MR
✓ Shows bone pathology earlier than radiographs
❖ Nowadays, seldom used for focal lesions
❖ We still use Nuc Med Bone Scans for:
✓ Looking for bone metastases in entire body
➢ Breast Cancer
➢ Prostate Cancer
❖ Nuclear Medicine: PET/CT
❖ Most recent innovation in Nuc Med
❖ PET: Positron Emission Tomography
❖ Uses agents with very short half-lives
✓ Flourine-18 (100 min)
✓ Oxygen-15 (2 minutes)
✓ Made onsite with cyclotron
• These agents are taken up by tumors, metastases → Well
shows abnormal FUNCTION
• Combined with CT (Computed Tomography) → Well shows
underlying ANATOMY
• Used for staging cancer patients
CT PET PET/CT CT PET PET/CT

Why does it accumulate in one structure more then another

one?
We all know that tumor and some organs (thyroid) has more blood
supply then other organs so it will uptake the agent more then others
→ its appearance
Ultrasound:
History of Ultrasound:
• Developed after World War II
• Based upon SONAR
• “SOund Navigation And Ranging”
• Sound wave sent out
• If sound hits an object
• get reflected back
• Measure time for the reflected echo to return
• Multiplying the time by
speed of sound = distance from the object
• Works best in water because it transmits sound well

Sonography “Ultrasound”:
• Uses radio waves (Not X-rays, -rays) ・Ionizing Radiation
• Non-ionizing Radiation

1.X-rays
(man-made)

Radio Waves Infra-Red Light Ultra-Violet 2. -rays

(atomic decay)

Ultrasound
(3-17MHz) Radiographs
CT Nuclear
Fluoroscopy
medicine

Diagnostic Ultrasound
• Ultrasound is sound waves with frequencies which are higher than
those audible to humans (>20,000 Hz).
• Ultrasonic images also known as sonograms are made by sending
pulses of ultrasound into tissue using a probe.
• The sound echoes off the tissue; with different tissues reflecting varying
degrees of sound.
• These echoes are recorded and displayed as an image to the operator

‫*اﻟﻣوﺟﺎت اﻟﻔوق ﺻوﺗﯾﺔ ﺗﻌﺗﻣد ﻋﻠﻰ ﻣﻣﻧﺎﻋﺔ اﻟﻣوﺟﺔ وﻟﯾس اﻟﻛﺛﺎﻓﺔ ﻣﺛل اﻟﺳواﺋل ﻣﺎﻓﯾﮫ ﻣﻣﻧﺎﻋﺔ ﻓراح ﯾﺧﺗرﻗﮭﺎ و ﯾﺑﺎن أﺳود‬
 White areas: Black areas:
・Represent “echogenic” structures, which transmit & ・Represent areas that are “anechoic”
reflect sound waves ・Fluid: transmit but does not reflect sound waves
・Soft tissues, fat, vessels, nodes, masses.

Image interpretation:

Grey: Lines:
Helps widen the representative scale of black/white Occur at boundary of two markedly different tissue
“brightness” reflectors “boundary of organs”

Tissue characteristics of Ultrasound:

Fluid: near total

Air : near total reflector Bone: near total
propagator (no
(scatter reflector) reflection
reflection)

Soft tissue: partial reflection, partial propagator

・reflects every time tissue impedance changes –
every interface
・ideal for ultrasound images

:Sonography Useful for

• Tissues that contain/surrounded by water
• Abdominal organs
• Gall bladder (Gall Stones)
• Kidneys (Kidney Stones)
• Blood vessels
• Blood clots (DVT: Deep Venous Thrombosis)
• Imaging without Ionizing Radiation
• Pelvic organs
• Uterus, Ovaries
• Testes
• Babies (Newborn)
• Babies… before birth
• Obstetric Ultrasound

1: in radiology, a measure of how much detail a device can print or display.

 ・Does not work well in
・No radiation large or obese patients
・Portable
・Resolution1 less than CT
・Instantaneous (real time) and MRI.
・Excellent for cysts and fluid
・Air or bowel gas prevents
・Doppler ultrasound is visualization of structures.
excellent to assess blood flow
・Excellent for newborn brain,
thyroid, gall bladder, female
pelvis, scrotum, pregnancy. Organ limitation
(it can’t penetrate air nor
bone so we can’t use it for
brain or lung)

X-ray can be static or can be also dynamic

Fluoroscopy: we can take many x-rays “images” during
• Utilizes X-Rays patient movement for example to see
• Real-time imaging dynamic movement or to see bowel for
• Utilizes image intensifier * example patient can swallow some type of
• Involves use of contrast agents contrast and then we create images by
many x-ray we call this fluoroscopy.

Main Uses of Fluoroscopy:

• Gastrointestinal Imaging
• Genitourinary Imaging
• Angiography very important use
• Other
• Intraoperative
• Foreign body removal
• Musculoskeletal

Single Contrast vs Double Contrast:

* It shows x-ray not very sharp or very high, so we need very low amount of radiation because
contrast it self has high density.
 Magnetic Resonance Imaging (MRI):
• MRI doesn’t rely on X-rays to see projected shadows
of patients, unlike radiographs, CT & fluoroscopy.
• MRI sees tissues based upon sub-atomic
characteristics (magnetism).
- Proton nucleus of Hydrogen has small magnetic field
that can be used to detect tissues containing
hydrogen.

How MR Scanner Works:

2)Measures strength of
・Coil (antenna)
resonant RF echo
・Magnet 1) Sends RF pulse to flip
・At a specific time, TE,
- Aligns spins of protons in spinning protons
“Echo Time”
hydrogen nuclei ・After RF pulse is off,
Steps 1&2 repeated many
- Align in direction of protons realign to B0
times / image slice
magnetic field, B0 ・As protons realign,
・At a specific “Repetition
resonate RF energy.
Time”, TR

Tesla(T): Measure Magnetic Field Strength Simply, hydrogen

• Earth's magnetic field: atoms(protons) in water
• 30 µT (3×10−5 T) molecules and lipids:
1. magnetism affects all
• Typical refrigerator magnet: protons causes them to line
• 3 mT (3×10−3 T) up in one direction
2. magnets can be switched
• High Field MRI scanner: on and off to change the
• 1.5 – 3 T direction of the magnetic
• 1,000 times the strength refrigerator magnet field
• 100,000 times the Earth’s magnetic field 3. whenever the water
molecule spin around they
give a light radio wave
4. MRI machine can detect it
5. show it as images.

*numbers not for memorization!

*B0 = main magnetic field
 MRI: Need Multiple Sequences

PD “proton density”shows
T1 shows Fat best T2 shows Fluid best
Dense Stuff best

Most normal anatomy Most pathology Good for meniscus

surrounded by fat contains fluid (edema) and tendon tears

In essence, T2 shows
In essence, T1 shows pathology best Used mostly for MRI of
anatomy best Fat-suppression makes joint pain
fluid more conspicuous

MR Applications:
Part of the body Applications Images
Neuro-imaging • Excellent tool due to high soft
tissue contrast resolution
• Abundant water content of CNS
allows for imaging soft intracranial
MRI
tissue
Axial, T2-Weighted
Head and Neck imaging • Multi-planar capability allows for
monitoring extent of disease
• Differentiating subtle soft tissue
boundaries of head and neck

Body Imaging: Thorax mediastinal, hilar, chest wall

abnormalities

Limited lung imaging due to artifacts

New advances in breast imaging

Potentials for cardiac MRI with

coronary MR angiography
MRI Breast Imaging
MSK Imaging High sensitivity for neoplastic,
inflammatory, and traumatic
conditions of bone and soft tissue
• T1-weighted---fluid collections
and abnormalities in fatty marrow
• T2-weighted---lesions in both
marrow and soft tissue
 Advantages & disadvantages of MRI:

Advantages Disadvantages

1.Very expensive
1.No overlapping artifact 2.Patients cannot have a
2.Excellent resolution pacemaker or ferromagnetic
material
3.Very good at detecting
3.Slower to acquire images
fluid
(approximately 45 minutes)

•Note: now mostly metals are

4.Excellent for imaging the MRI compatible (we can do
brain, spine and joints
MRI in that case) Can we do
5.No radiation
MRI For a pregnant patient?
6.Multiple imaging tests Yes, but only after the first
within the same study (T1,
T2, IR, GE) trimester

Note:
- MRI contrast may cause nephrogenic systemic fibrosis when we give it to
chronic renal failure patient
- Metallic Pacemaker is contraindicated in MRI, Titanium is fine
- Claustrophobia is a relative contraindication in MRI
- MRI contrast: You have to take precaution if there is renal impairment
- CT contrast: You have to take precaution if there is renal impairment or
allergy

X-ray US CT MRI

Black Radiolucent Hypo-echoic Hypo-dense Hypo-intense

coloration

White Radiopaque Hyper-echoic Hyper-dense Hyper-intense

coloration
 MCQs
• 1 Dark grey in x-ray images represents?

A. Bones
B. Metal
C. Air
D. Soft tissue

• 2 What is the organ that couldn’t be seen in the tomography but

can be seen in Computed tomography (CT)?

A. Heart
B. Brain
C. Lungs

• 3 The boundaries of the organs in ultrasound

represented as:

A. Lines
B. white
C. Black
D. Grey

• 4 Proton density (PD) in MRI shows ….. best?

A. Fat
B. Fluid
C. Dense stuff

1.D 2.B 3.A 4.C