heti sponsored radiology essentials teaching dr noel young department of radiology westmead hospital

HETI SPONSORED HETI SPONSORED RADIOLOGY RADIOLOGY

ESSENTIALS TEACHINGESSENTIALS TEACHING

Dr Noel YoungDr Noel Young

Department of RadiologyDepartment of Radiology

Westmead HospitalWestmead Hospital

BASIS OF THIS TALKBASIS OF THIS TALK

Recommendations to HETI by Recommendations to HETI by Intern / RMO advisory group.Intern / RMO advisory group.

OTHER CONSIDERATIONSOTHER CONSIDERATIONS

Should follow your University Imaging Should follow your University Imaging teaching.teaching.

Key points of:Key points of:a.a. recognising key pathologies,recognising key pathologies,

b.b. understanding clinical contexts for understanding clinical contexts for radiology requestingradiology requesting

c.c. understanding context of reports per understanding context of reports per individual patient requirements / status,individual patient requirements / status,

d.d. keeping your boss happy.keeping your boss happy.

With PACS in all NSW public With PACS in all NSW public hospitals, seeing all patients’ images hospitals, seeing all patients’ images is easy.is easy.

But interpretation is still the big issue.But interpretation is still the big issue.

DIFFERENTIAL FORCES IN DIFFERENTIAL FORCES IN RADIOLOGYRADIOLOGY

Cost to GovernmentCost to Government Cost to patientCost to patient Radiation cost to patient Radiation cost to patient

VSVS Keeping patients happyKeeping patients happy Keeping lawyers at bayKeeping lawyers at bay Differential clinical needsDifferential clinical needs

TALK DIVIDED INTO THREE TALK DIVIDED INTO THREE PARTSPARTS

Part I – CT BrainPart I – CT Brain

Part II – CT Abdomen and PelvisPart II – CT Abdomen and Pelvis

Part III – Abdominal Ultrasound (A)Part III – Abdominal Ultrasound (A)

– – + Doppler Ultrasound (B)+ Doppler Ultrasound (B)

PART I: PART I: CT BRAINCT BRAIN

Key Learning ObjectivesKey Learning Objectives When / what to request -When / what to request -

contrast issuescontrast issues sedation issuessedation issues

How to look at a CT Brain.How to look at a CT Brain. Common pathologies.Common pathologies.

Question: When to request?Question: When to request? AnswerAnswer: When your boss wants it.: When your boss wants it.

(Side issue – 4 hour Emergency objectives)(Side issue – 4 hour Emergency objectives)

Real test – how to get Radiology to do it.Real test – how to get Radiology to do it. AnswerAnswer: Communicate: Communicate (best done by going to the Department)(best done by going to the Department)

Question: When to sedate?Question: When to sedate? AnswerAnswer::

1.1. Whenever you want nice pictures and patient Whenever you want nice pictures and patient non-cooperative.non-cooperative.

2.2. When patient is crashing.When patient is crashing.

(n.b. - be nice to your anaesthetist! – you (n.b. - be nice to your anaesthetist! – you have little that anaesthetists need!)have little that anaesthetists need!)

Question: How to interpret?Question: How to interpret? AnswersAnswers::

1.1. Remember normal anatomyRemember normal anatomy2.2. Look systematically – ask key questions -Look systematically – ask key questions -

is there raised ICPis there raised ICP is there bloodis there blood is there an infarctis there an infarct is there normal white / grey differentiationis there normal white / grey differentiation

3.3. Go ask someone more experienced (n.b. - Go ask someone more experienced (n.b. - Your university should have taught this stuff Your university should have taught this stuff – you have already paid for it!).– you have already paid for it!).

COMMON PATHOLOGIES TO COMMON PATHOLOGIES TO RECOGNISERECOGNISE

Raised ICPRaised ICP Recent territorial infarctRecent territorial infarct Blood - EDH (be careful!)Blood - EDH (be careful!)

- SDH - SDH

- SAH- SAH

- focal haematomas- focal haematomas

Right old middle cerebral artery infarct. 1. No mass effect. 2. Margins of the infarct are Right old middle cerebral artery infarct. 1. No mass effect. 2. Margins of the infarct are well defined.well defined.

CT – recent left PICA infarct involving the cerebellum. 1. Ill defined low density CT – recent left PICA infarct involving the cerebellum. 1. Ill defined low density change. 2. Mass effect with compression of the 5change. 2. Mass effect with compression of the 5 thth ventricle. ventricle.

CT – Acute right posterior cerebral artery infarct, involving the occipital lobe. 1. The CT – Acute right posterior cerebral artery infarct, involving the occipital lobe. 1. The area of low density is ill-defined. 2. Local mass effect is present.area of low density is ill-defined. 2. Local mass effect is present.

CT – Acute infarct of right cortical hemisphere. 1. Loss of grey-white differentiation. 2. CT – Acute infarct of right cortical hemisphere. 1. Loss of grey-white differentiation. 2. Compression of right lateral ventricle.Compression of right lateral ventricle.

Small extra-dural – right temporal region. Note the lentiform shapeSmall extra-dural – right temporal region. Note the lentiform shape

Small left acute extra-dural haemorrhage. Local mass effect with cortical sulcal Small left acute extra-dural haemorrhage. Local mass effect with cortical sulcal effacement is present.effacement is present.

CT – Large right extra-dural haematoma. Significant mass effect.CT – Large right extra-dural haematoma. Significant mass effect.

CT – Acute left subdural haematoma. Massive mass effect. Significant shift of midline CT – Acute left subdural haematoma. Massive mass effect. Significant shift of midline structures to the right. Note crescent shape of haematoma.structures to the right. Note crescent shape of haematoma.

Diffuse intraventricular blood and subarachnoid haemorrhage. There is effacement of Diffuse intraventricular blood and subarachnoid haemorrhage. There is effacement of sulcal spaces globally indicating raised intracranial pressure. sulcal spaces globally indicating raised intracranial pressure.

Diffuse intraventricular blood and subarachnoid haemorrhage. There is ventricular Diffuse intraventricular blood and subarachnoid haemorrhage. There is ventricular dilatation.dilatation.

Subarachnoid haemorrhage involving the basal cisterns.Subarachnoid haemorrhage involving the basal cisterns.

Left sylvian fissure and traumatic subarachnoid haemorrhage. A subtle finding. Due to Left sylvian fissure and traumatic subarachnoid haemorrhage. A subtle finding. Due to a small, ruptured, left MCA aneurysm. a small, ruptured, left MCA aneurysm.

1. Right subdural chronic haematoma. It is low density. 2. Small amount of more 1. Right subdural chronic haematoma. It is low density. 2. Small amount of more recent blood (higher density) anteriorly. recent blood (higher density) anteriorly.

IV CONTRAST ISSUESIV CONTRAST ISSUES

Iodinated, isotonic contrast used.Iodinated, isotonic contrast used. Beware bad renal function (when pre-Beware bad renal function (when pre-

med with NAC, don’t forget the med with NAC, don’t forget the saline).saline).

Beware history iodine allergyBeware history iodine allergya.a. YES – allergy exists (anaphylaxis!)YES – allergy exists (anaphylaxis!)

b.b. Every hospital has a pre-med protocolEvery hospital has a pre-med protocol

CT BRAIN (SURVIVAL KIT)CT BRAIN (SURVIVAL KIT)

Is there white stuff around (blood)?Is there white stuff around (blood)? Is there dark stuff around (infarct)?Is there dark stuff around (infarct)? Is there raised intracranial pressure (can’t Is there raised intracranial pressure (can’t

see sulci or cisterns)?see sulci or cisterns)?

PART II: PART II: CT ABDOMEN / PELVISCT ABDOMEN / PELVIS

Key Learning ObjectivesKey Learning Objectives When / what to request -When / what to request -

contrast (IV and oral) issuescontrast (IV and oral) issues How to look at a CT abdomen.How to look at a CT abdomen. Common pathologies.Common pathologies.

Question: When to request?Question: When to request? AnswerAnswer: When your boss tells you.: When your boss tells you. Question: What to request?Question: What to request? AnswerAnswer: Go ask your friendly : Go ask your friendly

neighbourhood radiologist neighbourhood radiologist

(n.b. - please supply relevant clinical (n.b. - please supply relevant clinical information).information).

HOW TO INTERPRETHOW TO INTERPRET

Actually, CTs of the abdomen are Actually, CTs of the abdomen are a lot more complex than CTs of a lot more complex than CTs of the brain.the brain.

Need best images to have a Need best images to have a fighting chance.fighting chance.

HOW TO INTERPRETHOW TO INTERPRET

Remember what they taught you Remember what they taught you at University.at University.

Be systematic, follow the Be systematic, follow the

anatomy.anatomy.

HOW TO INTERPRETHOW TO INTERPRET

General principlesGeneral principles Does the liver look OK -Does the liver look OK -

is there a tumouris there a tumour are the bile ducts dilatedare the bile ducts dilated is there a collectionis there a collection

Does the pancreas look OK -Does the pancreas look OK - is there a massis there a mass is it swollenis it swollen is there fluid around itis there fluid around it

HOW TO INTERPRETHOW TO INTERPRET

General principles continuedGeneral principles continued Is there free peritoneal gasIs there free peritoneal gas Is there free peritoneal fluidIs there free peritoneal fluid Is there a peritoneal collectionIs there a peritoneal collection Are there renal collecting systems Are there renal collecting systems

dilateddilated Is the aorta too bigIs the aorta too big Is there blood around the placeIs there blood around the place

COMMON PATHOLOGIESCOMMON PATHOLOGIES

a.a. PerforationPerforation free intraperitoneal gasfree intraperitoneal gas can see on CT little as 5 mlcan see on CT little as 5 ml look in anterior abdomenlook in anterior abdomen look in region falciform ligament of liverlook in region falciform ligament of liver

(n.b. - post abdomen surgery, free (n.b. - post abdomen surgery, free gas can persist up to three weeks)gas can persist up to three weeks)

COMMON PATHOLOGIESCOMMON PATHOLOGIES

b.b. Obstruction Obstruction• when large bowel >5 cm diameterwhen large bowel >5 cm diameter• when small bowel >3 cm diameterwhen small bowel >3 cm diameter• actually better seen on plain AXRactually better seen on plain AXR• CT better to defineCT better to define

• massesmasses• bowel wall thickeningbowel wall thickening

COMMON PATHOLOGIESCOMMON PATHOLOGIES

b.b. Obstruction continued Obstruction continued• if caecum >9 cm diameter – risk of if caecum >9 cm diameter – risk of

perforationperforation• beware toxic megacolon (gas and beware toxic megacolon (gas and

wall thickening in transverse colon)wall thickening in transverse colon)• look for other lesionslook for other lesions

COMMON PATHOLOGIESCOMMON PATHOLOGIES

c. c. CollectionCollection• fluid densitiesfluid densities• round, walledround, walled• main scenariosmain scenarios

• around pancreas in pancreatitisaround pancreas in pancreatitis• in subphrenic spacesin subphrenic spaces• in pelvis after bowel surgeryin pelvis after bowel surgery

CT – very dilated intrahepatic bile ducts.CT – very dilated intrahepatic bile ducts.

CT - Metastases – gross ascites with tumour in peritoneum.CT - Metastases – gross ascites with tumour in peritoneum.

CT – 1. Ascites – due to peritoneal metastases. 2. Metastasis to right lobe liver.CT – 1. Ascites – due to peritoneal metastases. 2. Metastasis to right lobe liver.

CT - acute cholecystitis. 1. Thickened gallbladder wall. 2. Fluid around gallbladder.CT - acute cholecystitis. 1. Thickened gallbladder wall. 2. Fluid around gallbladder.

Subphrenic collection and percutaneous drain.Subphrenic collection and percutaneous drain.

Subphrenic collection and percutaneous drain. Subphrenic collection and percutaneous drain.

Severe, acute pancreatitis. 1. Diffuse pancreatic necrosis. 2. Calcified gallstones.Severe, acute pancreatitis. 1. Diffuse pancreatic necrosis. 2. Calcified gallstones.

Acute pancreatitis & gallstones. Severe pancreatic necrosis.Acute pancreatitis & gallstones. Severe pancreatic necrosis.

CT – small pancreas pseudocyst, following previous pancreatitis.CT – small pancreas pseudocyst, following previous pancreatitis.

CT - Rectus haematoma – on Warfarin. The blood is layered.CT - Rectus haematoma – on Warfarin. The blood is layered.

CXR – 1. Right subphrenic abscess. 2. Right subpulmonic pleural fluid.CXR – 1. Right subphrenic abscess. 2. Right subpulmonic pleural fluid.

CT – Mild appendicitis. Thickened wall of appendix. CT – Mild appendicitis. Thickened wall of appendix.

CT – 1. Recto-sigmoid carcinoma, mass-like lesion. 2. Metastases to liver.CT – 1. Recto-sigmoid carcinoma, mass-like lesion. 2. Metastases to liver.

CT – Severe appendicitisCT – Severe appendicitis

CT ABDO / PELVIS CT ABDO / PELVIS (SURVIVAL KIT)(SURVIVAL KIT)

Is there free gas?Is there free gas? Are bowel loops dilated?Are bowel loops dilated? Is there a lump in the liver?Is there a lump in the liver? Is the pancreas swollen?Is the pancreas swollen? Are the renal collecting systems too big?Are the renal collecting systems too big?

(these are >90% of conditions you need to (these are >90% of conditions you need to identify)identify)

PART III (A): PART III (A): ABDOMINAL ULTRASOUNDABDOMINAL ULTRASOUND

Key Learning ObjectivesKey Learning Objectives When to do Ultrasound When to do Ultrasound VSVS

When to do a CTWhen to do a CT Patient considerations -Patient considerations -

fastingfasting sizesize

How to interpretHow to interpret

Question: When to do an Ultrasound?Question: When to do an Ultrasound? AnswersAnswers::

a.a. if looking at gallbladder and biliary if looking at gallbladder and biliary tree pathologytree pathology

b.b. if pregnantif pregnant

c.c. in Emergency - portabilityin Emergency - portability

Question: What can’t be seen on Question: What can’t be seen on Ultrasound?Ultrasound?

AnswerAnswer: Actually quite a lot. : Actually quite a lot. Particularly -Particularly -

a.a. AAA (rupturing)AAA (rupturing)

b.b. free gasfree gas

c.c. pancreatitispancreatitis

Question: ? FastingQuestion: ? Fasting AnswerAnswer: if looking for gallstones (otherwise : if looking for gallstones (otherwise

gallbladder is contracted). Fasting for at least 6 gallbladder is contracted). Fasting for at least 6 hours.hours.

Question: When too big to bother?Question: When too big to bother? AnswerAnswer: If over 100 kg: If over 100 kg Question: When to not bother asking for Question: When to not bother asking for

Ultrasound?Ultrasound? AnswerAnswer: Pretty much anytime after sun sets: Pretty much anytime after sun sets

(n.b. – you can always get a CT)(n.b. – you can always get a CT)

HOW TO INTERPRET (1)HOW TO INTERPRET (1)

Really quite hardReally quite hard Go do a courseGo do a course

BUT ……..BUT …….. You are going to be expected to do it You are going to be expected to do it

in the future …….in Emergencyin the future …….in Emergency

HOW TO INTERPRET (2)HOW TO INTERPRET (2)

Key things to look forKey things to look for Is the CBD too big – normal Is the CBD too big – normal ≤7 mm≤7 mm Has the liver a “smooth” appearanceHas the liver a “smooth” appearance Are there GB calculiAre there GB calculi Are the renal collecting systems Are the renal collecting systems

diluteddiluted Is there an aortic aneurysm – normal Is there an aortic aneurysm – normal

≤3 cm≤3 cm

Ultrasound – mild appendicitis. 1. The wall of the appendix is thickened. 2. No fluid Ultrasound – mild appendicitis. 1. The wall of the appendix is thickened. 2. No fluid around appendix. around appendix.

Ultrasound - dilated biliary tree.Ultrasound - dilated biliary tree.

Ultrasound - dilated biliary tree. 1. The channel in front is the dilated CBD. 2. The Ultrasound - dilated biliary tree. 1. The channel in front is the dilated CBD. 2. The channel in the back is the portal vein.channel in the back is the portal vein.

Ultrasound – 1. CBD. 2. CBD is dilated at 1 cm.Ultrasound – 1. CBD. 2. CBD is dilated at 1 cm.

Ultrasound – Acute cholecystitis. 1. Gallbladder is thickened. 2. The gallbladder lumen Ultrasound – Acute cholecystitis. 1. Gallbladder is thickened. 2. The gallbladder lumen is filled with material.is filled with material.

Ultrasound - dilated renal collecting system.Ultrasound - dilated renal collecting system.

Ultrasound - ureteric calculus causing the collecting system obstruction.Ultrasound - ureteric calculus causing the collecting system obstruction.

ABDOMINAL ULTRASOUNDABDOMINAL ULTRASOUND(SURVIVAL KIT)(SURVIVAL KIT)

Is the bile duct dilated?Is the bile duct dilated? Is there stuff in the gall bladder?Is there stuff in the gall bladder? Is the aorta too big?Is the aorta too big? Are the renal collecting systems dilated?Are the renal collecting systems dilated?

(these are >90% of conditions you need to (these are >90% of conditions you need to identify).identify).

PART III (B): PART III (B): ULTRASOUND DOPPLERULTRASOUND DOPPLER

Key Learning ObjectivesKey Learning Objectives IndicationsIndications InterpretationInterpretation

Question: What are indications to request?Question: What are indications to request? I will change the question – What are the I will change the question – What are the

usual clinical scenarios?usual clinical scenarios? Presence of DVT in leg veins (most Presence of DVT in leg veins (most

common)common) Presence of thrombus in arm veins (post-Presence of thrombus in arm veins (post-

lines)lines) Looking for abdominal AAA (CT is better)Looking for abdominal AAA (CT is better) Looking for arterial ischaemia -Looking for arterial ischaemia -

leg arteriesleg arteries neck arteriesneck arteries

INTERPRETATION VASCULAR INTERPRETATION VASCULAR ULTRASOUNDULTRASOUND

Very difficultVery difficult Only for expert operatorsOnly for expert operators Best advice to you -Best advice to you -

a.a. Read the reports (not always Read the reports (not always done!)done!)

b.b. Go ask the reporter if you have a Go ask the reporter if you have a query.query.

Ultrasound of abdominal aortic aneurysm – transverse view.Ultrasound of abdominal aortic aneurysm – transverse view.

Ultrasound of abdominal aortic aneurysm – longitudinal view.Ultrasound of abdominal aortic aneurysm – longitudinal view.

Doppler ultrasound – right femoral vein – thrombus.Doppler ultrasound – right femoral vein – thrombus.

Doppler ultrasound – right femoral vein – thrombus in long view.Doppler ultrasound – right femoral vein – thrombus in long view.

Doppler ultrasound – right ICA – plaque with stenosis.Doppler ultrasound – right ICA – plaque with stenosis.

Doppler ultrasound – right ICA – stenosis – colour flow image.Doppler ultrasound – right ICA – stenosis – colour flow image.

CLOSING COMMENTSCLOSING COMMENTS

This is a teaching file on subjects This is a teaching file on subjects considered priority by previous considered priority by previous RMOsRMOsOKOK

BUT ……BUT ……Plain AXR interpretation far more Plain AXR interpretation far more important for you guys early in your important for you guys early in your medical career.medical career.