Positional Terms

Imaging

Typical chest x-ray views

Required projections can vary by country and hospital, although an erect posteroanterior (PA) projection is typically the first
preference. If this is not possible, then an anteroposterior view will be taken. Further imaging depends on local protocols which
is dependent on the hospital protocols, the availability of other imaging modalities and the preference of the image interpreter.
In the UK, the standard chest radiography protocol is to take an erect posteroanterior view only, and a lateral one only on
request by a radiologist.[5] In the US, chest radiography includes a PA and Lateral with the patient standing or sitting up. Special
projections include an AP in cases where the image needs to be obtained stat and with a portable device, particularly when a
patient cannot be safely positioned upright. Lateral decubitus may be used for visualization of air-fluid levels if an upright image
cannot be obtained. Anteroposterior (AP) Axial Lordotic projects the clavicles above the lung fields, allowing better visualization
of the apices (which is extremely useful when looking for evidence of primary tuberculosis)

CTScan

CT, or CAT scans, are special X-ray tests that produce cross-sectional images of the body using X-rays and a computer. CT scans
are also referred to as computerized axial tomography. CT was developed independently by a British engineer named Sir
Godfrey Hounsfield and Dr. Alan Cormack. It has become a mainstay for diagnosing medical diseases. For their work, Hounsfield
and Cormack were jointly awarded the Nobel Prize in 1979.

CT scanners first began to be installed in 1974. CT scanners have vastly improved patient comfort because a scan can be done
quickly. Improvements have led to higher-resolution images, which assist the doctor in making a diagnosis. For example, the CT
scan can help doctors to visualize small nodules or tumors, which they cannot see with a plain film X-ray.

CT Scan Facts

 CT scan images allow the doctor to look at the inside of the body just as one would look at the inside of a loaf of
bread by slicing it. This type of special X-ray, in a sense, takes "pictures" of slices of the body so doctors can look right
at the area of interest. CT scans are frequently used to evaluate the brain, neck, spine, chest, abdomen, pelvis, and
sinuses.
 CT is a commonly performed procedure. Scanners are found not only in hospital X-ray departments, but also in
outpatient offices.
 CT has revolutionized medicine because it allows doctors to see diseases that, in the past, could often only be found
at surgery or at autopsy. CT is noninvasive, safe, and well-tolerated. It provides a highly detailed look at many
different parts of the body.
 If one looks at a standard X-ray image or radiograph (such as a chest X-ray), it appears as if they are looking through
the body. CT and MRI are similar to each other, but provide a much different view of the body than an X-ray does. CT
and MRI produce cross-sectional images that appear to open the body up, allowing the doctor to look at it from the
inside. MRI uses a magnetic field and radio waves to produce images, while CT uses X-rays to produce images. Plain X-
rays are an inexpensive, quick test and are accurate at diagnosing things such as pneumonia, arthritis, and fractures.
CT and MRI better to evaluate soft tissues such as the brain, liver, and abdominal organs, as well as to visualize subtle
abnormalities that may not be apparent on regular X-ray tests.
 People often have CT scans to further evaluate an abnormality seen on another test such as an X-ray or an
ultrasound. They may also have a CT to check for specific symptoms such as pain or dizziness. People with cancer may
have a CT to evaluate the spread of disease.
 A head or brain CT is used to evaluate the various structures of the brain to look for a mass, stroke, area of bleeding,
or blood vessel abnormality. It is also sometimes used to look at the skull.
 A neck CT checks the soft tissues of the neck and is frequently used to study a lump or mass in the neck or to look for
enlarged lymph nodes or glands.
 CT of the chest is frequently used to further study an abnormality on a plain chest X-ray. It is also often used to look
for enlarged lymph nodes.
 Abdominal and pelvic CT looks at the abdominal and pelvic organs (such as the liver, spleen, kidneys, pancreas, and
adrenal glands) and the gastrointestinal tract. These studies are often ordered to check for a cause of pain and
sometimes to follow up on an abnormality seen on another test such as an ultrasound.
 A sinus CT exam is used to both diagnose sinus disease and to detect a narrowing or obstruction in the sinus drainage
pathway.
 A spine CT test is most commonly used to detect a herniated disc or narrowing of the spinal canal (spinal stenosis) in
people with neck, arm, back, and/or leg pain. It is also used to detect a fracture or break in the spine.

MRI

Magnetic resonance imaging (MRI) is a test that uses powerful magnets, radio waves, and a computer to make detailed pictures
inside your body.
Your doctor can use this test to diagnose you or to see how well you've responded to treatment. Unlike X-rays and computed
tomography (CT) scans, MRIs do not use the damaging ionizing radiation of X-rays.

Why Would You Get an MRI?

 A MRI helps a doctor diagnose a disease or injury, and it can monitor how well you’re doing with a treatment. MRIs
can be done on different parts of your body.
 A MRI of the brain and spinal cord looks for:
 Blood vessel damage
 Brain injury
 Cancer
 Multiple sclerosis
 Spinal cord injuries
 Stroke

A MRI of the heart and blood vessels looks for:

 Blocked blood vessels

 Damage caused by a heart attack
 Heart disease
 Problems with the structure of the heart

A MRI of the bones and joints looks for:

 Bone infections
 Cancer
 Damage to joints
 Disc problems in the spine
 MRIs can also be done to check the health of these organs:
 Breasts (women)
 Liver
 Kidneys
 Ovaries (women)
 Pancreas
 Prostate (men)

A special kind of MRI called a functional MRI (fMRI) maps brain activity.

This test looks at blood flow in your brain to see which areas become active when you do certain tasks. A fMRI can detect brain
problems, such as the effects of a stroke, or for brain mapping if you need brain surgery for epilepsy or tumors. Your doctor can
use this test to plan your treatment.

Skull
 Organization of the Cerebrum

 A thin layer of gray matter known as the cerebral cortex is found immediately beneath the convoluted surface of the
cerebrum.
Intra cranial hemorrrhage

1-Staging of intra cranial hematoma

-Acute hematoma---hyper dense.
-Sub acute hematoma---iso dense.
-Chronic hematoma---Hypo dense.
2-Sites of intra cranial hemorrhage:
-Epi dural or extra dural hematoma---between the dura and the skull bone.
-Sub dural hematoma---between the dura and the arachnoid.
-Sub arachnoid hematoma---below the sub arachnoid, here you observed that this kind of hemorrhage is entering inside cortical
sulci.
-Intra parenchymal hematoma---hemorrhage inside the brain parenchyma.
-Intra ventricular hematoma---hemorrhage inside the ventricle.

3-Anatomic Localization:
-Extra axial hematoma = hematoma outside the brain tissue as epi dural, sub dural and sub arachnoid hematomas.
-Intra axial hematoma = hematoma inside the brain parenchyma as intra parenchymal hematoma.
-Intra ventricular hematoma could be considered as extra axial or intra axial.

4-Sub arachnoid hemorrhage:

-Means blood in the CSF.
-Seen in sulci and cisterns.
-Most common cause is rupture of an aneurysm.

5-Epi dural hematoma:

-If the hematoma is adherent to the bone and moving along with the bone, this will be extra axial hematoma.
-If there is a brain tissue between in the bone and the hematoma, so it will be intra axial hematoma.
-The epi dural hematoma shows convex inner margin which can cross the mid line and it is almost always in the acute stage as
patient should be manifested early.
-In case of epi dural hematoma, the dura is strictly adherent to the skull bones, so the epi dural hematoma will face a very
strong resistence to migrate anterior or posterior, so it is more easy to press upon more liable brain tissue making this convex
inner border, so the hematoma will increase in size transversely and not longitudinally.

6-Sub dural hematoma:

-Sub dural space is not limited anteriorly and posteriorly, so sub dural hematoma can move freely above and down making
concave inner border which do not cross the mid line and it can be acute, sub acute or chronic in staging.
-Can be seen in the inter hemispheric fissure.
-Usually seen in the elderly with history of minor trauma.

7-Intra parenchymal hematoma:

-It could be primary or secondary to trauma.
-If it is secondary to trauma, this is known as contusion.
-So if this hematoma is associated with history of fracture and evident fracture seen on radiology, this is a brain contusion and
not intra parenchymal hematoma.
-If there is no history of trauma or fracture, this will be the hematoma caused by cerebro-vascular stroke seen routinely in the
practice.
-Intra parenchymal hematoma caused by cerebro-vascular insult is usually been situated near the ventricle, and as the wall of
the ventricle is too smooth, so it will be easy for the hematoma to penetrate it and reach the ventricle to form intra ventricular
hemorrhage.
-So we have two causes producing intra ventricular hematoma which are intra parenchymal hematoma and sub arachnoid
hematoma.

8-Follow up of intra cranial hematoma:

-Epi dural hematoma is almost always acute due to severe symptoms as it occurs in a tight space. Patient are usually evaluated
by CT and evacuation is done on emergency basis.
-Sub dural hematoma can be acute, sub acute and chronic due to minor symptoms as it occurs in a wide space, patients are
usually evaluated by CT and evacuation is done usually in the chronic stage.
-If we see a sub dural hematoma with fluid level with hypo and hyper dense density along the side of this level, this appearance
is considered sub acute hematoma.
-So we have three pictures for sub acute hematoma
*The first is when it is iso dense to the density of the brain, here we can know its presence by its effect on the sulci and also by
mass effect if present.
*Secondly by presence of sedimentation level.
*Thirdly by presence of white and black densities along the hematoma.

9-Causes of iso dense lesions causing mass effect are two

-Sub acute sub dural hematoma leading to intact grey white matter interface.
-Infiltrating glioma leading to disappearance of grey white matter interface due to its destruction by the tumor.
-This is better evaluated by MRI.