Basic Knowledge

Radiology
Nuclear Medicine and
Radiotherapy
Martina Kahl-Scholz
Christel Vockelmann
Editors

123
Basic Knowledge Radiology
Martina Kahl-Scholz • Christel Vockelmann
Editors

Basic Knowledge
Radiology
Nuclear Medicine and Radiotherapy With 215 Illustrations
Editors
Martina Kahl-Scholz Christel Vockelmann
Münster, Germany Christophorus Clinics GmbH
Coesfeld, Germany

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ISBN 978-3-662-66350-9    ISBN 978-3-662-66351-6 (eBook)

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 V

Dream your life nice and make those dreams a reality.

Marie Curie (1867–1934)
Preface

Modern medicine without imaging diagnostics and therapy is no longer imaginable

in this day and age. Although every medical specialty deals “a little bit” with the
imaging procedures of its own spectrum, the radiologists’ and nuclear medicine spe-
cialists’ claim is to have an overview of the diagnostics necessary for the problem and
to keep an eye on the secondary findings, which may become the main findings for
the patient.
At the same time, the fields of radiology, nuclear medicine, and radiotherapy
remain in constant flux due to technical developments. Due to the diversity and the
increasingly strong interventional field (especially in radiology), the areas are far
from a “work in the dark closet.”
In particular, the radiologist treats patients of any age and with almost any dis-
ease. So one is something like a specialized all-rounder. But there is also a need for
specialization: pediatric radiology, neuroradiology, or interventional radiology
require special knowledge and skills. Nuclear medicine specialists and radiologists
work closely together to offer patients the best possible diagnostics in PETCT exam-
inations. And the constant technical development also demands continuous training
for colleagues who have been working in the profession for many years.
In the course of your studies, you have certainly had some contact with X-rays,
nuclear medicine, or radiation therapy. But how does it all actually work? And why
does the nuclear medicine doctor get upset about your blood pressure medication
before the kidney scintigraphy? Why does the MTRA stop her when she walks into
the MRI? And why doesn’t the radiotherapist want to give radiation to the demented
patient for whom surgery seems far too costly? We want to answer these and other
questions and share our enthusiasm for our specialties with you.
With the basic knowledge of radiology and imaging procedures, we want to give
you an overview of diagnostic and therapeutic options for the most common dis-
eases. In doing so, a book alone cannot claim to be complete; it is not for nothing
that the libraries of the radiology departments tend to be the most extensive ones in
a hospital. But we want to lay a starting point for a very interesting field of medicine,
from which you can at least go the first part of the way. This includes the correct use
of the methods with knowledge of the advantages and disadvantages and the correct
description of the findings. The evaluation of the same is also in the professional
everyday life often a rereading in thick special tomes and the discussion of the pos-
sible diagnoses with colleagues of their own and the treating specialty.
Special thanks go to our author colleagues, without whom this book would not be
equipped with so much expertise: Dr. Blum, Dr. Kremers, Dr. Wenker, Dr. Heilsberg,
and Dr. Münstermann. We would also like to thank our colleagues Heinrich Rühe,
Madlen Hagemann, and Dominika Kotas, as well as Dr. Matthias Göb, who actively
supported us in compiling the images.
Further thanks go to the staff at Springer-Verlag, above all to Mrs. Rose-Marie
Doyon in project management, for the opportunity to make this book a reality and
for the corresponding support.
We welcome suggestions and comments from you to further develop the book and
adapt it to the needs of our readers.
 VII
Preface

We hope that this book will be a valuable companion for you as a student in clini-
cal traineeship or PJ and also as a resident in radiology, nuclear medicine, or radio-
therapy in your everyday student and professional life.

Christel Vockelmann
Coesfeld, Germany

Martina Kahl-Scholz
Münster, Germany
January 2017
 IX

Contents

I Basics
1 Physical Basics................................................................................................................................. 3
Martina Kahl-Scholz and Christel Vockelmann
1.1 Radioactivity and Its Interactions................................................................................................... 4
1.1.1 Radioactive Decay Modes.........................................................................................................................4
1.1.2 The Physical Half-Life..................................................................................................................................5
1.1.3 Physical Interaction Processes of Electromagnetic Radiation with Matter.............................6
1.1.4 Interaction of Particle Radiation with Matter.....................................................................................7
1.2 X-Rays....................................................................................................................................................... 7
1.3 Dose Terms............................................................................................................................................. 8
1.3.1 Kerma = Kinetic Energy Released in Matter.......................................................................................9
1.3.2 Ion Dose...........................................................................................................................................................9
1.3.3 Absorbed Dose.............................................................................................................................................9
1.3.4 Equivalent Dose............................................................................................................................................9
1.3.5 Incident Dose.................................................................................................................................................10
1.3.6 Surface Dose..................................................................................................................................................10
1.3.7 Deep Dose......................................................................................................................................................10
1.3.8 Dose Area Product.......................................................................................................................................10
1.3.9 Dose Length Product..................................................................................................................................10
1.3.10 Organ Dose.....................................................................................................................................................11
1.3.11 Effective Dose................................................................................................................................................11
1.3.12 Personal Dose, Local Dose and Body Dose.........................................................................................11
1.4 Effect of Ionizing Radiation on the Organism............................................................................ 12
1.4.1 Radiation Effects...........................................................................................................................................12
1.4.2 Phases of the Radiation Effect.................................................................................................................13

2 Conventional X-ray Diagnostics........................................................................................... 17

Christel Vockelmann
2.1 Design and Operation of an X-ray System................................................................................... 18
2.1.1 The X-ray Source...........................................................................................................................................18
2.1.2 The X-ray Generator....................................................................................................................................20
2.1.3 Mapping Laws...............................................................................................................................................21
2.1.4 Quality of the X-ray Image and Quality Improvement Measures...............................................23
2.1.5 Setting Up a Bucky Workstation.............................................................................................................24
2.1.6 Mobile X-ray Equipment............................................................................................................................25
2.1.7 Special Radiation Protection Measures................................................................................................25
2.2 Digital Image Processing................................................................................................................... 26
2.2.1 Matrix................................................................................................................................................................26
2.2.2 Color Depth....................................................................................................................................................28
2.2.3 Error Correction............................................................................................................................................28
X Contents

3 Mammography................................................................................................................................ 29
Christel Vockelmann
3.1 Design and Function of a Mammography Device..................................................................... 30
3.1.1 The Heel Effect..............................................................................................................................................30
3.1.2 Compression, Scattered Radiation Reduction...................................................................................30
3.1.3 Magnification Mammography................................................................................................................31
3.1.4 Automatic Exposure Control....................................................................................................................31
3.1.5 Image Receiver, Image Viewing..............................................................................................................31

4 Transillumination........................................................................................................................... 33
Martina Kahl-Scholz
4.1 Image Intensifier (BV)......................................................................................................................... 34
4.1.1 Structure of A Fluoroscopy Unit.............................................................................................................35

5 Angiography, Rotational Angiography/Angio-CT................................................... 37

Martina Kahl-Scholz and Christel Vockelmann
5.1 DSA Technique...................................................................................................................................... 38
5.2 Angiography-CT Rotational/Angio-CT......................................................................................... 40
5.3 Seldinger Technique............................................................................................................................ 41

6 Computed Tomography (CT).................................................................................................. 43

Mirja Wenker
6.1 History...................................................................................................................................................... 45
6.2 Design and Operation of A Computer Tomograph................................................................... 45
6.3 Investigation Techniques................................................................................................................... 45
6.3.1 CT Sequence..................................................................................................................................................45
6.3.2 CT Dynamic....................................................................................................................................................46
6.3.3 CT Spiral/CT Singleslice (SS-CT)..............................................................................................................46
6.3.4 CT Multislice (MS-CT)..................................................................................................................................46
6.3.5 CT Dual-Source (DS-CT).............................................................................................................................47
6.4 Important Parameters in Spiral CT................................................................................................. 47
6.4.1 Pitch Factor.....................................................................................................................................................47
6.4.2 Collimation.....................................................................................................................................................48
6.4.3 Tube Voltage (kV).........................................................................................................................................48
6.4.4 Tube Current-Time Product (mAs).........................................................................................................48
6.4.5 Scan Time (S)..................................................................................................................................................48
6.4.6 z-sharp Technology.....................................................................................................................................48
6.5 Parameters for Image Reconstruction.......................................................................................... 49
6.5.1 Layer Thickness.............................................................................................................................................49
6.5.2 Increment........................................................................................................................................................49
6.5.3 Convolution Kernel, Reconstruction Filter or Algorithm...............................................................49
6.5.4 Windowing.....................................................................................................................................................49
6.5.5 z-Interpolation..............................................................................................................................................49
6.6 Image Formation.................................................................................................................................. 50
6.6.1 Filtered Back Projection.............................................................................................................................50
6.6.2 Iterative Reconstruction............................................................................................................................50
6.6.3 Hounsfield Scale...........................................................................................................................................50
 XI
Contents

6.6.4 Window Technology...................................................................................................................................50

6.7 Post-Processing..................................................................................................................................... 51
6.7.1 2D Representation.......................................................................................................................................51
6.7.2 3D Representation.......................................................................................................................................52
6.8 Artifacts................................................................................................................................................... 53
6.8.1 Movement Artefact.....................................................................................................................................53
6.8.2 Pulsation Artefact.........................................................................................................................................53
6.8.3 Metal Artifact.................................................................................................................................................53
6.8.4 Partial Volume Effect/Partial Volume Effect........................................................................................53
6.8.5 Hardening Artefact......................................................................................................................................54
6.8.6 Measuring Field Overrun...........................................................................................................................54
6.8.7 Photon Starvation Artefact.......................................................................................................................54
6.8.8 Ring Artefact..................................................................................................................................................55
6.8.9 Line Artifact....................................................................................................................................................55
6.9 Radiation Protection Measures and Dose Reduction.............................................................. 55
6.9.1 Dosage Modulation.....................................................................................................................................55
6.9.2 Adaptive ECG Pulsing.................................................................................................................................55
6.9.3 Avoidance of Overranging........................................................................................................................55
6.9.4 Iterative Reconstruction............................................................................................................................55

7 Magnetic Resonance Imaging (MRI).................................................................................. 57

Carla M. Kremers
7.1 
Which Core Is Actually Spinning Here and What Does It Have
to Do with Magnets?............................................................................................................59
7.2 Longitudinal Magnetization............................................................................................................. 60
7.3 MR Signal................................................................................................................................................ 60
7.3.1 T1 Relaxation Time.......................................................................................................................................61
7.3.2 T2 Relaxation Time.......................................................................................................................................62
7.4 Location Coding.................................................................................................................................... 63
7.4.1 Layer Selection..............................................................................................................................................63
7.4.2 Phase Coding.................................................................................................................................................63
7.4.3 Frequency Coding........................................................................................................................................63
7.4.4 K-space and Fourier Transformation.....................................................................................................64
7.5 Proton Thrusting and Gradient Ballet: the Interplay of High-Frequency
Pulses and Spatial Coding................................................................................................................. 64
7.5.1 Refocusing......................................................................................................................................................64
7.5.2 Echo and Repetition Time or T1 and T2 Contrast.............................................................................66
7.6 Sequence Theory.................................................................................................................................. 68
7.6.1 Gradient Echo Sequences.........................................................................................................................68
7.6.2 Fat Saturation................................................................................................................................................69
7.6.3 Vessel Mapping.............................................................................................................................................69
7.6.4 Diffusion Imaging........................................................................................................................................70
7.7 Contrast Agent...................................................................................................................................... 71
7.8 Security.................................................................................................................................................... 71
7.8.1 Attraction of the Magnet...........................................................................................................................71
7.8.2 Implants...........................................................................................................................................................71
7.8.3 Volume.............................................................................................................................................................72
XII Contents

7.8.4 Tissue Stimulation........................................................................................................................................72

7.8.5 Emergency Bell.............................................................................................................................................72

8 Sonography....................................................................................................................................... 75
Christel Vockelmann and Martina Kahl-Scholz
8.1 Physical Basics of Sonography......................................................................................................... 76
8.1.1 Ultrasonic Waves..........................................................................................................................................76
8.1.2 Procedure........................................................................................................................................................77
8.2 Design and Operation of a Sonography Device........................................................................ 79
8.2.1 Transducers....................................................................................................................................................80
8.2.2 Where to Press…..........................................................................................................................................80
8.3 Possibilities and Limits of Ultrasound Diagnostics................................................................... 81

9 Contrast Agent................................................................................................................................. 83

Martina Kahl-Scholz
9.1 X-ray Contrast Medium...................................................................................................................... 84
9.1.1 Classification of X-ray CMs........................................................................................................................84
9.2 MR Contrast Medium.......................................................................................................................... 89
9.2.1 Gadolinum......................................................................................................................................................90
9.3 Sonographic Contrast Agent............................................................................................................ 91
9.4 Contraindications................................................................................................................................. 91
9.5 Side Effects............................................................................................................................................. 91
9.6 Pregnancy and Breastfeeding.......................................................................................................... 92

10 Radiotherapy.................................................................................................................................... 93
Guido Heilsberg
10.1 Possibilities and Principles of Radiooncology............................................................................ 94
10.1.1 Brachytherapy...............................................................................................................................................94
10.1.2 Particle Therapy............................................................................................................................................94
10.1.3 Therapy Concepts in Radiooncology....................................................................................................94
10.1.4 Fractionation..................................................................................................................................................95
10.2 Irradiation Planning............................................................................................................................ 95
10.2.1 Further Processing.......................................................................................................................................96
10.3 Design and Function of Radiooncological Irradiation Equipment...................................... 96
10.3.1 Linear Accelerator........................................................................................................................................96
10.3.2 Dose Distribution in Tissue.......................................................................................................................97
10.3.3 Irradiation Techniques................................................................................................................................97
10.3.4 Irradiation Variants.......................................................................................................................................99
10.3.5 X-ray Therapy Equipment..........................................................................................................................99

11 Nuclear Medicine........................................................................................................................... 101

Ursula Blum
11.1 Imaging and Therapeutic Options................................................................................................. 103
11.1.1 Scintillation Counter: Scanner, Gamma Camera, Gamma Probe................................................103
11.1.2 Semiconductor Cameras...........................................................................................................................103
11.1.3 PET.....................................................................................................................................................................103
11.1.4 Hybrid Systems.............................................................................................................................................104
11.1.5 Therapy Options...........................................................................................................................................104
 XIII
Contents

11.2 Radiation Protection........................................................................................................................... 106

11.2.1 Hot Laboratory..............................................................................................................................................106
11.2.2 Investigation Area........................................................................................................................................107
11.2.3 Leaving the Department...........................................................................................................................107
11.3 Detection of Radioactivity................................................................................................................ 107
11.3.1 Scintillation Detectors................................................................................................................................107
11.4 Image Formation Systems................................................................................................................. 110
11.4.1 Gamma Camera............................................................................................................................................110
11.5 Radionucleotides in Medical Application.................................................................................... 113
11.5.1 Diagnostic Imaging.....................................................................................................................................114
11.6 Radiopharmacology............................................................................................................................ 114
11.7 Quality Assurance Measures of Radiopharmaceuticals.......................................................... 114
11.7.1 Radioisotope Purity.....................................................................................................................................115
11.7.2 Chemical Purity.............................................................................................................................................115
11.7.3 Radiochemical Purity..................................................................................................................................115
11.7.4 Specific Activity.............................................................................................................................................116
11.7.5 Stability............................................................................................................................................................116
11.7.6 Microbiological Purity................................................................................................................................116
11.8 Contamination and Decontamination Measures...................................................................... 116
11.8.1 Contamination..............................................................................................................................................116
11.8.2 Decontamination.........................................................................................................................................116

12 Emergencies and Extreme Situations............................................................................... 119

Christel Vockelmann and Martina Kahl-Scholz
12.1 Extreme Situations............................................................................................................................... 120
12.1.1 Polytrauma.....................................................................................................................................................120
12.1.2 Anaphylactoid Reaction............................................................................................................................120
12.1.3 CT-Guided Puncture....................................................................................................................................120
12.1.4 Seizure During Stent Angioplasty..........................................................................................................121
12.2 Contrast Agent Incident and Emergency Medication............................................................. 121
12.2.1 Side Effects.....................................................................................................................................................121

13 Legislation.......................................................................................................................................... 125
Christel Vockelmann
13.1 Basic Law (GG)....................................................................................................................................... 126
13.2 Patients’ Rights Act.............................................................................................................................. 127
13.2.1 Reconnaissance............................................................................................................................................127
13.3 Data Protection..................................................................................................................................... 128
13.4 Atomic Energy Act (AtG).................................................................................................................... 128
13.5 X-ray Ordinance (RöV)........................................................................................................................ 129
13.6 Radiation Protection Ordinance (StrSchV).................................................................................. 129
13.7 Radiation Protection Areas............................................................................................................... 129
13.8 Occupationally Exposed Persons.................................................................................................... 131
13.9 Technical Knowledge.......................................................................................................................... 132
13.10 Justifying Indication............................................................................................................................ 132
13.11 Medical Devices Act (MPG)............................................................................................................... 132
13.12 Maternity Protection Act (MuSchG)............................................................................................... 133
13.13 Working Time Act................................................................................................................................. 133
XIV Contents

II Disease Patterns
14 Neurology......................................................................................................................................... 137
Christel Vockelmann, Ursula Blum, Martina Kahl-Scholz,
and Guido Heilsberg
14.1 Anatomical Structures...........................................................................................................................138
14.2 Disease Patterns.......................................................................................................................................138
14.2.1 Intracranial and Spinal Hemorrhages................................................................................................138
14.2.2 Ischemic Diseases......................................................................................................................................141
14.2.3 Intracerebral Tumors................................................................................................................................143
14.2.4 Cerebrospinal Fluid Circulation Disorder..........................................................................................146
14.2.5 Intracranial Extraaxial Tumors...............................................................................................................146
14.2.6 Cystic Intracranial Lesions......................................................................................................................147
14.2.7 Chronic Inflammatory CNS Processes: Multiple Sclerosis...........................................................147
14.2.8 Acute Inflammatory CNS Processes....................................................................................................149
14.2.9 Epilepsy.........................................................................................................................................................149
14.2.10 Phacomatoses.............................................................................................................................................150
14.2.11 Neurodegenerative Diseases................................................................................................................151
14.3 Diagnostics.................................................................................................................................................152
14.3.1 Diagnostic Radiology...............................................................................................................................152
14.3.2 Nuclear Medicine.......................................................................................................................................153
14.3.3 Valence..........................................................................................................................................................156
14.4 Therapy.........................................................................................................................................................157
14.4.1 Interventional Radiology........................................................................................................................157
14.4.2 Radiotherapy...............................................................................................................................................158

15 Head/Neck........................................................................................................................................ 161
Martina Kahl-Scholz, Christel Vockelmann, Ursula Blum,
and Guido Heilsberg
15.1 Anatomical Structures...........................................................................................................................162
15.2 Disease Patterns.......................................................................................................................................163
15.2.1 Head...............................................................................................................................................................163
15.2.2 Neck................................................................................................................................................................166
15.3 Diagnostics.................................................................................................................................................167
15.3.1 Diagnostic Radiology...............................................................................................................................167
15.3.2 Nuclear Medicine.......................................................................................................................................168
15.3.3 Valence..........................................................................................................................................................168
15.4 Therapy.........................................................................................................................................................169
15.4.1 Radiotherapy...............................................................................................................................................169

16 Gynecology...................................................................................................................................... 171
Carla M. Kremers, Guido Heilsberg, Ursula Blum, Christel Vockelmann,
and Martina Kahl-Scholz
16.1 Anatomical Structures...........................................................................................................................172
16.2 Disease Patterns.......................................................................................................................................172
16.2.1 Chest..............................................................................................................................................................172
16.2.2 Small Basin...................................................................................................................................................177
 XV
Contents

16.2.3 Tumors of the Uterus................................................................................................................................178

16.2.4 External Female Genitalia.......................................................................................................................183
16.3 Diagnostics.................................................................................................................................................183
16.3.1 Diagnostic Radiology...............................................................................................................................183
16.3.2 Nuclear Medicine.......................................................................................................................................185
16.3.3 Valence..........................................................................................................................................................186
16.4 Therapy.........................................................................................................................................................186
16.4.1 Interventional Radiology........................................................................................................................186
16.4.2 Radiotherapy...............................................................................................................................................187

17 Respiratory System.................................................................................................................... 191

Martina Kahl-Scholz, Christel Vockelmann, and Ursula Blum
17.1 Anatomical Structures...........................................................................................................................192
17.1.1 Trachea and Lungs (Pulmo)...................................................................................................................192
17.2 Disease Patterns.......................................................................................................................................192
17.2.1 Pleura.............................................................................................................................................................192
17.2.2 Emphysema.................................................................................................................................................195
17.2.3 Bronchiectasis.............................................................................................................................................195
17.2.4 Pulmonary Oedema.................................................................................................................................196
17.2.5 Pulmonary Fibrosis....................................................................................................................................197
17.2.6 Infectious Diseases....................................................................................................................................197
17.2.7 Interstitial Lung Disease..........................................................................................................................201
17.2.8 Pneumonitis Radiation............................................................................................................................202
17.2.9 Lymphangiosis Carcinomatosa............................................................................................................203
17.2.10 ARDS...............................................................................................................................................................203
17.2.11 Sarcoidosis...................................................................................................................................................203
17.2.12 Tumors...........................................................................................................................................................204
17.2.13 Pulmonary Embolism...............................................................................................................................207
17.2.14 Childhood.....................................................................................................................................................208
17.3 Diagnostics.................................................................................................................................................209
17.3.1 Diagnostic Radiology...............................................................................................................................209
17.3.2 Nuclear Medicine.......................................................................................................................................210
17.3.3 Valence..........................................................................................................................................................212
17.4 Therapy.........................................................................................................................................................213
17.4.1 Interventional Radiology........................................................................................................................213
17.4.2 Radiotherapy...............................................................................................................................................213

18 Gastrointestinal Tract............................................................................................................... 217

Christel Vockelmann, Ursula Blum, and Guido Heilsberg
18.1 Anatomical Structures.............................................................................................................................218
18.2 Disease Patterns.......................................................................................................................................218
18.2.1 Pharynx, Oesophagus..............................................................................................................................218
18.2.2 Stomach and Duodenum.......................................................................................................................222
18.2.3 Duodenal Diverticulum...........................................................................................................................223
18.2.4 Jejunum and Ileum...................................................................................................................................225
18.2.5 Colon and Rectum.....................................................................................................................................226
18.2.6 Mesentery, Peritoneum and Abdominal Wall.................................................................................230
XVI Contents

18.2.7 Liver and Biliary System.............................................................................................................................233

18.2.8 Gall Bladder and Bile Ducts......................................................................................................................240
18.2.9 Pancreas...........................................................................................................................................................241
18.3 Diagnostics............................................................................................................................................. 243
18.3.1 Diagnostic Radiology..................................................................................................................................243
18.3.2 Nuclear Medicine.........................................................................................................................................245
18.3.3 Valence.............................................................................................................................................................249
18.4 Therapy.................................................................................................................................................... 249
18.4.1 Interventional Radiology...........................................................................................................................249
18.4.2 Radiotherapy.................................................................................................................................................251

19 Urogenital........................................................................................................................................... 253
Carla M. Kremers, Guido Heilsberg, Ursula Blum, Christel Vockelmann,
and Martina Kahl-Scholz
19.1 Anatomical Structures........................................................................................................................ 254
19.2 Disease Patterns................................................................................................................................... 254
19.2.1 Urinary Tract...................................................................................................................................................254
19.2.2 Urolithiasis......................................................................................................................................................254
19.2.3 Urothelial Carcinoma..................................................................................................................................255
19.2.4 Kidney Diseases............................................................................................................................................257
19.2.5 Injuries to the Kidneys and Urinary Tract............................................................................................265
19.2.6 Adrenal Gland................................................................................................................................................266
19.2.7 Prostate............................................................................................................................................................268
19.2.8 Testis and Epididymis.................................................................................................................................269
19.3 Diagnostics............................................................................................................................................. 271
19.3.1 Diagnostic Radiology..................................................................................................................................271
19.3.2 Nuclear Medicine.........................................................................................................................................272
19.3.3 Valence.............................................................................................................................................................274
19.4 Therapy.................................................................................................................................................... 275
19.4.1 Interventional Radiology...........................................................................................................................275
19.4.2 Radiotherapy.................................................................................................................................................275

20 Musculoskeletal Diseases......................................................................................................... 279

Mirja Wenker, Christel Vockelmann, Ursula Blum, and Guido Heilsberg
20.1 General..................................................................................................................................................... 280
20.2 Anatomical Structures........................................................................................................................ 280
20.2.1 Bone Structure..............................................................................................................................................280
20.3 Clinical Pictures..................................................................................................................................... 281
20.3.1 Fractures..........................................................................................................................................................281
20.3.2 Luxation...........................................................................................................................................................286
20.3.3 Inflammatory Diseases...............................................................................................................................287
20.3.4 Degenerative Diseases...............................................................................................................................290
20.3.5 Tumors and Tumor-like Lesions..............................................................................................................293
20.3.6 Congenital Disorders of the Skeletal System.....................................................................................296
20.3.7 Diseases of the Infantile Skeleton..........................................................................................................298
20.4 Diagnostics............................................................................................................................................. 300
20.4.1 Diagnostic Radiology Services................................................................................................................300
 XVII
Contents

20.4.2 Nuclear Medicine Diagnostics.................................................................................................................302

20.4.3 Valence.............................................................................................................................................................303
20.5 Therapy.................................................................................................................................................... 303
20.5.1 Interventional Radiology...........................................................................................................................303
20.5.2 Nuclear Medicine.........................................................................................................................................304
20.5.3 Radiotherapy.................................................................................................................................................305

21 Cardiovascular Diseases............................................................................................................ 307

Mirja Wenker, Ursula Blum, and Christel Vockelmann
21.1 Anatomical Structures........................................................................................................................ 308
21.2 Disease Patterns................................................................................................................................... 308
21.2.1 Heart.................................................................................................................................................................308
21.2.2 Vessels..............................................................................................................................................................313
21.3 Diagnostics............................................................................................................................................. 321
21.3.1 Radiological Diagnosis...............................................................................................................................321
21.3.2 Nuclear Medicine.........................................................................................................................................322
21.3.3 Valence.............................................................................................................................................................325
21.4 Therapy.................................................................................................................................................... 326
21.4.1 Interventional Radiology...........................................................................................................................326

22 Endocrinological System.......................................................................................................... 327

Martina Kahl-Scholz, Christel Vockelmann, Ursula Blum,
and Guido Heilsberg
22.1 Anatomical Structures........................................................................................................................ 328
22.2 Disease Patterns................................................................................................................................... 328
22.2.1 Thyroid Goiter................................................................................................................................................328
22.2.2 Thyroid Carcinoma......................................................................................................................................329
22.2.3 Adrenal Adenoma........................................................................................................................................329
22.2.4 Adrenocortical Carcinoma........................................................................................................................329
22.2.5 Pituitary Adenoma.......................................................................................................................................330
22.3 Diagnostics............................................................................................................................................. 330
22.3.1 Diagnostic Radiology..................................................................................................................................330
22.3.2 Nuclear Medicine.........................................................................................................................................332
22.3.3 Valence.............................................................................................................................................................334
22.4 Therapy.................................................................................................................................................... 335
22.4.1 Radiotherapy.................................................................................................................................................335
22.4.2 Nuclear Medicine.........................................................................................................................................335

23 Lymphatic System.......................................................................................................................... 339

Martina Kahl-Scholz, Christel Vockelmann, Ursula Blum,
and Guido Heilsberg
23.1 Anatomical Structures........................................................................................................................ 340
23.2 Disease Patterns................................................................................................................................... 340
23.2.1 Systemic Diseases........................................................................................................................................340
23.2.2 Hodgkin’s Disease........................................................................................................................................341
23.2.3 Non-Hodgkin’s Lymphoma.......................................................................................................................341
23.2.4 Lymph Node Metastases...........................................................................................................................342
XVIII Contents

23.2.5 Splenic Cysts..................................................................................................................................................342

23.2.6 Spleen Abscess..............................................................................................................................................342
23.2.7 Splenic Infarction.........................................................................................................................................342
23.2.8 Splenic Rupture............................................................................................................................................342
23.2.9 Thymoma........................................................................................................................................................343
23.3 Diagnostics............................................................................................................................................. 343
23.3.1 Radiological Diagnosis...............................................................................................................................343
23.3.2 Nuclear Medicine.........................................................................................................................................344
23.3.3 Valence.............................................................................................................................................................347
23.4 Therapy.................................................................................................................................................... 348
23.4.1 Interventional Radiology...........................................................................................................................348
23.4.2 Radiotherapy.................................................................................................................................................348

24 Pediatrics............................................................................................................................................. 351
Esther Münstermann and Christel Vockelmann
24.1 Thorax...................................................................................................................................................... 352
24.1.1 Respiratory Distress Syndrome (ANS)...................................................................................................352
24.1.2 Meconium Aspiration.................................................................................................................................352
24.1.3 Oesophageal Atresia...................................................................................................................................353
24.1.4 Catheter in the Thoracic Region.............................................................................................................353
24.2 Gastrointestinal Tract.......................................................................................................................... 354
24.2.1 Necrotising Enterocolitis (NEC)...............................................................................................................354
24.2.2 Duodenal Atresia..........................................................................................................................................354
24.2.3 Invagination...................................................................................................................................................354
24.3 Urogenital Tract.................................................................................................................................... 355
24.3.1 Vesicourethral Reflux (VUR)......................................................................................................................355
24.4 Musculoskeletal.................................................................................................................................... 356
24.4.1 Child Abuse (Battered Child)....................................................................................................................356
24.4.2 Osteomyelitis.................................................................................................................................................356
24.4.3 Hip Dysplasia.................................................................................................................................................356
24.5 Oncology................................................................................................................................................. 356
24.5.1 Neuroblastoma.............................................................................................................................................356
24.5.2 Nephroblastoma (Wilms’ Tumor)............................................................................................................357
24.5.3 Medulloblastoma.........................................................................................................................................357

III Testing
25 MC Questions and Answers..................................................................................................... 361
Mirja Wenker, Christel Vockelmann, and Martina Kahl-Scholz
25.1 MC Questions......................................................................................................................................... 362
25.2 MC Responses........................................................................................................................................ 365

26 Clinical Cases.................................................................................................................................... 369

Mirja Wenker, Christel Vockelmann, and Martina Kahl-Scholz
26.1 
Pulmonary Embolism or …............................................................................................................... 370
26.2 Swollen Hands....................................................................................................................................... 370
 XIX
Contents

26.3 
Pain in the Lower Leg.......................................................................................................................... 370
26.4 Chest Pain and Circulatory Problems............................................................................................ 371
26.5 A Swollen Leg........................................................................................................................................ 371
26.6 Hematuria............................................................................................................................................... 371
26.7 Frequent Urination.............................................................................................................................. 372
26.8 Riding Accident..................................................................................................................................... 372
26.9 Laceration to the Forehead............................................................................................................... 373
26.10 Persistent Headache............................................................................................................................ 374

27 Solutions.............................................................................................................................................. 375
Mirja Wenker, Martina Kahl-Scholz, and Christel Vockelmann
Editors and Contributors

About the Editors

Martina Kahl-Scholz
is a medical doctor and graduate pedagogue. She did her doctoral thesis in radiology
and discovered her passion for this broad subject. Together with Dr. Vockelmann she
has already published several books in this medical branch.

Christel Vockelmann
is chief physician of the radiology department of the Christophoruskliniken Coes-
feld, Dülmen and Nottuln. She is also a member of the PJ examination board. In
addition to being the editor of Fachwissen MTRA, Dr. Vockelmann can look back
on co-authorship of several books.

Contributors

Ursula Blum Practice for nuclear medicine, Mühlheim an der Ruhr

Guido Heilsberg Clinic for Radiotherapy and Radio-Oncology, Klinikum Dortmund

gGmbH, Dortmund

Martina Kahl-Scholz Münster

Carla M. Kremers Radiological Clinic, Christophorus-Kliniken GmbH, Dülmen

Esther Münstermann Clinic for Radiotherapy and Radio-Oncology, Klinikum Dortmund

gGmbH, Dortmund

Christel Vockelmann Christophorus Clinics GmbH, Coesfeld, Germany

Mirja Wenker Radiological Clinic, Christophorus-Kliniken GmbH, Coesfeld

 1 I

Basics
Contents

Chapter 1 Physical Basics – 3

Martina Kahl-Scholz and Christel Vockelmann

Chapter 2 Conventional X-ray Diagnostics – 17

Christel Vockelmann

Chapter 3 Mammography – 29
Christel Vockelmann

Chapter 4 Transillumination – 33
Martina Kahl-Scholz

Chapter 5 Angiography, Rotational Angiography/

Angio-CT – 37
Martina Kahl-Scholz and Christel Vockelmann

Chapter 6 Computed Tomography (CT) – 43

Mirja Wenker

Chapter 7 Magnetic Resonance Imaging (MRI) – 57

Carla Kremers

Chapter 8 Sonography – 75
Christel Vockelmann and Martina Kahl-Scholz

Chapter 9 Contrast Agent – 83

Martina Kahl-Scholz

Chapter 10 Radiotherapy – 93
Guido Heilsberg
Chapter 11 Nuclear Medicine – 101
Ursula Blum

Chapter 12 Emergencies and Extreme Situations – 119

Christel Vockelmann and Martina Kahl-Scholz

Chapter 13 Legislation – 125

Christel Vockelmann
 3 1

Physical Basics
Martina Kahl-Scholz and Christel Vockelmann

Contents

1.1 Radioactivity and Its Interactions – 4

1.1.1  adioactive Decay Modes – 4
R
1.1.2 The Physical Half-Life – 5
1.1.3 Physical Interaction Processes of Electromagnetic Radiation
with Matter – 6
1.1.4 Interaction of Particle Radiation with Matter – 7

1.2 X-Rays – 7

1.3 Dose Terms – 8

1.3.1  erma = Kinetic Energy Released in Matter – 9
K
1.3.2 Ion Dose – 9
1.3.3 Absorbed Dose – 9
1.3.4 Equivalent Dose – 9
1.3.5 Incident Dose – 10
1.3.6 Surface Dose – 10
1.3.7 Deep Dose – 10
1.3.8 Dose Area Product – 10
1.3.9 Dose Length Product – 10
1.3.10 Organ Dose – 11
1.3.11 Effective Dose – 11
1.3.12 Personal Dose, Local Dose and Body Dose – 11

1.4 Effect of Ionizing Radiation on the Organism – 12

1.4.1  adiation Effects – 12
R
1.4.2 Phases of the Radiation Effect – 13

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 4 M. Kahl-Scholz and C. Vockelmann

Ionizing radiation is used for the early detec- the type of decay, the energy is emitted in
1 tion and diagnosis of diseases by imaging the form of particle or electromagnetic radi-
techniques and for the treatment of malig- ation. The unit of radioactivity is Becquerel
nant tumors. The physical principles, the (Bq). Antoine-Henri Becquerel discovered
origin of the different types of radiation and uranium at the end of the 19th century.
their interaction with matter will be exam-
ined in more detail in the following sections. >>The type and energy of the emitted radi-
Special attention will be paid to the radia- ation is characteristic for each radionu-
tion protection of the examiner. clide.

z Alpha Decay (α-Decay)

1.1 Radioactivity and Its In heavy nuclides, α-radiation is produced
Interactions by the emission of an α-particle consisting
of two protons and two neutrons. This
In order to understand how we use different causes Z to decrease by two, A by four. In
types of radiation in the diagnosis and ther- addition, two electrons leave the atomic
apy of diseases, but also what dangers ema- bond. The α-particle is accelerated by the
nate from the various types of radiation, we released energy. The amount of this kinetic
must first take a look at the physical and energy is the same for each α-particle, so it is
chemical fundamentals. This includes the monoenergetic radiation. Due to the large
characterization of atomic nuclei, which are mass of the α-particles, they are rapidly
made up of protons and neutrons. Protons decelerated by matter, i.e. also by the body,
and neutrons are called nucleons. The mass and release their energy directly to the tissue.
number A is the number of nucleons (that is, As a result, the affected cell is severely
protons and neutrons) in the nucleus. The destroyed. Because of this pronounced
number of protons in the nucleus gives the effect, α-radiation is almost no longer used
atomic number Z. Atomic number Z and in medicine. α-radiation can already be
mass number A occur repeatedly in the fol- shielded by a simple sheet of paper.
lowing section, since both numbers change
with the different types of decay. z Beta-Minus Decay (β−-Decay)
β− emitters are used in medicine for nuclear
>>Atomic number Z corresponds to the medical therapies. The treatment of benign
number of protons in the nucleus. Mass and malignant thyroid diseases with
number A corresponds to the number of iodine131 (131 J) is particularly worth men-
protons and neutrons in the nucleus. tioning here. The range of the β−-radiation
is higher than that of the α-radiation, but it
is not sufficient for diagnostic applications,
where an image of the radiation outside the
1.1.1 Radioactive Decay Modes body is to be captured. In atomic nuclei with
a high neutron excess, a neutron is converted
Radioactivity is produced by the emission of into a proton, an electron (β−-particle) and
radiation through spontaneous nuclear an antineutrino. Thus the additional proton
transformations. In this process, radionu- increases Z by 1, A does not change. The β−
clides change from an unstable to a stable particle and the antineutrino leave the
state while releasing energy. Depending on nucleus, and the kinetic energy released is
Physical Basics
5 1
distributed between them. So the β−-particle tron from an outer, higher-energy shell, and
can have energy values between zero and when it bounces back, the energy released
maximum energy, we do not get monoener- from the energy difference between the two
getic radiation but a continuous energy shells is emitted as characteristic X-rays.
spectrum. The antineutrino has an extremely Some nuclides used in nuclear medicine
small interaction with matter, but must be diagnostics are produced by EC e.g.201
taken into account in the energy balance of Thallium. If the atomic number of the
the β−-decay. nuclide is below 30, the energy is mainly
transferred directly to electrons. These so-
z Beta-Plus Decay (β+-Decay) called Auger electrons leave the atomic
The radiation produced by β+ decay is used bond.
in medicine primarily in positron emission
tomography (PET). The most commonly z Internal Conversion/γ-Radiation
used emitter is18 fluorine. After a nuclear transformation, a residual
In atomic nuclei with an excess of pro- energy often remains in the daughter nucleus
tons, a proton transforms into a neutron, a for a short time, the nuclides are excited or
positron (β+-particle) and a neutrino, Z metastable. This residual energy is released
decreases by one, A remains constant. β+- via two competing processes.
particle and neutrino leave the nucleus. As in On the one hand, the excitation energy
β−-decay, the released kinetic energy is dis- of the nucleus is transferred directly to an
tributed with a continuous spectrum. The electron of the shell. If the binding energy
neutrino interacts negligibly with matter, of the electron is exceeded, the electron
but must be taken into account in the energy leaves its place. The resulting gap is also
balance of the β decay.+ filled with an electron of a higher, more
As an antiparticle, the positron has only energetic shell; again, depending on the
a short lifetime and unites with a free elec- atomic number, characteristic X-rays or the
tron of the environment within microsec- emission of Auger electrons are produced.
onds. Near the nucleus, the mass of both However, the energy released when the
particles is converted into two photons, nucleus is excited can also be emitted as elec-
which fly apart at an angle of 180° and with tromagnetic radiation in the form of gamma
an energy of 511 keV per quantum (annihi- quanta of equal or different energy. A
lation radiation). The β+ decay can therefore gamma emitter frequently used in nuclear
only occur if the energy difference between medical diagnostics is99m Tc.
mother and daughter is 1022 keV.

z Electron Capture 1.1.2 The Physical Half-Life

If the decay energy at proton excess is
smaller than 1022 keV, electron capture Another characteristic quantity of a radio-
occurs instead of β+-decay. An electron from active substance is the so-called physical
the near-nuclear shell migrates into the half-life. In this period of time, half of the
nucleus and combines with a proton. A neu- originally existing atoms have decayed.
tron is produced and a neutrino leaves the Depending on the substance, the physical
nucleus, Z decreases by one. A does not half-life ranges from fractions of seconds to
change. The electron gap is filled by an elec- billions of years.
 6 M. Kahl-Scholz and C. Vockelmann

1.1.3 Physical Interaction binding energy and the energy required for
1 Processes of Electromagnetic ionization is transferred to the photoelec-
tron released from the atomic shell as kinetic
Radiation with Matter
energy.
I nteraction of Photon Radiation
>>The higher the residual energy, the more
with Matter
the photoelectrons are emitted in the
The interaction of photons with matter, direction of the primary beam.
including the patient, attenuates the radia-
tion intensity in proportion to the material In order to be able to delimit hollow organs
thickness d and the attenuation coefficient μ. and vessels in the native X-ray image, the
Mathematically, the relationship is expressed patient is given a so-called positive contrast
in Lambert-Beer’s law: I(d) = I(0) exp(−μd). medium with a high atomic number (J:
The attenuation coefficient μ depends on the Z = 53; Ba Z = 56…), which absorbs the
material and its nuclear charge number Z X-rays more strongly than the surrounding
and on the energy E of the photons. The tissue. In nuclear medicine, the scintigraphic
attenuation of the radiation occurs by image is produced by the unscattered pho-
absorption (photoelectric effect and pair tons emerging from the body.
formation) and by scattering (Compton When electrons excited by the photoelec-
effect). tric effect jump back to their original orbit
and release the energy again, this is called
>>Attenuation = Absorption + Scattering classical scattering. The emitted photon
radiation has the same energy and therefore
also the same frequency as the original radi-
z Photoelectric Effect ation. If the frequency is in the range of vis-
In the energy ranges of up to 100 keV used ible light, we can see these light quanta as
in radiology, the photoelectric effect is the luminescence. Luminescence is the basis of
basis for image formation. The X-rays emit- the imaging plate technique, with which the
ted from the X-ray tube are attenuated by resulting radiation image is stored as an
tissues such as bone and soft tissue with X-ray image that we can use. Barium halides,
their different densities according to for example, are excited in the imaging plate,
Lambert-­Beer’s law. The resulting radiation which is in the X-ray cassette, by means of a
image has different shades of gray due to the photoelectric effect. A laser in the readout
different attenuation. unit causes the previously held electrons to
fall back to their original state and the imag-
>> The more energetic the photon radiation, ing plate lights up, producing the X-ray
the weaker the contrast, as the attenuation image.
decreases with increasing beam energy.
z Compton Scattering
In photoabsorption, the total energy of the The Compton effect describes a scattering
photon radiation is transferred to an elec- of the photon, which gives only a part of its
tron of the atomic shell of matter. The shell energy to the shell electron of the outer
electron is either excited and thus raised to a shell. The photon itself is scattered with the
shell of higher energy or ionized and residual energy in a changed direction.
knocked out of the atomic shell. Ionization Secondary electrons of lower energy are
occurs when the energy of the photon scattered in the lateral direction, the higher
exceeds the binding energy of the electron to the residual energy, the more the secondary
the nucleus. The difference between the electrons are scattered in the forward direc-
Physical Basics
7 1
tion. These scattered photons degrade image Neutrons and protons are used to treat
quality in diagnostic imaging and therapy. deeper tumors. These procedures are tech-
These scattered photons are captured by nically very complex and therefore only
scattering beam grids (7 Chap. 2) made of available at specialized centers. Neutrons
lead lamellae; in nuclear medicine, the cor- and protons emit their energy at a certain
responding counterpart is the placement of resonance energy of the tissue. As long as
a corresponding energy window to capture this resonance energy is exceeded, they
low-energy scattered photons. penetrate deeper into the tissue with little
energy release. When the initial energy has
z Pair Formation decreased to the level of the resonance
The pair formation effect occurs at high energy, the energy delivery to the tissue
photon energies from 1022 keV. Near the increases and the tissue in the target area
nucleus, the photon forms a pair of an elec- is destroyed.
tron (negatively charged) and a positron
(positively charged). The atomic nucleus >>55 The higher the number of atoms present,
remains unchanged. The formed pair anni- the more interaction processes occur.
hilates with an electron of the absorber in The attenuation depends on the density
two annihilation quanta of 511 keV each. and thickness of the matter irradiated.
This effect of energy dissipation plays an 55 The probability of photoabsorption
essential role in radiation therapy when occurring depends on the atomic
ultra-hard photons are used. number of the matter being irradi-
ated and thus also on the number of
electrons available.
1.1.4 Interaction of Particle 55 High-energy radiation penetrates matter
Radiation with Matter without significant photoabsorption.

The energy output of electrically negative

particles to matter can be achieved by ion- 1.2 X-Rays
ization, generation of deceleration radiation
and excitation. The energy output of the In contrast to radio waves, for example,
electrons is proportional to the density of X-rays are very short-wave and therefore
the matter, in contrast to photon radiation, have a high frequency. X-rays are generated
the range of the electrons is finite. The in an evacuated glass bulb, the X-ray tube,
occurring interactions of the particle beams which contains a cathode and an anode.
with the matter depends on mass and charge Two different types of voltage are applied to
of the particle, which is determined by its the tube: a heating voltage for the cathode
rest mass and velocity. and a high voltage between the cathode and
the anode. Due to the thermoelectric effect,
>>As a rule of thumb, the range of elec- the heating voltage initially causes an elec-
trons in centimeters in tissue-equivalent tron cloud to “evaporate” at the cathode.
matter (water) corresponds to half the This is accelerated to the anode by the high
energy in MeV. voltage applied (20,000–200,000 volts).
When the electrons hit the anode, there is an
Electrons are used in the radiotherapy of abrupt deceleration of the electrons, and the
superficial tumors. The depth of treatment kinetic energy of the electrons is converted
and thus the protection of the underlying into X-rays, electromagnetic waves and heat.
tissue is achieved by the appropriate choice In addition, direct interactions of the elec-
of electron energy. trons with the anode material occur.
 8 M. Kahl-Scholz and C. Vockelmann

>>The higher the atomic number of the Characteristic X-ray radiation is pro-
1 anode material and the higher the high duced in addition to X-ray deceleration radi-
voltage with which the electrons are ation and is a so-called line spectrum, which is
accelerated towards the anode, the exclusively dependent on the anode material.
higher the yield of X-rays. The characteristic line spectrum is, so to
speak, the fingerprint of the anode material.
The energy of the accelerated electrons This line spectrum is produced by the
before impacting the anode is given by: knocking out (ionization) or excitation (lift-
1. the number of electrons accelerated to ing to a higher energy level) of electrons
the anode, i.e. evaporated from the cath- from the two inner shells of the atoms of the
ode, and anode material. The empty spaces on the
2. from the tube voltage, which accelerates inner electron shells are filled up again from
the electrons towards the anode. the outside, the released energy is released in
the form of characteristic X-rays, which are
The unit of this energy is the electron volt clearly defined according to their wave-
(eV). length.

>>One eV is defined as the energy absorbed >>In an X-ray tube, only 1–2% of the
by an electron when it is accelerated dur- X-rays are produced; the rest of the
ing the free passage of a voltage of 1 V energy of the accelerated electrons is
(without resistance in vacuum). converted into heat.

Two types of X-ray radiation are produced: Gamma rays have the same properties as
X-ray deceleration radiation and character- X-rays. The two types differ only in the place
istic X-ray radiation. of their origin and energy.
The deceleration of the electrons at the
nucleus produces X-ray deceleration radia- >>While X-rays are produced in the atomic
tion. Some electrons release radiation as shell, gamma rays are produced by
soon as they hit the anode, others penetrate radioactive decays in the atomic nucleus.
deeper into the electron material, whereby
they have already lost part of their energy X-ray quanta have an energy of 100 eV to
and only generate X-rays afterwards. This 200 keV. For gamma quanta, this range
process explains why the X-rays produced extends from about 1 keV to several MeV.
have different wavelengths. The amount of
X-rays produced depends on how much the >>X-rays, together with α-, β- and γ-rays,
electron is decelerated. The immediately belong to the group of ionizing rays.
produced X-ray deceleration radiation has a This means that all these types of radia-
smaller wavelength than the radiation pro- tion interact with matter.
duced by the initially decelerated electrons.
X-rays of different wavelengths produce
a gapless, continuous X-ray deceleration
spectrum that is independent of the anode 1.3 Dose Terms
material. Short-wave radiation can pene-
trate matter better than long-wave radiation. When dealing with ionizing radiation, one
In practice, it is possible to produce shorter-­ encounters a myriad of dose terms where
wave X-ray radiation, which can penetrate one can quickly lose track. Let us try to
matter better, by applying a higher pick-up bring some order into the many terms and
voltage (high voltage) to the generator. to understand when we need which terms.
Physical Basics
9 1
1.3.1 Kerma = Kinetic Energy from which the absorbed dose for specific
Released in Matter materials or the human body can be
calculated.
Photon and neutron beams, i.e. indirectly
ionizing beams, release charged particles,
so-called secondary particles. Kerma is
1.3.4 Equivalent Dose
therefore dependent on the irradiated
The dose equivalent describes the absorbed
medium. The sum of the energy transferred
dose multiplied by a weighting factor. This
during the first impact corresponds to the
takes into account the relative biological
kerma. Kerma is expressed in Gray (Gy). In
effectiveness (RBE) of the absorbed type of
medical dosimetry, the kerma corresponds
radiation. Since the weighting factor has no
approximately to the absorbed dose.
dimension, the unit of dose equivalent is the
same as that of absorbed dose, i.e. joules per
1.3.2 Ion Dose kilogram. However, to avoid confusion with
the absorbed dose, the equivalent dose is
The ion dose describes the electric charge of expressed in sieverts (Sv).
the ions of the same sign, which are pro-
duced by ionizing radiation in a certain >>Equivalent dose rate describes the equiv-
mass. The unit of ion dose is coulomb per alent dose absorbed per unit of time.
kilogram. In the past, the ion dose was
expressed in X-rays. Let us return to the relative biological effec-
tiveness. The different types of radiation
>>Rod dosimeters or ionization chambers show different biological effects. The RBE is
measure the ion dose. defined as the ratio of the absorbed dose of
a reference radiation, which causes a certain
>>Ion dose rate describes the absorbed ion biological effect, to the dose of another
dose per time unit radiation, which leads to the same biological
effect on the same object.
The RBE thus correlates to the energy
transfer of the radiation to the irradiated
1.3.3 Absorbed Dose object. The measure for this is the linear
energy transfer (LET). This is an indirect
The absorbed dose is the basic quantity in measure of the number of ionizations per
dosimetry. It describes the absorbed radia- path length. Radiation of heavy, charged par-
tion energy in relation to the irradiated mass. ticles exhibits a higher linear energy transfer,
i.e. it generates a large number of ionizations
Dose = absorbed energy / mass and triggers more biological effects on the
Unit of absorbed dose is also Gray (Gy). In irradiated object. In addition to the type of
older books you may come across the term radiation, the linear energy transfer also
rad (rd), which was used until 1985. A con- depends, of course, on the irradiated object.
version is made as follows:
>>The RBE increases only up to a maxi-
One rd  0.001Gy  0.001 Jkg 1 mum at about 100–200 keV/μm, and
then drops sharply. The reason for this is
The absorbed dose cannot be measured in the so-called overkill. More energy is
the body. Therefore, the ion dose is mea- transferred to the cell than is necessary
sured in an air-filled ionization chamber, for inactivation.
 10 M. Kahl-Scholz and C. Vockelmann

After these theoretical basics, we come to The dose distribution at depth is caused
1 values that are important in daily practice. by three effects:
These are partly displayed directly on the 1. the weakening in the tissues,
devices and are also subject to documenta- 2. the dose decrease due to the distance
tion according to the X-ray ordinance. increasing with depth,
3. added scattered radiation.

1.3.5 Incident Dose Scattered radiation also plays a role in the

depth dose. Therefore, there is also a depen-
This describes the dose in Gy, that is mea- dence on the field size here.
sured “free air” without stray bodies. By
scattering bodies are meant phantoms or
also patients, which would lead to a scatter- 1.3.8 Dose Area Product
ing of the radiation. The incident dose
depends on the focal distance, energy (in As the name suggests, the dose area product
X-rays kV and filter) and the dose rate. The (DFP) is the product of dose and area. This
field size has only little influence. is the dose value that is calculated, for exam-
ple, during a normal X-ray examination of
the lungs and must be documented in accor-
1.3.6 Surface Dose dance with the X-ray Ordinance.
It gets a bit more complicated, because
Now the patient or a phantom comes into the dose is sometimes given in cGy, some-
play. In addition to the incident dose, the times in μGy and also the unit for the area
backscatter from the irradiated object, e.g. can be given e. g. in m2 or cm.2
the patient, is added to the surface dose. The conversion is implemented as fol-
On the inlet side, the backscattering can lows:
be up to 50%. The backscattering is strongly
dependent on the field size. 1cGy cm 2  10 mGy cm 2  0.1dGy cm 2
In radiotherapy, the surface dose at the  1Gy m 2  10 6 Gy m 2
exit side is also important, as this must be Occasionally, the term area dose product
taken into account in the case of opposing with the abbreviation FDP is also used as a
fields. More on this later. synonym.

1.3.7 Deep Dose 1.3.9 Dose Length Product

The depth dose describes the dose at a cer- The dose length product (DLP) is the equiva-
tain body depth, measured from the irradia- lent of the dose area product for computed
tion surface. The relative depth dose tomography. The product is formed from the
indicates the ratio of a depth dose to the dose in a slice, the weighted CTDI (Computed
dose maximum in percent. The depth dose is Tomography Dose Index), and the number of
particularly important in radiation therapy, slices. The CTDI is necessary because, in con-
since here a specific dose at a specific loca- trast to projection radiography, the patient is
tion in the body, e.g. a lung tumor, is tar- exposed to X-rays from all sides. The CTDI is
geted for therapeutic success. At the same determined with the aid of water phantoms
time, surrounding healthy tissue should of that simulate the conditions of the human
course not be damaged. body as accurately as possible.
Physical Basics
11 1
The dose terms DFP and DLP used so far The sum of all tissue weighting factors is 1.
do not ultimately say anything about how dan- By calculating the effective dose, radiation
gerous or harmless the radiation used is for the exposures can be compared with each other.
patient. In order to be able to make a state- Numerous computer programs are now
ment about this, one must know which organ available for estimating the effective dose.
regions have been exposed to the radiation.

1.3.10 Organ Dose 1.3.12  ersonal Dose, Local Dose

P
and Body Dose
Organ dose stands for the absorbed dose to
an organ or body part in Gy, multiplied by a According to the Radiation Protection
radiation weighting factor. This depends on Ordinance and the X-ray Ordinance, it is
the type of radiation used. Actually, you generally required that body doses are deter-
already know this from relative biological mined for persons who are in controlled
effectiveness. In contrast to the experimen- areas. For the whole-body dose, a homoge-
tally scientifically determined relative bio- neous radiation exposure of the entire body
logical effectiveness, the radiation weighting is assumed. The mean value of the equiva-
factor is determined by legal standard. It is lent dose for the head, torso, upper arm and
not yet assessed how radiation-sensitive the thigh is then calculated. For partial body
corresponding organ is. doses, the mean value of the equivalent dose
in an organ or body part is determined.
These values are important in occupational
1.3.11 Effective Dose radiation protection. Here, limit values are
specified both for the whole-body dose and
The effective dose takes into account the for partial-body doses.
sensitivity of the individual organs. The However, the problem with partial body
effective dose is determined by the sum of doses and also whole body doses is that
the organ dose multiplied by the tissue these values cannot be measured directly.
weighting factors. The tissue weighting fac- Therefore, simpler measurands (local dose
tors are calculated and determined by the and personal dose) are defined as a proxy,
International Radiation Protection which allow an estimation of the effective
Commission (IRCP). dose if required.
The following table shows some exam-
ples of tissue weighting factors (. Table 1.1). z Local Dose
Here, the equivalent dose for soft tissue is
measured at a specific location.
..      Table 1.1 Examples of tissue weighting
factors
z Personal Dose
Organs and Tissues Tissue Weighting Factor Measured at a representative site on the
body surface, the personal dose represents
Gonads 0.08 the equivalent dose to soft tissue.
Rred bone marrow 0.12
Chest 0.12
>> The personal dose is determined on the
basis of the X-ray badge. You should wear
Skin 0.01 this ventrally on your torso. If you work
Brain 0.01 in controlled areas, the badge belongs on
your clothing under the lead apron.
 12 M. Kahl-Scholz and C. Vockelmann

1.4  ffect of Ionizing Radiation

E The properties of the different types of
1 on the Organism radiation also play a major role when con-
sidering the effects of radiation on the
As the tragic and well-known events from human organism. One measure of the dam-
Japan and Ukraine, among others, have aging effect is the Linear Energy Transfer
shown, ionizing radiation is very dangerous (LET), which describes how many ioniza-
for humans. Both accidents released radio- tions a radiation quantum can trigger on its
active iodine and cesium – both are beta way through tissue.
emitters that are incorporated and thus trig- LET  lost of energy  keV  /
ger more interactions in the organism.
flight distance   m 
Particle radiation is one of the densely ion-
1.4.1 Radiation Effects izing types of radiation that are hardly scat-
tered but trigger numerous ionizations.
The effect of the different types of radiation X-rays (photon radiation), on the other
depends on the frequency of the radiation hand, trigger comparatively fewer ioniza-
and the associated interaction processes tions, but are more strongly scattered and
which the types of radiation enter into with thus also influence surrounding cells.
matter. These are based on the elementary The Linear Energy Transfer corresponds
processes of excitation and ionization. to the physical consideration of the radia-
During excitation, an atom is moved to a tion effect. Relative biological effectiveness
higher energy state by supplied energy. In (RBE) describes the potential health hazard
this process, a shell electron of an inner shell posed by different types of radiation. The
is lifted to a higher shell. Within a very short RBE factors relate the biological effects
time, the excess energy is usually released obtained by using the same dose in Gray:
again by emitting electromagnetic wave 55 X-rays: 1
radiation. The excited atoms are very reac- 55 Gamma radiation: 1
tive and can enter into chemical reactions 55 Beta radiation: 1
which are relevant for the effect of the radia- 55 Neutron radiation (depending on
tion on the organism as a whole. energy): 5–20
Ionization describes the absorption or 55 Proton radiation: 5
release of an electron and the associated dis- 55 Alpha radiation: 20
turbance of the equilibrium of charges in an
atom. This can occur either by impact ion- The effect radiation can cause in the organ-
ization, i.e. direct ionization (a charged par- ism depends on several factors:
ticle hits a shell electron and releases energy) 55 Which tissue is irradiated?
or by absorption and thus indirect ioniza- 55 What dose was administered?
tion (electromagnetic waves or neutrons hit 55 What is the LET/ionization density of
an atom and their energy is absorbed, releas- the radiation?
ing an electron from the atomic bond).
When passing through matter, the electro- For this reason, the effects of radiation acci-
magnetic radiation is weakened by absorp- dents such as those in Fukushima or
tion of the energy. This absorbed part of the Chernobyl are also not comparable with
radiation, whose energy has thus been trans- their use in medicine. Irrespective of this,
ferred to the matter that has been radiated such events and their effects serve to research
through, is relevant for the effect on the body. the consequences of radiation.
Physical Basics
13 1
All these results are used by professional protection, deterministic damage must not
societies for the assessment of necessary occur. From the point of view of therapy,
limit values for e.g. foodstuffs and the devel- however, it is precisely this damage that is
opment of medical applications. “desired”, since research results can prove
A distinction is made between two types when the threshold dose of a tumor is also
of radiation effect: reached.
In radiotherapy, deterministic damage is
Stochastic Radiation Effect specifically inflicted on malignant tumors.
Stochastics involves probability calcula- In order to successfully combat a tumor, a
tions. For the effect of ionizing radiation, compromise must be found between the safe
this means: Theoretically, every X-ray quan- destruction of the tumor and the still toler-
tum can trigger a damaging event. The more able side effect of the surrounding tissue.
X-ray quanta hit the organism, the higher As early as the 1930s, Hermann
the probability of a “hit”. Holthusen, a radiologist from Hamburg,
This stochastic radiation effect is the illustrated this in the diagram named after
basis for the top priority of radiation pro- him. He described that one can never strive
tection: for 100% tumor control, as the side effect
rate of 50% is then also too high. The ther-
>>“As Low As Reasonably Achievable” apy should be directed in such a way that
(ALARA principle)—only as little radi- one achieves 85–90% tumor control with
ation as absolutely necessary may be 5–10% side effects to be expected.
used, as there is no threshold dose for a
specific radiation damage.
1.4.2 Phases of the Radiation
For everyday medical practice, this means: Effect
Can I carry out the diagnosis without X-rays
(i.e. sonography, magnetic resonance imag- In connection with health damage caused by
ing)? Have I observed all the preliminary ionizing radiation, keywords such as
examinations? Do I need the X-ray examina- “radiation-­induced tumor” or “mutations in
tion at all, or am I only “interested” in it, but the offspring” are used. This suggests that
the treatment of the patient does not change? after exposure to radiation, an effect cannot
When performing the examinations, the be observed immediately, but may occur
same applies: Which area do I need to exam- many years or even generations later.
ine? Can I narrow down my radiation field? In order to explain this effect, one must
Can I reduce the dose for the question? first deal with the temporal sequence of the
Typical stochastic radiation damages are radiation effect.
gene and cell mutations that lead to tumors The phases of the radiation effect can be
and hereditary diseases only years after divided into four phases.
exposure.
Physical Phase
Deterministic Radiation Effect In this phase, the absorption of the radia-
Deterministic radiation effects occur above tion in the tissue takes place in fractions of a
a certain dose. We know, for example, after second (10–16 s). It is the starting point for
how much radiation the healthy skin reacts all further processes, since only the absorbed
with a skin reaction (erythema), there is a energy triggers an effect in the organism.
threshold dose. This is defined for each tis- The absorption leads to ionizations, molecu-
sue. From the point of view of radiation lar excitations and heat.
 14 M. Kahl-Scholz and C. Vockelmann

Physical and Chemical Phase kIrradiation Damage

1 This phase describes the chemical reactions After irradiation with 1 Gy of X-rays, the
and associated damage (direct and indirect) following damage can be found in a cell:
to the molecules. Direct damage is caused by 55 1000–2000 base changes
loss of bonding electrons in the molecules, 55 500–1000 single strand breaks
causing them to break apart. Indirect dam- 55 800–1600 changes in sugar molecules
age is caused by radicals, which are chemi- 55 150 crosslinks
cally very reactive substances. These 55 50 Double strand breaks and bulky
reactions also take place in the body in times lesions
far below one second (10−6 s).
This phase is also called the radiochemi- Sophisticated safety systems exist in the cells
cal phase. The free radicals are formed by to repair damage and thus prevent mutations.
the radiolysis of the water. Since the human Most of these repairs are completed in 6–8
cell consists of about 80% water, radiation h. Some, quick repairs take place in 10–20 min,
energy has plenty of points of attack here. others need the full repair time of a few days.
About 95% of all damage can be repaired.
Biochemical Phase
In the biochemical phase, which is in the sec- >>As a rule of thumb, after 2 h most of the
onds to minutes range, there are damaging possible repair processes on normal tis-
changes to organic molecules, which partic- sues are completed, after 6–8 h. This
ularly affect cell DNA. As a result of radi- temporal relationship is significant for
olysis, radicals are formed, including H2O2 the planning of a radiation therapy, if
(hydrogen peroxide), which is a powerful cell one wants to destroy tumor tissue and
toxin. spare normal tissue.
Which radicals are predominantly
formed and how strong their effect is also All unrepaired damage can lead to cell death
depends on the Linear Energy Transfer or mutations and thus to tumor ­disease.
(LET). The higher the LET, the:
55 more H2 O2 is formed, Biological Phase
55 less the presence of the oxygen plays a The last phase of the radiation effect is the
role, biological phase, which cannot be limited in
55 the radical yield is lower, time, in which mutations, changes in metab-
55 higher is the direct number of hits on the olism or cell death can occur at the cellular
cell and thus a higher number of non-­ level. Such changes often only become visi-
repairable cell damages. ble after decades through the development
of malignant tumors or even in subsequent
The radicals primarily attack the DNA of generations if damage has been inherited.
the cells and cause various types of damage Serious radiation effects on the cell
there. In basic experimental research, the include various forms of cell death:
following damage can be determined so far: 1. Loss of function in cells that are in the
55 Base modifications and base losses G0 phase and are no longer able to
55 Changes in sugar molecules divide, e.g. nerve cells, muscle cells.
55 Single and double strand breaks 2. Reproductive cell death, the cells lose
55 DNA crosslinks their ability to divide, e.g. hematopoietic
55 Multiple DNA alterations (bulky lesions) stem cells.
Physical Basics
15 1
3. Interphase death affects cells that are just
between two mitoses. The cell dies in a Practice Questions
few hours and does not reach the next 1. Briefly describe what is meant by pho-
mitosis. toelectric effect, Compton effect and
pair formation.
In radiotherapy, the relationships between 2. What is meant by incident dose, sur-
dose, cell damage, repair processes, tempo- face dose and depth dose?
ral dependencies and cell survival curves are 3. What is the difference between decel-
represented in various models (e.g. multitar- eration X-ray and characteristic X-ray
get model, linear-quadratic model) in order radiation?
to determine the ideal therapy for the indi- 4. What is the Relative Biological
vidual patient. Effectiveness (RBE)?
Not all tumor cells behave in the same way. 5. What are stochastic and what are
There are particularly radiation-­ sensitive deterministic radiation damages?
tumors (e.g. leukemia) and those that require
Solutions 7 Chap. 27
higher treatment doses (e.g. bone sarcomas).
Since in comparatively radiation-resistant
tumors the surrounding tissue is also exposed
to radiation, the radiation sensitivity of a
tumor can be increased, e.g. chemotherapy.
 17 2

Conventional X-ray
Diagnostics
Christel Vockelmann

Contents

2.1 Design and Operation of an X-ray System – 18

2.1.1 T he X-ray Source – 18
2.1.2 The X-ray Generator – 20
2.1.3 Mapping Laws – 21
2.1.4 Quality of the X-ray Image and Quality
Improvement Measures – 23
2.1.5 Setting Up a Bucky Workstation – 24
2.1.6 Mobile X-ray Equipment – 25
2.1.7 Special Radiation Protection Measures – 25

2.2 Digital Image Processing – 26

2.2.1  atrix – 26
M
2.2.2 Color Depth – 28
2.2.3 Error Correction – 28

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 18 C. Vockelmann

The chapter “Conventional X-ray diagnos-

tics” deals with the origin of X-ray radia- Tube protection
tion, the structure of the X-ray tube and the
Housing rotary anode
2 possibility of regulating the type and
amount of radiation. Furthermore, the for-
mation of the digital X-ray image as well as
Cathode Rotor
the processing of the images are dealt with,
and special devices of conventional X-ray e
diagnostics are described as examples.
Filament
Furthermore, you will find an overview of
the basic specifications of the guidelines of
the German Medical Association for con- X-rays
ventional X-ray diagnostics.
..      Fig. 2.1 Schematic structure of an X-ray source.
(From Hartmann et al. 2014)

2.1 Design and Operation i.e. airless, glass bulb. This glass bulb is
of an X-ray System located in an oil-filled radiation protection
housing. The oil serves to protect against the
An X-ray system always consists of the fol- high voltage and to dissipate heat to the out-
lowing components: side. The protective housing also shields the
55 an X-ray source that generates the beams, parts of the X-ray radiation that do not exit
55 an X-ray generator, which supplies the through the radiation exit window. Below
X-ray source with high voltage, the radiation exit window is a legally
55 an X-ray application device used for required filter made of 1.5 mm thick alumi-
positioning the patient, and num. This filters out the radiation that is
55 an X-ray image converter (X-ray film, unable to penetrate the body due to its
detector,…). energy.

z The Cathode
2.1.1 The X-ray Source The cathode consists of one or two fila-
ments which are heated by the so-called
Structure of the X-ray Tube tube current. The heat causes the electrons
An X-ray source is a cathode source and to oscillate (thermal electron emission) and
consists of a negatively charged cathode and they can be released by the voltage trig-
a positively charged anode. By heating the gered between the cathode and the anode.
cathode, electrons can be released from the The filaments are mainly made of tung-
cathode. Due to the different charges sten, since tungsten has the highest melting
between the cathode and the anode, these point of all metals (3680 K = 3406.85 °C)
electrons are then accelerated towards the and the electrons can also be released rela-
anode and finally hit the anode where, tively easily. The released electrons or the
among other things, X-rays are produced electron cloud is now accelerated towards
(. Fig. 2.1). the anode.
Since the electrons would be slowed Since the electrons would travel undi-
down and deflected in normal air, the cath- rected in the direction of the anode, they are
ode and anode are located in an evacuated, focused by a Wehnelt cylinder. This cylinder
Conventional X-ray Diagnostics
19 2
is located in the immediate vicinity of the z Focal Spot/Focus
cathode. By applying a negative charge, the Since X-rays are generated in the X-ray tube
exit of the electrons can be regulated and the not only at one point but on a surface, the
direction of flight focused. phenomenon of the penumbra occurs
(. Fig. 2.2). On the X-ray image, the image
z The Anode of details becomes blurrier due to this phe-
When the electrons hit the focal spot (also nomenon.
called focus) at the anode, various processes In order to reduce the area as much as
or even interactions occur. Only 1% of the possible, two tricks are used:
energy is converted into X-rays, 99% of the 1. By bevelling the edge of the plate, not
energy is released into heat. only a more favorable change in the
Because of the large amount of heat gen- direction of the radiation is achieved,
erated, the anode must be made of a particu- but also an optical reduction in the size
larly heat-resistant and thermally conductive of the focal spot, depending on the angle
material. Here, too, tungsten or a tungsten-­ of the bevel.
rhenium mixture has proven to be ideal. In 2. The tubes usually have two different
order to distribute the heat generated over a sized cathode filaments, the large and the
large volume, rotating anodes are used in small focus. The small focus allows a
X-ray diagnostics. The anode is shaped like a higher spatial resolution, but is not as
plate and is rotated by an electric motor powerful.
(typical speed: approx. 3000 rpm). This heats
not only a single point, but an entire circular
path. Since the electrons always “destroy” The Depth Stop with Light Sighting
tiny parts of the anode, this distribution also The depth diaphragm is mounted below the
prolongs the life of the anode. X-ray protection housing.
Nowadays, the entire plate is no longer In the upper area of the depth stop, there
made of tungsten, but consists of molybde- are additional filters that can be moved into
num and graphite to optimize heat distribu- the beam path either manually or electroni-
tion (composite anode). Only the focal spot cally. These filters have the same task as the
track is still made of tungsten. filter located directly at the beam exit win-

..      Fig. 2.2 Penumbra as a function of focal size. (From Hartmann et al. 2014)
 20 C. Vockelmann

dow. The low-energy radiation components generators are no longer approved for use in
that do not contribute to imaging are filtered human medicine.
out. This is also referred to as “hardening” Nowadays, only so-called converter or
2 of the radiation. high-frequency generators are used. In princi-
The depth diaphragm contains adjust- ple, the tube voltage is generated according to
able lead blades that block the X-rays. A dis- the same principle. By means of electronic cir-
tinction is made between the near-focus and cuits, however, a much more uniform tube
near-object apertures. While the near-tube voltage is achieved and can also be adapted to
diaphragms shield the radiation that has not the characteristic curves of the tube in order to
originated directly at the focus (extrafocal ensure an optimum yield of radiation.
radiation), the near-object diaphragms serve
to adjust the field size, i.e. the area to be Tube Voltage
examined. The voltage applied between the cathode
In order for this field to be visible, a and anode is used to control the speed of the
transmissive mirror is placed in the beam electrons and thus the energy with which
path of the X-rays, which is illuminated by these electrons hit the anode. Due to the
a light bulb. The deflected light field is vis- effects mentioned above, the radiation
ible below the depth stop and corresponds becomes more energetic (beam quality).
exactly to the radiation field of the X-ray
tube. The depth diaphragm is also rotat- >>Higher-energy radiation has a shorter
ably attached to the protective housing in wavelength than low-energy radiation.
order to optimally adapt the field to the High-energy (or as it is called in radiol-
exposure. ogy “harder”) radiation can penetrate
An area dose meter is attached to the exit dense structures more easily than lower-­
window of the depth aperture. energy (“soft”) radiation.

These differences are used, for example, to

2.1.2 The X-ray Generator make the ribs appear almost transparent on
an X-ray of the thorax. This makes it easier
The main component of a generator is the to assess the lungs.
transformer. Since the radiation produced in the tube
With a single-phase generator, “gaps” in consists primarily of deceleration radiation,
the applied tube voltage occur again and an increase in voltage does not only lead to an
again due to the blocking of the negative increase in energy. Due to the higher-­energy
voltage. Now one can convert this negative electrons, more radiation is also produced at
part by means of a rectifier. But even then the lower energy spectrum. The voltage there-
the effective voltage is still full of gaps (two- fore has a disproportionate influence on the
phase generator). If a three-phase supply is amount of radiation (. Fig. 2.3).
chosen (this consists of three alternating
voltages which are applied to the coil in a Tube Current
time-shifted manner), these gaps become With the heating current applied to the cath-
smaller, but there is no constant voltage in ode, the amount of radiation can be dosed.
the X-ray tube (three-phase or six-phase
generator). >>A high current releases more electrons,
Since these fluctuations in the tube volt- which can migrate to the anode: thus one
age deteriorate the quality of the resulting increases the amount of radiation (radi-
X-rays to the detriment of the patient, these ation quantity).
Conventional X-ray Diagnostics
21 2
>>The higher the voltage, i.e. the harder the
radiation, the less detail can be seen of
the bone structures.

It is therefore necessary to choose the opti-

mal mix between radiation quality and
quantity for each body region.

Exposure Point System

If you want to set the voltage (kV) or the
90kV amount of charge (mAs) for an X-ray expo-
sure on the X-ray generator, the first thing
..      Fig. 2.3 Radiant energy as a function of current you notice is that this setting can only be
intensity. (From Hartmann et al. 2014) made in certain stages. These individual
steps are called exposure points (BP). The
values of these steps depend on the X-ray
tube and can differ from one X-ray system
to another.

Automatic Exposure Control

A more precise setting of the dose can be
achieved with the automatic exposure con-
trol.

70kV 90kV
2.1.3 Mapping Laws
..      Fig. 2.4 Radiant energy as a function of voltage.
(From Hartmann et al. 2014) As is known from natural light, the known
laws also apply to X-rays:
The amount of radiation is largely pro-
portional to the current intensity (. Fig. 2.4). Ray Theorem
The tube current at the generator is usu- The X-ray image is always a central projec-
ally controlled by adjusting the current-time tion with the focus as the center (. Fig. 2.5).
product, i.e. the amount of charge. The X-rays represent an object (G) on a pro-
jection surface (B) (film, detector). Here, the
Dose beam coming directly from the focus and
The dose is always a mixture of tube current located in the center of the irradiated field is
and voltage. If, for example, the voltage is called the central beam. The beam that
increased for a forearm exposure, the result- strikes the irradiated surface perpendicu-
ing radiation can travel more easily through larly is called the perpendicular beam.
the bones. Thus, less radiation is needed for With such a type of projection, the law
the X-ray image than if a radiation is of mapping applies:
selected, a large part of which “gets stuck in In X-ray imaging, the distance g is called
the bone”. the focus-object distance and the distance b
 22 C. Vockelmann

for example, a specific region is enlarged by

enlarging the OFA.
When taking a thoracic image, one would
2 like to image the heart as accurately as pos-
sible. However, since the heart is always at a
certain distance from the film, the FFA is
enlarged to reduce the magnification factor
g
(1.10 m/1.10 m − 0.20 = 1.22 → 2.0 m/2.0
m − 0.20 = 1.11).

Projection/Parallax
With a central projection it also happens
G b that two objects lying on top of each other
cannot be distinguished. This is particularly
problematic when these objects appear in
the same image size due to their size and
position.
However, if the focus is now shifted in a
plane, the object in the image plane also
shifts (parallax shift, . Fig. 2.6). In this
way, objects can be “free projected” in an
B
X-ray image, i.e. the objects that were previ-
ously displayed on top of each other are
then displayed next to each other.
..      Fig. 2.5 Ray set/central projection. (From Hart-
mann et al. 2014) Distortion
Since an X-ray image is a projection, it is
is called the focus-film distance (FFA). The unfortunately the case that objects are
distance B-G is called object-film distance only displayed in their full extent if they
(OFA). The variable V indicates the magnifi- are perpendicular to the central beam. If
cation of the image. the object is not perpendicular, it will be
displayed foreshortened. If it is not in the
>>The greater the object-to-film distance,
central beam, the size representation also
the larger the object is imaged, with all
changes (. Fig. 2.7).
objects in an image plane being magni-
fied equally.

In principle, one always wants a representation

in the X-ray that is as accurate as possible in
terms of size. Unfortunately, this cannot be
achieved because the patient has a certain
thickness. When setting the image, care is
therefore taken to ensure that the region to be
assessed is close to the film in order to achieve
a sharp and accurate image. (Sternum in prone
position, spine in supine position, …).
In some radiographs, these imaging laws ..      Fig. 2.6 Projection at parallax shift. (From Hart-
are exploited. In mammography (7 Chap. 3), mann et al. 2014)
Conventional X-ray Diagnostics
23 2
>>The harder the radiation, the easier it is
to penetrate dense structures, which can
lead to these differences in density being
displayed with similar brightness. The
mnemonic “kV makes gray” describes
exactly this fact: that at high kV values
the image consists of relatively equal
shades of gray.

Another quality feature of a good X-ray

image is the sharp representation of the
..      Fig. 2.7 Projection under distortion. (From Hart-
structures.
mann et al. 2014)

Motion Blur
Law of Distance Squared
Although X-ray diagnostics work with rela-
One of the most important physical laws in tively short exposure times, motion blur can
radiology is the distance-squared law. It occur in the image. Good patient care can
states that as the distance (r) increases, the already improve the quality of the image by
dose/intensity (I) decreases squared. actively ensuring that the patient maintains
This law is of particular importance in a calm and constant posture/position during
the field of radiation protection. the exposure. Sometimes it is advantageous
to perform an X-ray exposure lying down
rather than sitting down, as the patient can
2.1.4  uality of the X-ray Image
Q
be positioned more stably and unconscious
and Quality Improvement movements can be avoided.
Measures The well-known breathing command of
radiology: “Breathe in, breathe no more!”
The Good X-ray Image serves to minimize movement. Thus, not
What makes an X-ray image a good X-ray only the optimal position of the lungs is
image? Regardless of the body region to be ensured during lung inhalation, but of
examined and the structures to be depicted, course also the movement of the lungs is
the image should have homogeneous, suffi- reduced.
cient exposure and good contrast. In some images, on the other hand, one
An image is homogeneously exposed takes advantage of the motion blur. When
when the average blackening corresponds to taking an image of the cervical spine from
a medium grey tone, i.e. when bright and the front, the lower jaw would cover the ver-
dark areas in the image can be recognized tebral bodies. By moving the lower jaw
evenly. Only in this way can the complete quickly (“jaw flap”), it is possible to partially
grey spectrum be used for display. It is there- prevent this overlapping by “blurring” the
fore important to select the tube current, the lower jaw on the image.
exposure time and the quality of the radia-
tion (tube voltage, kV) optimally. Scattered Beam Reduction
For the representation of structures you In an X-ray image, not only the direct
need a sufficiently high contrast between the radiation that passes through the body
details. contributes to the imaging, but also the
 24 C. Vockelmann

radiation scattered in the body. This scat- however, was developed by each manufac-
tered radiation causes the structures in the turer itself and therefore cannot be trans-
image to no longer be clearly displayed. In ferred from one system to another.
2 order to improve the image quality, this
scattered radiation should therefore not
hit the detector. 2.1.5 Setting Up a Bucky
The amount of scattered radiation is Workstation
directly dependent on the tube voltage, the
patient thickness and the field size. The conventional X-ray workstation is often
called the Bucky workstation (. Fig. 2.8).
Image Noise in Digital X-ray Images Dr. Gustav Peter Bucky was, among other
The advantage of a digital X-ray image is things, a radiologist and developed the prin-
that almost every X-ray image results in a ciple of the “floating” table top and the scat-
usable image due to the high sensitivity of tered radiation grid.
the digital sensor technology. This tech-
nology is much less sensitive to deviation Bucky Table
in the amount of radiation than the “old” The table on which the patient lies during
X-ray film. While overexposure, i.e. too the examination is called a bucky table. The
much radiation, does not harm the quality special feature of this table is that the table
of the image, underexposure results in an top can be moved in all directions.
image that shows much less detail. This
­phenomenon is also called image noise. Grid Wall Stand
This noise is not always immediately vis- The grid wall stand is primarily used for
ible on the preview monitors of the X-ray recording while standing or sitting. Here,
systems. For this purpose, the dose indicator the height-adjustable grid drawer is located
exists in digital imaging technology, which, behind a plate.

..      Fig. 2.8 Example of a Bucky workstation (table and grid wall stand)
Conventional X-ray Diagnostics
25 2
Tripod lead gown. Infants can also be completely
The X-ray tube or, more precisely, the X-ray wrapped in so-called radiation protection
protection housing with depth diaphragm is wraps.
often located on a so-called ceiling pendant. When exposing the chest area, a half apron
The ceiling pendant consists of two vertical (gonad protection apron) or a radiation pro-
rail systems attached to the ceiling, to which tection skirt must always be worn to protect
a telescopic arm is attached. the lower half of the body from radiation.
For exposures of the pelvis or hip, you
can no longer put on a half-gun, as this would
2.1.6 Mobile X-ray Equipment cover the bone. There are special lead covers
for these exposures, depending on gender.
Mobile X-ray units are used in the intensive In male patients, the guidelines of the
care unit or in the operating theatre. German Medical Association prescribe (in
Generator and tube are mounted on a the case of gonadal admission) that the tes-
mobile unit. Through the use of converter ticles are protected by a testicular capsule)
generators, these units have become smaller which completely encloses the testicles.
and can be operated with a normal mains For women, a so-called ovarian protec-
voltage or even battery. tion should be used, which can be applied
either indirectly or directly. The indirect pro-
tection is attached with a splint or a mag-
netic holding system below the depth
2.1.7  pecial Radiation Protection
S
diaphragm and placed by means of the light
Measures visor in such a way that the ovaries are cov-
ered in the lower pelvic region. The direct
Direct Radiation Protection ovarian shield is placed on the patient’s
z Shielding lower abdomen. For images while standing,
When an X-ray is taken, the patient must of this can be fixed by means of a belt.
course be exposed to the X-rays. However, if During the X-ray exposure, all persons
possible, all parts of the body that are not except the patient should leave the room. In
being examined should be shielded from the addition, the doors of the examination room
radiation. Most aids for this purpose are should also be closed in order to shield
made of lead or lead compounds (“lead rub- against possible stray radiation. If a person is
ber”). Depending on the organ being exam- required to hold the patient during the X-ray
ined, the patient can be protected in various exposure, this person should always be pro-
ways. In particular, the organs that are sensi- tected with a radiation protection apron. In
tive to radiation should be protected. First pediatric radiology, there are additional spe-
of all, these are the gonads, i.e. the ovaries in cial radiation protection walls made of lead
women and the testes in men. But also the or lead glass for the person holding the
small intestine and the hematopoietic tissue patient during standing radiographs.
are particularly sensitive to radiation.
z Insertion
>>Since many cells in children are still One of the most effective methods of mini-
growing, children are generally more mizing X-ray radiation is to fade in the radi-
sensitive to radiation than adults and ation field.
therefore require special protection.
>> The smaller the irradiated field, the less
When exposing the extremities, the patient dose reaches the patient and the less scat-
should ideally always wear a lead apron or a tered radiation is produced in the patient.
 26 C. Vockelmann

This means that the overlay not only pro- ingful, diagnostic image. Therefore, careful
tects the patient, but also provides a better and concentrated work is important in
quality X-ray image. radiology. Thanks to digital imaging, the
2 z Additional Filters/Compensating Filters
number of false exposures has decreased,
but these are also possible here, for exam-
Filters were mentioned at the beginning of ple, due to incorrect setting technique or
this chapter. These also contribute to the too low a dose.
radiation protection of the patient. The fil- According to the X-ray Ordinance, the
ters in the depth diaphragm harden the rays justifying indication, i.e. the reason for this
so that the radiation that does not contrib- examination, must be carefully examined
ute to image formation does not reach the before each examination. Particularly in the
patient in the first place. case of children, it must be considered
whether an X-ray image must be taken or
z Radiation Quality whether other examination methods such as
The dose for the patient can also be minimized an ultrasound would be sufficient to answer
by changing the radiation quality. Whereas a the question.
few years ago, for example, the fingers were
X-rayed with a voltage of 44 kV, the Medical
Association now prescribes a voltage of at 2.2 Digital Image Processing
least 50 kV. This makes it easier for the rays to
pass through the bones and the current inten- One of the greatest advantages of digital
sity can be reduced. With the introduction of radiography is the linear sensitivity of the
digital imaging techniques, the lower contrast imaging plate and solid-state detector. This
resulting from the higher voltage can be means that there are virtually no more false
increased by suitable image processing. exposures, as good imaging can be achieved
with the digital systems even with too little
Indirect Radiation Protection or too much radiation. However, there is a
Before taking an X-ray, i.e. emitting radia- small limitation in the lower dose range. If
tion, it is important to check the precondi- too little image information (in the form of
tions for this. light pulses) is available, a noisy image is
produced.
>>It should always be checked whether an Digital images also offer the possibility
X-ray of the same region has already of processing them after they have been
been taken beforehand. In this way, any taken. In the following chapter, you will
unnecessary duplicate examinations can learn about some of these options.
be avoided.

Viewing the preliminary images is also very 2.2.1 Matrix

important because this is the only way to
select the correct imaging technique. For A digital image consists of many individual
patients with hip prostheses, it may be neces- pixels. These are arranged in rows and col-
sary to select a different cassette format for umns, this arrangement is then called a pixel
the hip images in order to be able to image matrix or matrix for short (. Fig. 2.9).
the complete prosthesis. Depending on the system, an X-ray image
Radiation protection also includes consists of between 1024 × 1024 and
avoiding erroneous images. The applied 4096 × 4096 pixels. One speaks of a 1024
radiation should always result in a mean- pixel matrix or a 4096 pixel matrix.
Conventional X-ray Diagnostics
27 2

a b

c d

..      Fig. 2.9 a–d Examples of different image matrices. (From Hartmann et al. 2014)
 28 C. Vockelmann

..      Fig. 2.10 Examples of the different color depths. (From Hartmann et al. 2014)

>>The larger this matrix is for the same not “fit” the environment due to detector
image size, the more accurate the image errors or measurement errors are replaced by
representation. the average value of the surrounding pixels.
Such mismatched pixels can be those that are
permanently interpreted as black or white,
2.2.2 Color Depth but also pixels that do not respond to radia-
tion as efficiently as those surrounding them.
A specific color is stored for each pixel. This These errors can be detected during the cali-
color information depends on the so-called bration of the system. The result of this cal-
color depth of the image. If only the infor- culation is called a “pre-processed image”.
mation 1 (white) or 0 (black) is stored for The next processing step is a so-called
each pixel of an image, the color depth is histogram analysis. Here, the brightness
said to be one bit (. Fig. 2.10). However, ­distribution of the complete image is ana-
since the X-ray image does not only consist lyzed. The software used is precisely adapted
of black or white, but of different shades of to the type of detector used and cannot sim-
gray, each pixel is described with a certain ply be exchanged. The histogram analysis
value, which describes the gray value makes it possible to detect direct radiation
between black and white. and scattered radiation and to use this infor-
With a color depth of 1 bit, only two mation to improve the contrast of the image
color values, black and white, can be dis- accordingly.
played (21 = 2 colors), with a color depth of
2 bits, four colors can be stored (22 = 4), and
so on. The image that is created at the detec-
tor has a color depth of 14 bits, i.e. it con- Practice Questions
tains 16,384 gray values. 1. Name the main technical components
of an X-ray system.
2. What is meant by “image noise”?
2.2.3 Error Correction 3. What is the law of mapping?
4. Which measures count as direct radia-
As soon as you take a digital X-ray image, it tion protection?
is processed by the acquisition system itself in 5. What is a matrix?
the first step. The so-called raw image is ana-
lyzed directly by the acquisition system. First, Solutions 7 Chap. 27
image errors are corrected, i.e. pixels that do
 29 3

Mammography
Christel Vockelmann

Contents

3.1 Design and Function of a Mammography Device – 30

3.1.1 T he Heel Effect – 30
3.1.2 Compression, Scattered Radiation Reduction – 30
3.1.3 Magnification Mammography – 31
3.1.4 Automatic Exposure Control – 31
3.1.5 Image Receiver, Image Viewing – 31

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 30 C. Vockelmann

The chapter “Mammography” describes

which technical means of a mammography Rotary
device are used to achieve the special require-
ments of an X-ray mammography. The
effects of compression and magnification in
mammography are also discussed.
3

3.1  esign and Function of a

D
Mammography Device
e–
A cathode ray also works in mammogra-
phy. However, since in mammography, on
the one hand, the finest microcalcifications
and, on the other hand, breast and fat tis-
sue have to be distinguished from each
other, particularly soft, low-energy radia-
tion is required. For this purpose, mainly
molybdenum anodes are used in order to
make use of the part of the characteristic 120% 100% 75%
X-ray radiation (17.5 and 19.6 keV). Unlike Chest wall Mamille
conventional X-rays, the hard radiation is
reduced by filters.
..      Fig. 3.1 Schematic of the Heel effect. (From Hart-
mann et al. 2014)

3.1.1 The Heel Effect

3.1.2 Compression, Scattered
If we now look at the distribution of the Radiation Reduction
resulting X-rays at the anode, we find that
there is a certain distribution (Herzt’s dipole) Thin objects cause less scattered radiation
(. Fig. 3.1). than thick objects. This dogma is exploited
Due to this special distribution and in mammography. The breast is clamped
due to the slope of the anode and the and compressed in the mammography
resulting self-absorption, a characteristic device. This simultaneously minimizes the
intensity distribution occurs within the overlapping of the different structures as
field. The radiation decreases in the direc- well as the motion blur. Another effect is
tion of the cathode. This phenomenon is that due to the compression, the breast has
called the Heel effect. The mammography at least approximately the same thickness
tube is therefore constructed in such a way both near the thoracic wall and near the
that the cathode is located close to the mammilla, thus achieving homogeneous
thoracic wall, since the breast is thicker exposure of the image (. Fig. 3.2).
and denser here than close to the mam-
milla. >>Due to the compression of the breast,
the tissue is distributed homogeneously
>>The Heel effect refers to the anode-side both thoracic and mammillary and can
dose drop. thus be assessed more precisely.
Mammography
31 3
3.1.4 Automatic Exposure Control

An automatic exposure system can also be

used in mammography. Here, care must be
taken to ensure that the measuring chamber
is placed in projection onto the gland body.
Depending on the size of the mamma or
also in the case of breast implants, manual
exposure is therefore also frequently selected
in order to avoid incorrect positioning of the
measuring chamber and thus incorrect
exposure of the mammogram.

3.1.5 I mage Receiver, Image

Viewing

As in conventional X-ray, mammography

devices are nowadays equipped with digital
image receivers. The requirements for spatial
and contrast resolution are significantly
..      Fig. 3.2 Mammography image higher here. Pixel sizes between 0.05 and
0.1 mm are required for the correct delinea-
A scattered radiation grid is also used in tion of fine connective tissue strands and
mammography. Unlike in conventional microcalcifications.
X-ray, however, a much more complex grid In order to be able to use this matrix size
movement is necessary so that the grid is not for diagnostic purposes, appropriate moni-
imaged in the image due to the soft radiation. tors are required. While 2-megapixel moni-
tors are sufficient for conventional images,
5-megapixel are required for mammography.
3.1.3 Magnification Mammography

In magnification mammography, the dis- Practice Questions

tance between the breast and the image 1. What is meant by the Heel effect?
receiver is increased. Due to the imaging laws 2. Why is it necessary to compress the
(7 Chap. 2), this results in an enlargement of breast during mammography?
the structures, e.g. in order to better recog- 3. What is magnification mammography?
nize the shape of microcalcifications, even if
the geometric blurring becomes somewhat Solutions 7 Chap. 27
greater. In addition, the grid can be dis-
pensed with in the enlarged image, since the
scattered radiation is already too far attenu-
ated and no longer reaches the image receiver.
 33 4

Transillumination
Martina Kahl-Scholz

Contents

4.1 Image Intensifier (BV) – 34

4.1.1 Structure of A Fluoroscopy Unit – 35

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 34 M. Kahl-Scholz

This chapter deals with the basic operation Beyond the focal point, the electrons also
of fluoroscopy equipment and its applica- strike the output screen, and the resulting
tion in medicine. luminance image is brighter, inverted, and
reduced in size.
The fluoroscopy technique is used for: This change in brightness is caused by
55 Reduction of bone fractures, the acceleration of the electrons inside the
55 Examinations of the gastrointestinal image intensifier and by the higher electron
tract and other body cavities using con- density in relation to the area compared to
4 trast media, the input screen.
55 Examinations of vessels also with con-
trast media, >>The resolution plays a big role. If the
55 Placement of probes or drains in the layer is too coarse, small details can eas-
body. ily get lost.

Of particular importance is the consider- Depending on the circuit of the electron

ation of real-time processes in the study of optics, the scale of the electron optical
the swallowing act. reduction can be changed by shifting the
The X-ray contrast media used are adapted focal point. Thus, only a small area of the
to their field of application (7 Chap. 9). input screen can be displayed on the output
screen to show details.
>>In fluoroscopy, the use of contrast agents The image of the output screen is
allows structures to be depicted that are recorded by a camera and displayed on a
otherwise difficult to visualize due to the monitor. This is done by means of a so-­
small differences in density compared to called tandem optics, i.e. two lens systems
the surrounding tissue. that forward the image of the output screen
to the camera system.
The image of the fluoroscopy is dis-
4.1 Image Intensifier (BV) played on a monitor in the examination
room. Due to the “Last-Image-Hold (LIH)”
The image intensifier consists of an evacu- function, the last image on the monitor is
ated, i.e. airless, glass or metal bulb. The retained and can be digitally stored, thus
slightly curved entrance surface of the replacing an additional X-ray image.
X-rays is coated with a luminescent material Since the image should be constant dur-
(caesium iodide). This layer produces a ing fluoroscopy, regardless of the area being
luminescent image when the radiation hits it. fluoroscoped, the electronics on the output
A photocathode is applied directly to this screen also control the generator power of
luminescent layer, which emits electrons cor- the X-ray tube, among other things.
responding to the luminescence image, the
so-called “electron image”. These electrons >>Because of the automatic dose control,
are accelerated towards the anode by the never hold or place a lead glove or other
applied voltage of approx. 25 kV–35 kV. opaque object (e.g., scissors, etc.) in the
Further electrodes are attached to the radiation path. This procedure increases
outer wall inside the glass bulb. Their neg- the X-ray dose for the patient and the
ative charge ensures that the free electrons examiner, as the generator regulates the
are focused on a specific point (= electron dose upwards until the object is
optics). ­transilluminated.
Transillumination
35 4
4.1.1 Structure of the patient standing (e.g. swallowing stud-
A Fluoroscopy Unit ies) or with the patient in the head or foot
down position (e.g. phlebography—exami-
A fluoroscopy system consists of an X-ray nation of the deep leg veins).
tube, a patient positioning table, an image
receiver and (in the case of digital systems) >>In a fluoroscopy-only unit, the tube
an evaluation unit. image receiver unit cannot rotate around
In the meantime, mainly under-table the patient. To take a lateral image, the
units are used, in which the tube is located patient must rotate on the table.
below the table. For optimal adjustment,
either the table can be moved or the X-ray
unit can be moved above the patient. In Practice Questions
addition, the entire system consisting of the 7 Chapter 5
target unit, tube and table can be tilted so
that examinations can be performed with
 37 5

Angiography, Rotational
Angiography/Angio-CT
Martina Kahl-Scholz and Christel Vockelmann

Contents

5.1 DSA Technique – 38

5.2 Angiography-CT Rotational/Angio-CT – 40

5.3 Seldinger Technique – 41

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 38 M. Kahl-Scholz and C. Vockelmann

This chapter deals with the basic operation is that the radiologist can use two images
of angiography equipment and its applica- from two spatial directions for orientation
tion in medicine. during an angiographic intervention. This
enables him to better assess the course of the
A further development of the classic fluo- vessels.
roscopy unit is the angiography unit with the
so-called C-arm. The image receiver and the
X-ray tube are connected by a semicircular 5.1 DSA Technique
rail, which is anchored to the rest of the sys-
tem by means of a holding module. This DSA, digital subtraction angiography, is an
holding module can rotate and can also be application that is primarily used for imag-
5 moved so that the tube can move sideways ing vessels using contrast medium. This can
along the patient (= images in all spatial be done either by injecting the contrast
directions are possible). agent directly into the punctured vessel (e.g.
For viewing the fluoroscopic images, in phlebography) or by inserting catheters
there are at least two monitors at the so-­ into the vascular system and injecting the
called traffic light. On one screen the fluoro- contrast agent “on site”.
scopic image can be seen, on the other Subtraction requires at least two X-ray
previous images can be displayed, which the images: one image without contrast medium
radiologist can use for orientation during and one or more images with the contrast-­
the angiography. filled vessel. The first image is called the mask,
The C-arm can either be floor-mounted which is subtracted from the subsequent
or suspended from a ceiling pendant. Some images. This subtraction eliminates the image
systems have two C-arms, the so-called portions of the mask from the subsequent
biplanar angiography systems. These image that have not moved in the time
C-arms can be positioned independently of between images. Only the changed image
each other. The advantage of these systems parts are still visible (. Figs. 5.1 and 5.2).

a b

..      Fig. 5.1 a,b Mask image without contrast agent with itself subtracted: A grey image is produced. (From
Hartmann et al. 2014)
Angiography, Rotational Angiography/Angio-CT
39 5

a b

..      Fig. 5.2 a,b Native image and subtraction image of an angiography sequence. (From Hartmann et al. 2014)

If contrast medium is already present on the serial image. This can be sufficient for
the mask image, this portion of the image is small examination areas for orientation, but
displayed white in the subtraction image. larger ones cannot be assessed in their entire
length in this way or used for the examina-
>>For a good subtraction, it is important tion procedure.
that the mask image “fits” the subse- For this purpose, the subtraction images
quent images as exactly as possible, i.e. are summed up or “appended” to each other.
that the image area does not change, i.e. In this way, not only the main stem of the
that the patient does not move. vessel, but also all the secondary branches
are visible in the image.
If the patient has moved, the mask can still Such a summation image can be placed
be shifted accordingly (= pixel shift, semi-transparently on the fluoroscopic
. Fig. 5.3). image for better orientation, so that the
Since the contrast medium continues to examiner can see the course of the vessels on
flow normally in the vessel with the injection the monitor even without further adminis-
and is diluted by the blood, only a limited tration of contrast medium (so-called
area of the vessels is always visible during ­roadmapping).
 40 M. Kahl-Scholz and C. Vockelmann

a b

..      Fig. 5.3 a,b Subtracted image with and without motion correction (pixel shift). (From Hartmann et al. 2014)

5.2 Angiography-CT Rotational/

Angio-CT

In order to better visualize the position of

the vessels, especially in the head region,
modern angiography systems are able to
produce a so-called rotational angiogra-
phy. In this case, the C-arm moves around
the patient by approx. 200° (manufacturer-­
dependent) during the series sequence.
The result is a raw data set of 180–560
individual images. From this data set,
CT-like slices can be calculated by means
of back projection and a 3-dimensional
vascular image can be calculated. These
methods are used, for example, in neuroin- ..      Fig. 5.4 Example of a dynamic sectional view
terventions to find the best working pro-
jection for the treatment of aneurysms. (HCC). Here, the calculation of a sec-
Another field of application is transarte- tional image can ensure the correct distri-
rial chemoembolization of the liver for the bution of medication and the avoidance
treatment of hepatocellular carcinoma of incorrect embolization (. Fig. 5.4).
Angiography, Rotational Angiography/Angio-CT
41 5
5.3 Seldinger Technique Therefore, changing catheters requires a
wire that is at least 2.5 to three times as long
In addition to the equipment technology, as the catheters. This means that you often
the examination technique plays a major “fight” with 3 m long wires.
role in angiography. The basis for this is the Locks, catheters and also many balloon
Seldinger technique. Sven-Ivar Seldinger and stent catheters are so-called “over-the-­
was a Swedish radiologist who developed a wire” catheters. With these, there is a lumen
technique for puncturing blood vessels in through which the wire runs from the begin-
the 1950s. The central point here is the ning to the end of the catheter.
Seldinger wire over which each step of the In the meantime, there is also the alter-
procedure is performed (. Fig. 5.5). After native of the monorail system or also
puncturing the artery with a hollow needle “rapid-­exchange catheter”, especially in
or a needle with a removable inner stylet, a neurointervention. With these catheters
wire is advanced into the vessel. Often the (especially balloons and stents), the wire is
wire is bent in a J-shape at the tip to avoid only guided through a second lumen of
vascular injury. Catheters, locks, balloons or the catheter for the first 20–30 cm, after
stents are then inserted via this wire. which it runs freely parallel to the cathe-
Depending on the task, there are various ter. In addition to the shorter wires, this
special wires, e.g. for recanalization of occlu- also allows a faster catheter change, but
sions or particularly soft ones for probing the guidance of the catheter is somewhat
aneurysms. worse, since the wire reinforcement is only
given at the catheter tip.
>>The golden rule is always to hold the end
of the wire in your hand so as not to lose
the wire in the jar. Practice Questions
1. What are the main questions for
which fluoroscopy is used?
2. What is meant by a “last image hold”?
3. What is the advantage of the C-arm?
4. What is the DSA suitable for?
5. What is a Rapid Exchange Catheter?

Solutions 7 Chap. 27

..      Fig. 5.5 Seldinger system

 43 6

Computed Tomography (CT)

Mirja Wenker

Contents

6.1 History – 45

6.2  esign and Operation of A Computer

D
Tomograph – 45

6.3 Investigation Techniques – 45

6.3.1  T Sequence – 45
C
6.3.2 C T Dynamic – 46
6.3.3 C T Spiral/CT Singleslice (SS-CT) – 46
6.3.4 C T Multislice (MS-CT) – 46
6.3.5 C T Dual-Source (DS-CT) – 47

6.4 Important Parameters in Spiral CT – 47

6.4.1  itch Factor – 47
P
6.4.2 Collimation – 48
6.4.3 Tube Voltage (kV) – 48
6.4.4 Tube Current-Time Product (mAs) – 48
6.4.5 Scan Time (S) – 48
6.4.6 z-sharp Technology – 48

6.5 Parameters for Image Reconstruction – 49

6.5.1 L ayer Thickness – 49
6.5.2 Increment – 49
6.5.3 Convolution Kernel, Reconstruction Filter or Algorithm – 49
6.5.4 Windowing – 49
6.5.5 z-Interpolation – 49

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
6.6 Image Formation – 50
6.6.1 F iltered Back Projection – 50
6.6.2 Iterative Reconstruction – 50
6.6.3 Hounsfield Scale – 50
6.6.4 Window Technology – 50

6.7 Post-Processing – 51
6.7.1  D Representation – 51
2
6.7.2 3D Representation – 52

6.8 Artifacts – 53
6.8.1  ovement Artefact – 53
M
6.8.2 Pulsation Artefact – 53
6.8.3 Metal Artifact – 53
6.8.4 Partial Volume Effect/Partial Volume Effect – 53
6.8.5 Hardening Artefact – 54
6.8.6 Measuring Field Overrun – 54
6.8.7 Photon Starvation Artefact – 54
6.8.8 Ring Artefact – 55
6.8.9 Line Artifact – 55

6.9  adiation Protection Measures

R
and Dose Reduction – 55
6.9.1  osage Modulation – 55
D
6.9.2 Adaptive ECG Pulsing – 55
6.9.3 Avoidance of Overranging – 55
6.9.4 Iterative Reconstruction – 55
Computed Tomography (CT)
45 6
Computed tomography (CT) produces sec- system, detector system, cooling system and
tional images using X-rays. Since computer mechanical elements are located under the
tomographs are available in almost all hos- cover. The entire gantry can be tilted hori-
pitals and radiology practices and the exam- zontally up to ±30 °. In a CT, the tube-­
ination time is very short, CT is the method detector systems rotate around the patient
of choice in emergency diagnostics. The with a weight of 2–3 t (in dual-source sys-
patient is exposed to radiation and the atten- tems even 4–5 t). This creates immense cen-
uation is determined. This produces images trifugal forces. The X-ray emitter of a CT is
of different structures that are free of super- a rotating housing emitter. Here, the entire
imposition and allow spatial delineation in housing, i.e. anode and cathode, rotates
all planes. Organs and pathologies can thus around the patient.
be precisely assigned and their extent X-rays are emitted continuously during
determined. the rotation. After penetrating the patient,
the X-rays are detected on the opposite
detector. Different tissue with different den-
sities is located in the beam path. These den-
6.1 History sity differences are registered or measured.
This weakened radiation, which has pene-
The history of computed tomography trated the patient, is converted into electrical
began in the early 1970s with Sir Godfrey signals. Behind the detector system there is
Hounsfield, who developed the first com- the DAS (= Data Acquisition System) to
puted tomograph. For this he received the record the signals. These are passed on to
Nobel Prize in 1979. Hounsfield received the computer where the generation or recon-
financial support from the record company struction of the digital images takes place.
EMI, which among others had the Beatles Both - the power supply of the tube and the
under contract. For this reason the first forwarding of the detector signals - are car-
scanner was also called EMI scanner, with ried out via slip rings.
which skull CT’s could be accomplished.
Since computers were not well developed at
that time, the resolution was low (matrix 6.3 Investigation Techniques
80 × 80) and the examination time very long
(about 10 min/image). However, it was pos- 6.3.1 CT Sequence
sible for the first time to diagnose large
brain processes without operating on the The first technique developed is sequential
patient. Larger tumors and hemorrhages recording technique. It is also called “step
could be delineated and ventricular width and shoot”. Transversal/axial exposures are
assessed. Today, in honor of Hounsfield, performed slice by slice. A table movement is
the units of attenuation are given in necessary between two exposures. The
Hounsfield Units (HU). amount of data to be reconstructed is small
and can be done immediately. The examiner
can therefore view the images directly.
6.2 Design and Operation However, the disadvantage is the long exam-
of A Computer Tomograph ination time. Since the data acquisition is
not continuous, there is a risk of not captur-
The CT scanner itself consists of the table ing the smallest details between two slices.
and the gantry. The gantry is the heart of There is no possibility of three-dimensional
the tomograph. The X-ray tube, aperture ­representation.
 46 M. Wenker

Nowadays, sequential CT is mainly used 6.3.3  T Spiral/CT Singleslice

C
for interventions and prospectively triggered (SS-CT)
cardio-CTs. Even cranial CTs are still
acquired sequentially in some cases today in New possibilities were opened up by the
order to avoid exposing the lenses of the eye, introduction of spiral CTs in the early 1990s.
which are very radiation-sensitive structures, Data acquisition was no longer “only”
to the direct beam with a tilted gantry. sequential, but also spiral, also called helical
However, modern equipment techniques are or helical. The patient is acquired throughout
increasingly replacing this technique with the volume with continuous table advance-
spiral scans. ment and continuous tube rotation, and there
are no data gaps. A detector array acquires
the data. The region to be examined can be
6 6.3.2 CT Dynamic covered very quickly by spiral acquisition.
This shortens the examination times to such
Dynamic CT images are also mainly taken an extent that the examination can be per-
using a sequential technique. However, only formed within one breathing phase. The
a selected slice position is continuously amount of contrast medium can also be
recorded. This makes it possible, for exam- reduced automatically. The volume coverage
ple, to perform flow measurements and thus is now seamless and allows the possibilities of
to depict and assess physiological processes. overlapping reconstruction, so-called multi-
These measurements can only be made with planar reformation (2D) and 3D imaging.
the aid of contrast media. The blood flow is
displayed by the contrast medium, so that
the kinetics are recorded and measured. 6.3.4 CT Multislice (MS-CT)
This makes it possible, among other things,
to make statements about organ perfusion In 1998, the first multislice CT came onto the
or the cardiac output rate. The dynamic CT market. It was a so-called “4-slice”, as four
examination plays an essential role for acute detector rows were available. With a tube rota-
stroke patients. Lysis therapy can be effec- tion around the patient, four slices could be
tive up to 4.5 h after the onset of the first recorded directly. Thus a larger volume cover-
symptoms; therefore, a patient with sus- age took place. The volume acquisition was
pected stroke must undergo imaging as soon therefore faster, which shortened the examina-
as possible. Computed tomography can tion times, which in turn led to a reduction in
detect the area of the brain that is poorly contrast medium. Another advantage of the
perfused by measuring the perfusion of the multislices is the post-­processing. By stringing
brain and identify the artery that should together several detectors, an isotropic voxel
supply this area. geometry can now be achieved. Isotropic
Another dynamic imaging technique is means that all edge lengths are of the same
bolus triggering. The contrast agent accu- length. This is important for the 3D display,
mulation in the focused vessel lumen is con- because it allows the step-free display of recon-
tinuously measured at a selected slice structed images in all spatial planes without
position. If a preset and predetermined den- ­continuity interruptions.
sity (HU) is reached, the device starts auto-
matically and acquires images of the desired >>The smaller the voxels, the better the
region. spatial resolution.
Computed Tomography (CT)
47 6
However, as the slice thickness decreases, source technique offers further possibilities
the signal-to-noise ratio deteriorates and the and advantages:
radiation dose to the patient increases. 55 The two images with different energies
can be added together to produce a
Detector Design “mixed image” equivalent to a 120 kV
The introduction of the multi-line tech- image.
nique, in which several detector rings are 55 Iodine can be accurately detected and
placed opposite the X-ray source, allows the subtracted from both images, resulting in
acquisition of several layers simultaneously. a “native” image, i.e. as if the examina-
The detector lines do not have to have the tion had been performed without
same width. There are two types of detec- KM. Thus, separate native images are no
tors. longer necessary beforehand. It is used,
for example, in liver and kidney diagnos-
z Adaptive Array Detector tics.
In the “Adaptive Array Detector”, the detec- 55 As an alternative to the virtual removal
tor chambers become wider and wider of iodine information from the image,
towards the periphery. This leads to the pos- this information can also be color-coded,
sibility of interconnecting individual ele- e.g. in the evaluation of myocardial isch-
ments and lines. Thus, the option of different emia, i.e. reduced blood flow to the heart
layer thicknesses exists. muscle, or pulmonary perfusion, i.e.
blood flow to the lungs.
z Fixed Array Detector 55 Besides iodine, other materials can also
With the “Fixed Array Detector” there are be differentiated and characterized by
fixed sizes of detector elements per detector this so-called material decomposition,
row. By selecting certain detector lines, the e.g. ureteral stones.
layer thickness can be determined.
The use of different energies is also made
possible in current device generations,
6.3.5 CT Dual-Source (DS-CT) depending on the manufacturer, by modu-
lating the tube voltage or a special detector
In the DS-CT, there are two tubes in the configuration (“double-layer detector”).
gantry at a 90° angle with two associated,
opposing detectors. The tubes work in par-
allel, but can be operated with different
energies. The first tube has with 80 kV a 6.4 Important Parameters
lower voltage than the 2nd tube with in Spiral CT
140 kV. Some manufacturers allow the use
of different tube voltages with only one 6.4.1 Pitch Factor
tube, this technique is called Dual-Energy.
Two images are created. The different The pitch describes the relationship between
tube current results in different attenuation table feed and detector width. It is calculated
values. Since the tube current is automati- with p (pitch = table feed/number of
cally adjusted, there is no increased radia- simultaneously detected detector lines) x
­
tion exposure. The acquisition time is very slice thickness.
short due to two separate acquisition units. With a pitch = 1 the volume is recorded
This is a distinct advantage for spatial reso- without gaps, with a pitch > 1 the data helix
lution, especially for involuntarily moving is pulled apart. Mathematically, one still
organs such as the heart. However, the dual- obtains a complete data set with a lower
 48 M. Wenker

image quality but also lower radiation expo- 6.4.4  ube Current-Time Product
T
sure. With a pitch < 1 the volume is acquired (mAs)
overlapping. The pitch regulates the speed
of the table feed and thus also the duration The tube current has a linear relationship to
of the examination. the radiation dose; doubling the tube cur-
rent also doubles the radiation dose.

6.4.2 Collimation >>The thicker the object being transmitted,

the more mAs are required to ensure
Collimation describes how thick or thin a adequate image quality.
slice is selected along the z-axis, i.e. the
longitudinal axis of the patient’s body. Since bone absorbs or scatters the radiation
Collimation is achieved by a system of more, a higher tube current must also be
6 apertures and detector elements. The aper- used in body regions with more skeletal
tures serve to focus the radiation and to parts, such as the shoulder girdle or the pel-
reduce scattered radiation in front of the vic skeleton. This is usually done using auto-
detector. The choice of collimation deter- matic dose modulation in order to obtain a
mines the activation of the detector rows homogeneous image quality of the examina-
and the detector elements. The detector tion (7 Sect. 6.9.1).
elements have different sizes. The layer
thickness is influenced by the choice of
detectors and can subsequently be reduced 6.4.5 Scan Time (S)
to a maximum of the size of the smallest
detector element. It indicates the actual examination time and
depends on the scan distance, the pitch and
the rotation time.
6.4.3 Tube Voltage (kV)
>>The longer the scan time, the slower the
The tube voltage is applied between the examination and therefore the higher the
cathode and anode and determines the dose.
penetration capability of the radiation
through the matter. Values between 70 and For examinations that involve increased
140 kV can be selected in steps, depending motion artifacts (thoracic CT with respira-
on the manufacturer. Higher kV values tory movements, abdominal CT with intesti-
mean a hardening of the X-ray radiation, nal peristalsis and pulsation artifacts
which means that it penetrates tissue types through the aorta), it is advantageous to
with higher absorption better and causes select the scan time as short as possible. This
less scattered radiation. For examinations can also reduce image blurring caused by
of the parenchyma, 120 kV tube voltage is involuntary patient movements.
usually selected, for CT angiographies (CT-
A), i.e. vascular imaging, or bony examina-
tions and examinations of children, 80 kV 6.4.6 z-sharp Technology
is usually selected. An increase in tube volt-
age has a disproportionate effect on the Spring focus, also called flying focal spot or
radiation dose. A change of the tube volt- double-z-sampling, is a novel technology.
age from 100 kV to 140 kV with otherwise The electron path is deflected by an electro-
unchanged parameters leads to a 4-fold magnetic field so that two focal spots are
higher dose. formed on the anode. The distance between
Computed Tomography (CT)
49 6
the two focal spots is half of the thinnest selected and the image is optically smoothed.
collimation selected, so there is an offset, The detail detectability of structures with
but also an acquisition overlapping by half. small density differences is improved.
With a 64-slice CT, double the volume cov-
erage can be achieved, i.e. 128 slices can be
acquired. The overlapping acquisition tech- 6.5.4 Windowing
nique results in a higher spatial resolution,
because the image information is added to The human eye has only a limited percep-
the same slice. tion, even the best radiologist cannot distin-
guish significantly more than 60 gray values.
Therefore, a narrowing down of the grey
6.5 Parameters for Image values is carried out with the help of win-
Reconstruction dowing. The range of gray values depends
on the region or organ to be examined,
6.5.1 Layer Thickness depending on where the focus lies. The focus
is referred to here as “Center (C)”. The spec-
trum of gray values used is called “Window
The slice thickness in which the images are to
Width (WW)”. The Center is the “zero
be reconstructed can be chosen by the exam-
point” of the window. Thanks to this set-
iner. It can be minimally equal to the thick-
ting, one can refer to the density of the inter-
ness of the smallest detector element and is
ested organs and delimit and judge them.
determined by the choice of collimation.

6.5.2 Increment 6.5.5 z-Interpolation

After or during a spiral acquisition, this

The degree of overlap in the reconstruction
measuring principle is carried out by soft-
of the individual slices is determined by the
ware in the background and only enables the
selection of the increment. An increment of
complete data acquisition. Due to a spiral,
20–30% should be selected for further 3D
no complete 360° acquisition takes place.
post-processing.
Data within a 360° rotation that lie outside
an image plane are “copied” to an image
plane, the z-axis, by z-interpolation. This is
6.5.3 Convolution Kernel, done by using a computational algorithm to
Reconstruction Filter calculate a second spiral that is 180° to the
or Algorithm measured spiral. The scanned spiral and the
calculated spiral together provide 360° cov-
This is a computational algorithm that is erage on a plane. Since the pixels have small
used to highlight certain structures during distances to each other, this provides a good
reconstruction. The edges of the bony struc- spatial resolution. In addition, the motion
tures and lung structures in the lung window artifacts that occur due to the permanent
are emphasized with a sharp convolution ker- table movement are eliminated. After the
nel so that they can be precisely delineated z-interpolation the next calculation is per-
and assessed. The smallest details are shown formed. The mean values of the image
with sharp separation. In soft tissue imaging, points are determined for image reconstruc-
i.e. parenchymal organs, a soft kernel is tion/image calculation.
 50 M. Wenker

6.6 Image Formation 50–60% is achieved, depending on the

examination region and object.
The patient is positioned isocentrically on the The noise or better signal-to-noise ratio
table, i.e. the object to be imaged is always in (SNR) is the quality criterion of CT images.
the center of the beam path during imaging It is measurable and should be between
and rotation. This is a very important point 12–15 HU. The measurement is made in the
for dose control, spatial resolution and thus peripheral area of the CT image, outside the
image quality. First, an overview image, a object, practically in the air.
topogram or scout, is taken. With its help, the
area to be examined is defined and delimited. >>The less radiation is incident, the fewer
The data acquisition is carried out with the X-ray quanta hit the detector elements.
preset parameters and the data is forwarded This increases the noise and the poorer
to the computer. After z-interpolation, the the image quality.
6 mean values of the image points are deter-
mined. This raw data forwarded to the com- So more radiation is needed, the tube current
puter, the attenuation values from all angles, must be increased. It is important to know that
is also called a sinogram. The result is a there is an exponential relationship between
blurred image. The filtered back projection is the mAs and the noise. So to halve the noise, a
necessary for a detailed recognizability. fourfold of mAs must be used.

6.6.1 Filtered Back Projection 6.6.3 Hounsfield Scale

The main role here is played by the selected The density values of individual structures
convolution kernel. Depending on the convo- and objects in computer tomographic exam-
lution kernel, the edge emphasis is enhanced inations are measured and an image is calcu-
by means of mathematical algorithms. For lated from them. The different density values
this purpose, a negative filter is assigned to are displayed in different grey scales. These
each voxel in the edge region. After subtrac- scaled values are called Hounsfieldunits
tion of filter and measurement data, the edge (HU) after the inventor of the CT. The refer-
region is signal-free. This results in edge ence values for water and air were set at
accentuation and sharper imaging and delin- room temperature. For water the value is
eation. The choice of a stronger edge empha- 0 HU, for air −1000 HU. Bone, although not
sis increases the image noise. a reference value, is still important and
ranges from +1000 to +3000 HU.
The spectrum of the Hounsfield scale
6.6.2 Iterative Reconstruction ranges from −1024 to 3071 HU. The human
eye cannot differentiate this amount of grey
This computational process plays an impor- levels. That is why the window technique
tant role in modern computed tomography. was introduced.
It is used for noise reduction, which means
that all examinations are performed with a
lower dose. Noise had previously greatly 6.6.4 Window Technology
affected images with lower doses and
degraded image quality. With iterative The window technique is used to limit the
reconstruction, the noise is “calculated number of gray values (. Fig. 6.1). The set-
away” and the image impression remains the ting and narrowing down refers to the HU
same. In the best case, a dose reduction of of the object of interest and is done by the
Computed Tomography (CT)
51 6
a b c

..      Fig. 6.1 a Soft tissue window. b Lung window. c Bone window

combination of Center (C) and Window data are displayed coronally and sagittally
Width (WW). The center, also called win- (. Fig. 6.2), so that the findings can be
dow location, sets the center of the window made in all planes. The curved MPR is a
width (WW). It is approximately at the den- special form of MPR. Objects that are not
sity value of the object of interest. The straight can be displayed straight thanks to
Window Width, also called Window Width this method. This is used, for example, in
or just Window, specifies the range of gray vascular examinations in order to better
values that will be used to differentiate the visualize the course.
structures. It determines the distribution of
gray values from white to black. z Maximum Intensity Projection (MIP)
In MIP, the structures with the highest
density in each slice are determined and
6.7 Post-Processing displayed in an enhanced form. This
method is usually not used in the axial
This refers to the post-processing of the images, but is intended for coronal and
acquired data in 2D or 3D representations. sagittal images. The axial datasets are the
These are not used for primary diagnosis, ones relevant to the findings. The slice
but can be used for better visualization. The thickness is usually chosen thicker than in
object can be viewed in all planes and at any MPR, because the accumulation of the
angle. The calculation should be done using denser structures leads to higher intensity
very thin, axial slices and there should be an and representation of the same. Areas of
overlap, i.e. the increment should be chosen application include thoracic CT in the
at least 20% smaller than the slice thickness. lung window (. Fig. 6.3) or all vascular
This avoids a step-like representation (step examinations.
artefacts) of the object.
z Minimum Intensity Projection (minIP)
In this case, the highest density is not deter-
6.7.1 2D Representation mined and amplified (MIP), but the lowest.
The rest of the principle is the same as for
z Multiplanar Reconstruction (MPR) the MIP. The representation of the chochlea
This post-processing is a standard part of can be done, for example, with this
every examination. The axially acquired ­projection.
 52 M. Wenker

a b c

..      Fig. 6.2 a Axial layer plane. b Coronal MPR. c Sagittal MPR

..      Fig. 6.3 MIP in the lung window

..      Fig. 6.4 SSD of the distal forearm bones and wrist

6.7.2 3D Representation joint

z Shaded Surface Display (SSD)

The 3D surface representation can be used
for surgical planning. It restricts the represen-
tation of a bone surface (. Fig. 6.4) to cer-
tain Hounsfield values above a threshold
value. Under certain viewing angles and a
hypothetical light source, which the computer
uses for shading, the surfaces appear plastic.

z Volume Rendering (VR)

This is a color assignment and transparency
of the individual CT values (. Fig. 6.5).
Furthermore, it is possible to measure
distances and angles as well as to carry out
calcification of vessels or bone density mea- ..      Fig. 6.5 VR of the vessels in the upper thoracic
surements. region
Computed Tomography (CT)
53 6
6.8 Artifacts

Artifacts are image disturbances that can

reduce the assessability of the images or even
prevent them altogether. Different types of
artifacts are distinguished, which can occur
both patient-based and physical-­technical.

6.8.1 Movement Artefact

This image disturbance (. Fig. 6.6) is

caused by movement of the patient, such as ..      Fig. 6.7 Metal artefacts due to implanted hip TEP
breathing. It can be either voluntary or
involuntary. The patient may need to be
sedated briefly for the examination.
6.8.3 Metal Artifact

6.8.2 Pulsation Artefact Metal in the examination field causes detail

obliteration (. Fig. 6.7). Therefore, all
These occur involuntarily, such as the heart- removable metal parts should be removed
beat, vascular pulsations or the peristalsis of from the examination region before the
the intestines. examination. If a metal part cannot be
removed, e.g. in the case of hip TEP, a higher
tube voltage can be selected directly in order
to reduce the artefacts.

6.8.4 Partial Volume Effect/Partial

Volume Effect

This effect occurs when two adjacent

objects in a layer show massive density dif-
ferences (. Fig. 6.8). In this case, the
mean value of the measured attenuation
values is converted into a gray value for
the image display. This can be prevented
..      Fig. 6.6 Cranial CT with motion artifacts by choosing thinner layers.
 54 M. Wenker

6 ..      Fig. 6.8 Incised sulcus right frontotemporal ..      Fig. 6.10 Exceeding the measurement field in a
patient with a large abdominal wall hernia

..      Fig. 6.9 Hardening artefact in the area of the ..      Fig. 6.11 Photon starvation artefact when the
brain stem patient’s left arm cannot be elevated

6.8.5 Hardening Artefact 6.8.7 Photon Starvation

Artefact
This artefact is caused by hardening of the
radiation as it passes through excessively dense This occurs when the amount of radiation
tissue. It occurs, among other things, when is too small and can lead to fringe arte-
examining the rock bones and causes artefacts facts (. Fig. 6.11). It often occurs in
in the adjacent brain tissue (. Fig. 6.9). This patients who cannot raise their arms above
artefact can be reduced by thinner collimation. their head. When the arms are positioned
next to the body, these artefacts occur at
the liver. This form of positioning results
6.8.6 Measuring Field Overrun in an increased demand for dose in the lat-
eral beam path. Positioning the arms on
Objects that protrude beyond the measuring the patient’s abdomen counteracts this
field lead to artefacts in the edge area and and the liver can be imaged almost arti-
cannot be assessed beyond this (. Fig. 6.10). fact-free.
Computed Tomography (CT)
55 6
6.8.8 Ring Artefact during the acquisition, the required dose
is determined. The measured values are
If individual detector rings deviate, ring-­ compared with the target values of the
shaped artifacts will appear in the image. If a average patient of 70/75 kg and the mAs
calibration does not solve this problem, the are adjusted simultaneously. Thus, the
examination with the device must be stopped radiation is individually adjusted. The
and the service technician must be contacted. application of lead covers e.g. on thyroid
gland and eye lenses can lead to an
increased dose exposure depending on the
6.8.9 Line Artifact type of dose modulation.

Failure of individual detector elements and/

or channels will cause black lines to appear 6.9.2 Adaptive ECG Pulsing
across the acquired image. The acquisition
must be stopped immediately and the manu- ECG pulsing is used in cardio-CT and
facturer notified. also in CT angiographies of the ascending
aorta. Here, the patient is connected to an
ECG. The examination always takes place
6.9 Radiation Protection in the same cardiac phase. In this phase,
Measures and Dose the acquisition takes place with 100%
dose, outside of which a reduction down
Reduction to approx. 4% takes place. The image
quality and the spatial resolution are thus
Before performing a CT scan, the indica-
maintained. Unnecessary repetitions are
tion should first be reviewed. If an exami-
avoided.
nation is justified, it must be considered
whether alternative imaging with compa-
rable informative value is possible without
6.9.3 Avoidance of Overranging
radiation exposure and how radiation
exposure can be minimized. This is par-
For the calculations in spiral acquisitions, it
ticularly true when examining infants,
is usually necessary to include half a revolu-
toddlers, and adolescents. Radiation
tion before and after the examination field.
reduction can be achieved by preset pro-
With asymmetric collimators, which close
grams on the CT:
before and after the actual scan, this excess
radiation is eliminated. This leads to a dose
reduction of up to 25%.
6.9.1 Dosage Modulation
First, a dose adjustment to the anatomy, 6.9.4 Iterative Reconstruction
shape and size of the patient can be made.
During the acquisition of the topogram For some years now, iterative reconstruc-
with the patient in isocentric position and tion has been used in image calculation in
 56 M. Wenker

addition to or as an alternative to filtered

back projection, by means of which image Practice Questions
noise can be “calculated away”. This 1. What kind of artifacts do you know
reduces the necessary dose of a CT exami- that affect image assessability?
nation considerably by up to 70%. Iterative 2. What is the difference between
reconstruction is somewhat reminiscent of sequence CT and spiral CT?
Sudoku for advanced students. Ultimately, 3. Which detector types in multislice CT
through repeated trial and error, the com- do you know? How do they differ?
puter calculates until it has the best value
for each voxel in the image to achieve the Solutions 7 Chap. 27
attenuation measured at the detector.

6
 57 7

Magnetic Resonance
Imaging (MRI)
Carla M. Kremers

Contents

7.1  hich Core Is Actually Spinning Here

W
and What Does It Have to Do with Magnets? – 59

7.2 Longitudinal Magnetization – 60

7.3 MR Signal – 60

7.3.1 T 1 Relaxation Time – 61
7.3.2 T2 Relaxation Time – 62

7.4 Location Coding – 63

7.4.1 L ayer Selection – 63
7.4.2 Phase Coding – 63
7.4.3 Frequency Coding – 63
7.4.4 K-space and Fourier Transformation – 64

7.5  roton Thrusting and Gradient Ballet:

P
the Interplay of High-Frequency Pulses
and Spatial Coding – 64
7.5.1  efocusing – 64
R
7.5.2 Echo and Repetition Time or T1 and T2 Contrast – 66

7.6 Sequence Theory – 68

7.6.1  radient Echo Sequences – 68
G
7.6.2 Fat Saturation – 69
7.6.3 Vessel Mapping – 69
7.6.4 Diffusion Imaging – 70

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
7.7 Contrast Agent – 71

7.8 Security – 71
7.8.1  ttraction of the Magnet – 71
A
7.8.2 Implants – 71
7.8.3 Volume – 72
7.8.4 Tissue Stimulation – 72
7.8.5 Emergency Bell – 72
Magnetic Resonance Imaging (MRI)
59 7
Magnetic resonance imaging is an elegant our body and the rotation is called spin.
method for imaging soft tissue in particular They spin both on their axis and in a cir-
with high contrast. A significant advantage cle—similar to a spinning top about to tip
is that MRI does not require ionizing radia- over (. Fig. 7.1a). This type of motion is
tion; a disadvantage, on the other hand, is called precession.
the time required for some of these examina- The speed of the precession motion (i.e.
tions. In this chapter, the structure and func- the number of rotations per unit time)
tion of such an MRI scanner are explained depends on the strength of the surrounding
and some frequently used sequences are pre- magnetic field and on the type of nucleus (in
sented. The difficulties associated with the our case hydrogen). It is called the Lamor
application are also discussed. frequency and has the unit megahertz
(MHz), which corresponds to the number of
revolutions per second.
In the Earth’s magnetic field, hydrogen
7.1  hich Core Is Actually
W protons precess at a frequency of 2 kHz, in a
Spinning Here and What 1.5 Tesla device at 62 MHz, and at 3 Tesla at
Does It Have to Do 128 MHz.
with Magnets? The Lamor frequency can be calculated
using the Lamor relation for different mag-
The “nucleus” primarily refers to the hydro- netic field strengths and core types:
gen protons (i.e. the central part of a hydro-
   B
gen atom) of the body under investigation,
which are constantly in motion. Each hydro- Here ϖ = corresponds to the lamor fre-
gen proton can be thought of as a small quency, γ = to the gyromagnetic constant (it
magnetic particle or even a compass needle. describes the rotational properties of the
Under normal conditions, these small com- respective proton) and B = to the magnetic
pass needles rotate purely randomly within field strength of the MR tomograph in Tesla.

a b

..      Fig. 7.1 a, b Free precession of the hydrogen pro- rotating hydrogen proton gyros are shown in the fol-
ton gyroscopes in the body. For the sake of simplicity, lowing text as an arrow in the precession axis b
the precession direction of the individual spins or the
 60 C. M. Kremers

7.2 Longitudinal Magnetization

It becomes exciting when the compass nee-

dles are brought into a magnetic field. They
then still rotate, but in the axis of the mag-
netic field, This is the task of the main mag-
net, which in most cases (exception e.g. in
the so-called open MRIs) is constructed in
the form of a large wire coil as an electro-
magnet (. Fig. 7.2).
In longitudinal magnetization, not all
hydrogen protons align in the direction of
Z
the magnetic field. Some spins align antipar-
allel, i.e. in the opposite direction. For imag-
ing, however, only the sum vector, i.e. in this ..      Fig. 7.3 Within a homogeneous magnetic field,
7 case the difference between parallel and the spins (i.e. the rotating hydrogen protons within the
antiparallel spins, comes into play. In the patient body) align themselves either parallel or anti-
parallel to the axis of the magnetic field. This is
image example (. Fig. 7.3), therefore, only referred to as longitudinal magnetization
one excess hydrogen proton of the original
five remains for the formation of the image.
responsible “excess protons” in the magnetic
However, the orders of magnitude in the
field direction in turn depends on the strength
real patient are distributed differently: here,
of the magnetic field.
only about 6 ppm (parts per million) form the
decisive amount to the image. That is, if
>>The stronger the magnetic field, the
10,00,006 protons align themselves parallel
stronger the longitudinal magnetization,
to the magnetic field, 10,00,000 align
the more spins align parallel to the mag-
themselves antiparallel, and six of these
­
netic field.
20,00,000 hydrogen protons can later be used
for the formation of the image. They decide
the alignment of the sum vector. Fortunately,
we are made up of an unmanageable amount 7.3 MR Signal
of hydrogen atoms. The amount of the image
The longitudinal magnetization alone does
not yet produce an image. For this, the pro-
tons must first be excited.
In order for an image to be created, the
tissue must first be excited. In the simplest
case, the longitudinal magnetization is
directed into a transverse magnetization by
a 90° pulse radiated into the examined tis-
sue. This so-called high-frequency pulse is a
pulse of radio waves which (in the case of
the 90° pulse) are aligned perpendicular to
Z the external magnetic field and coincide with
the precession frequency (Lamor frequency)
of the material under investigation. This
..      Fig. 7.2 The main magnet with its field lines. In
the magnet itself there is a homogeneous field in the causes the sum vector of the spins to be
direction of the patient’s position (z) deflected by 90° from its axis: it now no lon-
Magnetic Resonance Imaging (MRI)
61 7
ger rotates in the z-direction in an imaginary transverse magnetization again, no signal
coordinate system, but in the xy-plane. remains for the coil.
As an analogy, one can imagine a plate The T1 time is the time interval in which
juggler whose rod in the hand corresponds 63% of the longitudinal magnetization of a
to the z-direction. The plate, in turn, rotates tissue is rebuilt. It depends on the type or
after being deflected by a 90° impulse in the composition of the tissue and on the strength
yx-plane.
The rotating spin vector in xy-plane now
generates a voltage in a receiving coil.

>>The stronger the transverse magnetiza-

tion, the more spins align in the xy-plane
and the stronger the signal.

In the course of time, however, there is a

rapid drop in the signal. There are two rea-
sons for this.

7.3.1 T1 Relaxation Time

After the 90° pulse has flipped the spin vec-

tors into the xy-plane, they gradually seek
their way back into the z-axis of the main ..      Fig. 7.4 Schematic illustration of T1 relaxation.
magnetic field (. Figs. 7.4 and 7.5). Once After the 90° impulse, the spin vector wobbles back to
most of the spins have left the plane of its initial position: the z-axis

Fat
white
substance grey
63% substance

240 680 809 2500 t (ms)

..      Fig. 7.5 The reconstruction of longitudinal mag- signals of different strengths. T1 time is the time it
netization over time. Since different types of tissues takes for a tissue to rebuild 63% of its longitudinal
take different times to T1-relax, their spin vectors emit magnetization
 62 C. M. Kremers

of the magnetic field. A tissue with a short T1 The orientation of the spin vectors in the
relaxation time is fat. Water, on the other dial is called phase. In the context of trans-
hand, has a long T1 relaxation time. verse relaxation, they lose the original same
This results in a signal difference between direction: they dephase (. Fig. 7.7). This
the different tissue types depending on the effect is called T2 relaxation. The T2 time
tissue type and the “readout time”: this is
how the T1 contrast is created.

7.3.2 T2 Relaxation Time

For this, it first makes sense to understand 12

the term “phase”. Here, the direction of the
spin vector in the xy-plane is meant. If we
imagine the dial of a clock representing the
7 xy-plane, then the clock times correspond to 9 3
different phases to which the spin vectors
can be directed (. Fig. 7.6).
So now the spins start to rotate within 6
this dial. Since each hydrogen atom in the
main vector rotates at a minimally different ..      Fig. 7.6 The 90° pulse directs the spin vector from
frequency, they no longer point in the same the z-axis into the xy-plane, which lies there like a
direction over time. clock face

100%

63%

CSF

Fat
white matter
grey matter

84 92 101 1400 t (ms)

..      Fig. 7.7 The signal decay during T2 relaxation time. The strength of the magnetic field has no signifi-
over time. As with T1 relaxation, the signal decay var- cant influence on the T2 time
ies with tissue type and is described by the constant T2
Magnetic Resonance Imaging (MRI)
63 7
does not depend on the magnetic field ment of the magnetic field, additional gradi-
strength of the MR scanner, but it does ent coils are attached in all three spatial
depend on the type and composition of the directions.
tissue. Fat has a short T2 time, the T2 time Since the high-frequency pulse for
of water is long. deflecting the spins must exactly match their
With the aid of the different relaxation rotation frequency, it is possible not to excite
forms and times, correspondingly different the entire patient body with a corresponding
tissue contrasts can be achieved. Both relax- pulse, but only a single layer, from which sig-
ation forms begin simultaneously after the nals are then received.
proton spins have been deflected from their
original gyroscopic motion in the axis of the >>The steeper the layer selection gradient is
magnetic field. In this process, the protons chosen, the stronger is also the local dif-
lose their phase coherence faster than they ference of the rotation velocities and the
can restore longitudinal magnetization. thinner are the excited “body disks”.

>>By aligning the hydrogen protons in a

strong external magnetic field and pulse-­ 7.4.2 Phase Coding
controlled “pushing” of the magnetic
field vectors, a tissue-specific signal can The key to the next level is again a gradient
be generated due to the tissue-specific coil: in order to deduce from which region a
reaction to these alignment pulses, which received signal comes in y-plane, the mag-
MR tomography takes advantage of for netic field is again brought out of equilib-
imaging different types of tissue. rium via a gradient. This time, however, only
briefly, so that the spin vectors are brought
into other phases by short-term rotation at
7.4 Location Coding different speeds. To visualize how this works,
the dial again helps. By briefly turning on
How does the MR tomograph know from the phase-encoding gradient, the spins in the
which part of the patient which signal is dial rotate faster as the magnetic field
coming? This requires several steps and a strength increases. If the gradient is switched
few more components in addition to the off again, all spins of the excited layer run
main magnet and the high-frequency coil: again as fast as before—but in different
the gradient coils. phases—in other words: with different start-
ing clock times. Based on the phase of the
derived signal, a conclusion can then be
7.4.1 Layer Selection drawn about the position on the y-axis in the
excited layer.
The Lamor frequency (i.e. the rotation fre-
quency of the hydrogen proton gyroscopes)
depends on the strength of the magnetic 7.4.3 Frequency Coding
field. Thus, if we do not make the magnetic
field completely homogeneous, but slightly A gradient coil is also present for the third
stronger at the head end than at the foot end spatial plane, the x-direction, in order to
of the patient, the hydrogen protons rotate make the spins rotate at different speeds
with a minimally different frequency in each depending on their position on the y-axis.
part of the body: faster at the head, slower Based on these different rotation frequen-
at the feet. In order to generate this align- cies, when the signal is read out, it is deduced
 64 C. M. Kremers

from which position of the x-direction the 7.5 Proton Thrusting

signal comes. To visualize this, the analogy and Gradient Ballet:
to music helps: there, frequencies form dif-
the Interplay
ferent pitches. If we imagine that our layer
rotates with the frequency of the concert of High-Frequency Pulses
pitch A, the added gradient will cause the and Spatial Coding
higher layer parts to emit higher tones than
the lower ones. The pitch then reveals the Now we know how the signal is generated in
x-position in the excited layer. the MRI and how the tomograph detects the
origin of the received signal. But how does it
all work together?
7.4.4 K-space and Fourier The moment the patient is placed in the
Transformation center of the scanner, his hydrogen protons
begin to align themselves in the direction of
The data now received is “stored” in the so-­ the magnetic field and, in this alignment, to
7 called K-space. The K-space designates a circle around their axis somewhat faster
virtual data matrix in which the acquired than usual: Longitudinal magnetization
raw data are stored in order to process them happens even before the actual examination.
further afterwards. Accordingly, however, a In order to select the examination layer, a
gray value is not stored here pixel by pixel— layer selection gradient is now switched and
it is more complicated. at the same time a matching high-frequency
The K-space is filled step by step and pulse, which now deflects the protons from a
pixel by pixel. Each K-space line corre- body layer by 90° to the side: into the trans-
sponds to a data acquisition in the phase verse magnetization. The receiving coil
encoding direction. Each K-space pixel in already receives a signal at this point, but it
turn does not simply contain a gray value, is still identical from the entire layer and
but information about the entire image. does not produce an image. Now the phase-­
The information about the image contrast encoding gradient is switched on and off
is stored in the K-space center. The loca- again to enable the spatial encoding in the
tion information is stored in the edge y-direction. After an intermediate step—
regions. refocusing (7 Sect. 7.5.1)—the frequency
With the aid of the Fourier transforma- encoding gradient is switched on and the
tion, the data obtained is decoded and pro- signal is read out, which can now also be
cessed into an image. This is a computational assigned in the x-direction. This is how an
model that is used to decode the jumble of axial spin-echo sequence works.
phases, frequencies, location and contrast
information. This is done by an extremely
powerful computer. 7.5.1 Refocusing
To obtain an image, the Fourier trans-
form must be performed individually for Since, as already mentioned, the T2 relax-
each K-space row, or in our image example ation happens very quickly within a few mil-
for each phase column, in order to decode liseconds, the signal also goes out again just
the different frequencies from this column. as quickly. In order to still get enough signal
For a common image matrix of 256 × 256 for an image, we get it again with a 180° pulse.
pixels, this means 256 times. The different The signal generated again in this way in the
spatial frequencies are then decoded from opposite direction is called a (spin) echo
each phase column. (. Fig. 7.8). To ensure that the protons of
Magnetic Resonance Imaging (MRI)
65 7

a 180°
12 b
12

9 3 9 3

6
6
180°

..      Fig. 7.8 a, b With the refocusing pulse, the spins come back into phase and in this way generate a signal
that dephase in the xy-plane are “flipped” by 180° and again—now in the opposite direction within the xy-
converge again on the other side of the dial: they thus plane

180°

..      Fig. 7.9 The refocusing impulse using the example of a group of runners: if all runners remain constant in
their pace, they will arrive together at the start again when they turn around at the same time, e.g. 30 s later

the layer just examined are excited to an echo, (. Fig. 7.9) who start a race—each con-
a layer selection gradient is again switched. stantly at his personal maximum speed.
A popular analogy for a better under- After a short time, all runners are asked
standing of refocusing is a group of runners to turn 180° immediately. If all runners
 66 C. M. Kremers

maintain their speed constantly, they will ent types of tissue is low and the image has
arrive back at the starting point at the same little T2 weighting. A long echo time results
time. in a heavily T2-weighted image.
The repetition time (TR = Time to
repeat) is the time selected between two exci-
7.5.2  cho and Repetition Time or
E tation pulses. It is responsible for the T1
T1 and T2 Contrast contrast of the image. The longer the TR,
the more time the protons had for T1 relax-
Important parameters of an MR examina- ation. If we recall that the time taken for T1
tion sequence are the echo time and the rep- relaxation or for the reconstruction of longi-
etition time—both are decisive for the tudinal magnetization varies, it also stands
contrast in the resulting image, i.e. they to reason that a 90° pulse will cause little
determine which tissue types are imaged signal difference between different tissue
brightly (=hyperintensely) and which are compositions if T1 relaxation is again com-
imaged darkly (=hypointensely). plete at the time of excitation. If the TR is
7 Let us imagine again the structure of a chosen to be short, not all protons will be
spin-­echo sequence with the help of a dia- aligned along the axis of the main magnet at
gram (. Fig. 7.10). the time of re-excitation—accordingly, a 90°
The echo time (TE = Time to Echo) pulse will not “flip” them all into the xy-­
refers to the time span between the excita- plane. The signal differences generated in
tion of the protons and the reception of the this way correspond to a T1 weighting.
signal. It determines how much T2 contrast
is ultimately seen in the resulting images or >>A short repetition time TR produces a
how much an image is T2-weighted. If the T1-weighted image. A long echo time TE
TE is short, the contrast between the differ- produces a T2-weighted image.

90° 180° 90°

Gs Gp Gs Gf Gs

TE
TR

..      Fig. 7.10 Schematic drawing of the sequence of a spin-echo sequence

Magnetic Resonance Imaging (MRI)
67 7

a b

90°

1 2

90°

3 4

..      Fig. 7.11 a, b Schematic representation of the ates a lot of signal, it appears bright in the MR image,
formation of the T1 contrast with a drop of fat in the the water gives little signal, so it is dark in the MR
middle of a glass of water. Since the fat drop gener- image

T1 Weighting gray matter, is surrounded by water. Due to

Let’s imagine a scenario with a drop of fat in the recurring refocusing pulses, an almost
a glass of water and remember: fat has a identical echo is generated—but depending
short T1 relaxation time, the T1 relaxation on T2 effects, the signal decreases from echo
time of water is long. to echo, and at different rates: the T2 time of
After the first excitation, the protons in water is long—so dephasing is hardly notice-
the fat droplet are already aligned in the able and the signal remains strong for longer
plane of the main magnet, while the pro- (water is imaged brightly). The T2 relax-
tons of the water are still on their way back ation of gray matter follows more quickly,
to the z-axis (. Fig. 7.11). Thus, when a the signal of the brain tissue decreases more
90° pulse hits the water glass again at this rapidly and is imaged darkly in the image
point in time, the protons of the fat drop (. Fig. 7.12).
align themselves completely in the xy-plane
again and emit a lot of signal. The water >>In order to distinguish on an image
protons, on the other hand, are not yet whether it is T1- or T2-weighted, it helps
completely relaxed and most of them do to look for an image location with aque-
not circle either transversely or longitudi- ous fluid (e.g. cerebrospinal fluid): Water
nally, but obliquely to the magnetic field— is shown dark in T1 weighting and light in
so after the 90° pulse they are not folded T2 weighting.
into the xy-­plane and accordingly do not
emit any signal.
Characteristics of Different
T2 Weighting Weightings
Decisive for the T2 weighting are the long In addition to T1 and T2 weighting, there is
echo time and the recurring refocusing also proton weighting (PD). This is the
pulses. In our example, a piece of tissue, e.g. name given to the contrast obtained by a
 68 C. M. Kremers

90° 180° TE 180° TE

...

7
..      Fig. 7.12 Schematic representation of the formation of a T2-weighted image with gray matter in a water
glass

.       Table 7.1 Characteristics of the weightings

7.6 Sequence Theory

Weight- TR TE What else can the device do? At least some

ing important, widely available and common
sequences should be briefly explained here.
T1 Briefly Briefly
Approx. 500 ms Approx. 15 ms
T2 Long Briefly 7.6.1 Gradient Echo Sequences
Approx. Approx. 15 ms
2500 ms
In addition to the pulse or spin echo
PD Long Long sequences described above, it is also ­possible,
2500 ms Approx. 90 ms instead of high-frequency pulses, to set the
spin vectors in motion by rapidly switching
TR Time to repeat (repetition time), TE Time
to echo (echo time) strong gradients with the aid of the gradient
coils and to generate signals in this way. T1
as well as T2 and PD contrasts can be
obtained. The gradient echo sequences can
long repetition time and a short echo time also generate smaller excitation angles than
(. Table 7.1). the 90° and 180° known to us so far. This
can save time, for example, to avoid motion
>>Since the gray values in the images of an artifacts, but it also makes vessel imaging
MRI correspond to different signal inten- and diffusion imaging possible. On the other
sities, brightly imaged structures are hand, such sequences are also susceptible to
called signal-rich or hyperintense areas, artifacts and they generate less signal, which
and darkly imaged lesions are called sig- is why they have not replaced spin echo
nal attenuation or hypointense areas. sequences to date.
Magnetic Resonance Imaging (MRI)
69 7
7.6.2 Fat Saturation Chemical Shift or Dixon Method
This method of fat saturation also makes
Fat is mapped hyperintensely in both T1 and use of the minimal differences in precession
T2 weighting. In the T2 weighting, it is frequency between fat- and water-bound
therefore difficult to distinguish edema protons. It is particularly useful for visual-
(water = hyperintense) from fatty tissue. In izing microscopic lipids that are present in
order to make the pathological structures equal proportions along with water-bound
(e.g. fluid or edema) more visible, the signal protons within a voxel. Since the spins
of the fat can be suppressed. There are vari- within the voxel precess at different rates,
ous methods for this. there are always brief times when the spin
vectors of both tissue portions are pointed
Inversion Recovery in the same direction (i.e., they are “in
For this purpose, a 180° pulse is applied phase”) and give off a lot of signal accord-
before the actual examination sequence. It ingly. Similarly, there are times when the
changes the initial position of the spins. The vectors are pointing in the opposite direc-
90° pulse follows at the moment when the tion, this is known as the opposite phase or
vectors of the tissue contrast to be sup- “opposed phase”—as the differently aligned
pressed precede in the xy-plane. Thus, they vectors cancel each other out, the signal at
are flipped out of the 90° plane and give no this measurement time is weak. The images
signal. obtained at the different measurement times
This principle works for the suppression can then be compared: If the tissue contains
of fatty tissue, e.g. to make edema in the fat and water, it is imaged hypointense in the
fatty bone marrow visible. In the same way, opposed phase compared to the in phase
the signal from free fluid (cerebrospinal image.
fluid) in the brain can be suppressed to make
delicate edema in the brain tissue more visi-
ble. Sequences that function in this way are 7.6.3 Vessel Mapping
usually identified by an “IR” in their name,
e.g. STIR, FLAIR or TIRM. With magnetic resonance imaging it is also
possible to image blood vessels. There are
 requency Selective Saturation or
F also various methods for this, including
Spectral Saturation those that do not require the administration
Here, too, a pre-pulse is used. In this case, of a contrast agent.
however, it should not reach all protons of a
layer, but only the tissue to be saturated. Angiography Time-of-Flight
This works because the precession frequency This imaging is often used to image the large
differs minimally in different types of tissue. cerebral arteries. This again requires pre-­
Therefore, it is possible to switch a pre-pulse pulses, which ensure that the tissue whose
that specifically matches only the frequency vessels are to be examined no longer emits a
of the spins bound in the fat tissue. The fat-­ signal itself. The spins flowing in through
bound spins are deflected from the plane of the blood in the opposite direction are also
longitudinal magnetization by this highly saturated. Since the freshly inflowing blood
frequency-selective pulse, thus eliminating does not receive such prepulses, it emits a
their signal from the image. strong signal.
 70 C. M. Kremers

Phase Constrastangiography Tissue intact

Cytotoxic oedema
This type of vessel imaging is particularly Braun's molecular Brownian molecular
suitable for slow, i.e. venous, blood flow, e.g. movement motion normal
to exclude sinus vein thrombosis. For this
purpose, effects of gradient echo sequences
are used: When spins move in the direction
of a switched gradient, their phase changes,
which distinguishes them from the sur-
rounding tissue. This phase difference allows
them to be made visible.
Dephasing
Angiography Contrast-Enhanced
If longer arterial vessel sections are to be
imaged, contrast-enhanced angiography is
suitable. For this purpose, images of the
7 examination volume are first taken without
contrast medium. Then contrast medium is
injected intravenously and images are taken
again while the contrasted blood flows Diffusion
through the arterial vessels to be imaged.
The two series are then subtracted from each
other—this allows the section of vessel to be
imaged to be isolated.

7.6.4 Diffusion Imaging

Rephasing
With diffusion imaging it is possible, for
example, to image the cytotoxic edema of a
stroke. To do this, several gradients are first
switched in opposite directions in quick
succession in order to dephase the spins
within a voxel (. Fig. 7.13). If the tissue
under study is healthy, some of the dephased
spins diffuse the voxel through Braun’s
molecular motion. If the molecular motion
is disturbed, e.g., in the context of such
edema, the spins remain in place. Now a ..      Fig. 7.13 Schematic drawing of the diffusion mea-
rephasing pulse is generated. Then the spins surement procedure
remaining in their voxel generate a signal:
the diffusion-­disrupted areas are imaged areas are imaged hypointense here—so in
hyperintensely. Since T2 effects also influ- order to reliably distinguish a diffusion dis-
ence the image in this imaging, a so-called turbance from a hyperintense lesion of a
ADC map is also produced in addition to different type, these two parts of the
the diffusion images, in which the T2 effects sequence must be compared with each
are eliminated. The diffusion-disturbed other.
Magnetic Resonance Imaging (MRI)
71 7
7.7 Contrast Agent 7.8.1 Attraction of the Magnet

(See also 7 Chap. 9) In addition to contrast-­ Many noteworthy points are based on the
enhanced MR angiography, there are other strength of the main magnet. The most
applications for MR contrast agents, such as commonly used magnetic field strengths in
the search for inflammation or tumors. The medicine are in the range of 1–3 Tesla—a
currently approved preparations are all multiple of the Earth’s gravitational pull
based on gadolinum, a rare earth which, (1.5 Tesla is approximately 30,000 times the
where it accumulates, shortens the T1 relax- Earth’s gravitational pull).
ation time and leads to signal enhancement Magnetic materials (e.g. iron) are accord-
there through T1 weighting. ingly strongly attracted by such a magnet.
As with all medications, intolerances in Metallic objects therefore have no place in
all forms are also possible with gadolinium-­ the MRI scanner—unless they are explicitly
containing contrast media—even if they suitable and intended for this purpose. If
are rare. Nevertheless, the patient must be they come too close to the device, they are
informed of the possible risks before any drawn into the main magnetic field at high
contrast medium is administered. Although speed. Thus, a stethoscope dangling harm-
most MR contrast media are eliminated lessly around the neck of a concerned col-
renally, they do not worsen preexisting league, or even a ballpoint pen, can become
renal impairment. Nevertheless, knowl- a projectile that endangers the life of the
edge of renal function prior to contrast patient in or the staff in front of “the tun-
administration is important because nel”. The magnet’s attraction does not even
administration of gadolinium-containing stop at wheelchairs, oxygen cylinders, defi-
contrast agents may result in skin and con- brillators and patient beds!
nective tissue disease in the setting of In the event of an incident where a
markedly reduced renal function. patient or staff member needs to be “bailed
Nephrogenic systemic fibrosis means a out” and the solenoid needs to be shut down,
considerable reduction in quality of life for the most commonly used superconducting
the affected patients, but also in their life solenoids have a quench option. In a quench,
expectancy. In addition to the “normal” all the helium (which is used to cool the
contrast medium with renal elimination, magnet) is discharged through an outer
there are also so-called liver-specific con- tube. When the quench button—which is
trast media, which are absorbed into the usually secured by a flap or similar and spe-
hepatocytes and at least partially elimi- cially marked—is pressed, the magnetic field
nated via the bile ducts. They are particu- goes out. Once the helium has evaporated,
larly suitable for the evaluation of liver the device is inoperable until the next refill.
tumors. A helium filling is expensive—therefore this
variant should only be used in an emergency,
when there is immediate danger to a person.
7.8 Security

Although there is no X-ray radiation in 7.8.2 Implants

MRI—and therefore no ionizing radiation
that could endanger the patient being exam- Precautions must also be taken with
ined—there are still some aspects that need metallic material inserted into the patient’s
to be clarified before an MRI examination. body. Osteosynthesis and joint prostheses
 72 C. M. Kremers

of the last 20 years are mostly harmless— 7.8.3 Volume

here the magnetic attraction is less the
problem than possible heating of the Another—manageable—danger is the noise
material—which the patient should report generated during an MR examination: espe-
as soon as he notices it so that a burn does cially the rapid switching back and forth of
not occur. gradient coils leads to mechanical stresses in
There are also so-called “MR-­the device, which are loudly noticeable. There
compatible” models for pacemakers, neuro- are so-called “whisper sequences” which cause
stimulators and the like. However, this does less noise by certain settings on the device, but
not mean that all these patients can be on most devices you will not get along without
examined in MRI without any worries. It loud noises. It is therefore essential to use hear-
must first be clarified whether both probes ing protection on and in the running device.
and aggregate are suitable and also in the
implanted combination. If so, the materials
may not be approved for the examination of 7.8.4 Tissue Stimulation
7 all body regions and not for every magnetic
field strength. Since, for example, pace- Due to the movements that are triggered at the
maker settings can be adjusted during the molecular level during an examination, tissue
examination, it is important to know heating can occur. To prevent the movement
whether the patient is pacemaker-depen- from becoming a burn, the energy radiated
dent, i.e. whether his heart beats reliably into the patient’s body is measured as the spe-
without the motivation of the small external cific absorption rate (SAR). The device warns
assist device. And then such a patient must the examiner if the limit value is exceeded.
also be competently monitored during the Rapid switching of gradient fields can
examination. cause nerve stimulation with involuntary
Particular attention should be paid to twitching or electrifying sensations.
vascular clips when inserted within the head In the case of skin-to-skin contact, the
for cerebral artery aneurysm therapy. The development of small eddy currents is pos-
delicate vessels of the head are fragile and sible, which lead to local burns. Therefore, it
movement of such a clip can cause life-­ is important that, for example, the calves do
threatening bleeding. Here, too, it must be not lie directly next to or on top of each
clarified beforehand whether or not the clip other and that the hands are not folded over
is suitable for MRI. the chest or abdomen during the examina-
As a rule, shrapnel is not suitable, which tion. A thin layer of paper or cloth is already
can occur in older patients and in patients sufficient to avoid this reaction.
who have migrated from war zones.

>>As a general rule, you can tolerate a lot 7.8.5 Emergency Bell
of foreign material—but you have to be
sure whether it is suitable in general and Since the patient is usually alone in the closed
also for the planned examination. room, he must have the opportunity to make
himself heard—if he calls for help, no one
You can get information from the manufac- will hear him behind the soundproof wall
turer or from good sites on the net like with accompanying noise from the device.
7 mrisafety.­com. For this purpose, the patient must be given an
Magnetic Resonance Imaging (MRI)
73 7
emergency bell, which is available on every
device, before the examination begins. 3. Are there any contraindications for
an MRI examination?
4. Is contrast medium required for vas-
cular imaging in MRI?
Practice Questions 5. There is an emergency in the MRI:
1. How can you tell in an MRI image its Your patient is no longer breathing.
weighting? As a radiologist, what do you have to
2. Which sequence do you choose to watch out for now as well?
visualize edema, e.g. in the context of
inflammation? Solutions 7 Chap. 27
 75 8

Sonography
Christel Vockelmann and Martina Kahl-Scholz

Contents

8.1 Physical Basics of Sonography – 76

8.1.1  ltrasonic Waves – 76
U
8.1.2 Procedure – 77

8.2 Design and Operation of a Sonography Device – 79

8.2.1 T ransducers – 80
8.2.2 Where to Press… – 80

8.3  ossibilities and Limits of Ultrasound

P
Diagnostics – 81

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 76 C. Vockelmann and M. Kahl-Scholz

In this chapter, you will learn how ultra- sion—of the crystal (. Fig. 8.1a). An
sound waves are generated for use in sonog- applied external electrical voltage causes the
raphy and how sonographic examinations vibrations, i.e. the sound waves, to be emit-
can be technically controlled. ted (= sound wave emission).
If the sound waves encounter an imped-
In addition, you will learn about the areas of ance jump (wave resistance) on their way, e.g.
application, possibilities and limitations of at the boundary between fatty tissue and
this procedure and in which cases it can be water, they are reflected and received as an
used as a radiation-free alternative examina- echo or resonance on the quartz crystal. The
tion in imaging diagnostics. resulting sound pressure deforms the crystal
and the electrical charge is shifted. This piezo
8.1 Physical Basics effect (. Fig. 8.1b) produces a measurable
electrical voltage which is recorded by the con-
of Sonography nected electronics and displayed as an image.
Ultrasound waves are harmless to the
8.1.1 Ultrasonic Waves human body. Only a slight increase in body
temperature is conceivable during an inten-
Sonography uses ultrasound waves to pro- sive examination.
8 duce cross-sectional images of the human The speed of propagation of the sound
body. waves depends on the medium through
which they pass and its elasticity and molec-
>>Ultrasound is the term used to describe ular density (. Table 8.1).
sound waves with frequencies above the The ultrasound image is created by waves
range of human hearing. that are reflected, scattered and refracted at
tissue junctions. This effect is caused by
The ultrasonic waves in sonography devices impedance jumps, e.g. at organ boundaries
are generated via the so-called reciprocal or vessel walls. Impedance (z) stands for the
piezoelectric effect on a quartz crystal. The transition resistance, which is a product of
solid body serves as the transmitter and the speed of sound (c) in the medium and
receiver of the sound waves. The piezoelec- the density (ρ) of the medium:
tric effect is created by the contraction and
elongation—i.e. compression and expan- z = c´ r

a b
Membran
piezoelectric
element

Sound waves
Ci+ -+
Ci- + -
-+ Signal

Ci+ - Ci-

..      Fig. 8.1 In the resting state, the centers of the compressed, the centers of the charges shift towards
positive and negative charges lie on top of each other, each other, a measurable electric voltage is produced
the charges neutralize each other. When the crystal is a. Piezoelectric effect b. (From Hartmann et al. 2014)
Sonography
77 8

..      Table 8.1 Speed of ultrasound waves as a ..      Table 8.2 Frequency-dependent penetra-

function of the medium tion depth of sound waves into tissue

Air 340 m/s Frequency Resolution axial/ Depth of

lateral field
Water/grease 1450 m/s
Soft tissue 1540 m/s 3.5 1 mm/2 mm 160 mm

Bones 2700–4100 m/s 5 0.6 mm/1.2 mm 100 mm

7.5 0.4 mm/0.8 mm 50 mm

>>No border crossings, no ultrasound!

falling on the kitchen table.
z What Happens to the Ultrasound Waves 3. Refraction (Refraction)
in the Body? Refraction deflects ultrasound waves
1. Absorption as they enter another medium. The effect
A large part of the ultrasound waves is amplified by a more acute angle and by
is absorbed, i.e. completely absorbed into a higher resistance between the two
a medium (lat. absorptio = absorption). media. The same effect refracts sunlight
in rain and creates the rainbow.
>>The absorption increases exponentially 4. Diffraction (Diffraction)
with increasing image depth and increases
linearly with the applied ­frequency. >>Diffraction describes the deflection of
waves at an obstacle, which leads to the
The absorbed energy is converted into creation of new waves at the obstacle
heat. Therefore, there are different and their interference (superposition).
transducers that emit different frequen-
cies. Typically, frequencies of 3.5 MHz
are used for abdominal imaging; for 8.1.2 Procedure
superficial structures, high-­ frequency
transducers of up to 20 MHz can be A-Mode
used, which can produce an image The A-mode is the oldest method. “A”
extending only a few cm into the depth stands for amplitude modulation. Today, the
(. Table 8.2). method is still used for distance determina-
2. Reflection and Scattering tion in ENT, ophthalmology and neurology.
If the boundary surfaces are consid- In the early days, before the development of
erably larger than the wavelength, reflec- computer tomography, this method could be
tion occurs. used, for example, to detect a midline shift in
a brain tumor.
>> Reflection means that the angle of inci-
dence and the angle of reflection are equal. M-Mode
The M-mode (from “motion”) can be used
The sound waves are therefore reflected to map the temporal behavior of a tissue. It
back, like the billiard balls on the rail. is used in particular in cardiology
With small structures, the sound waves (. Fig. 8.2). A typical example is the imag-
are increasingly scattered. Scattering is ing of the movement of a heart valve or the
non-­directional, comparable to sugar myocardium.
 78 C. Vockelmann and M. Kahl-Scholz

v
α)

vc
Transducer in (

os
vs

(α
)
Skin
fα
α fβ
v
Vessel

..      Fig. 8.2 Examination of a heart valve. (From ..      Fig. 8.3 Angular ratios in the determination of
Hartmann et al. 2014) the Doppler shift. (From Hartmann et al. 2014)

B-Mode Doppler sonography is used to determine

The B-mode (for “brightness”) is the most flow velocities. From these, stenoses of vessels
8 frequently used method. In the 2D image, can be quantified. The classic field of applica-
the different pixels are detected with differ- tion is the examination of the carotid arteries.
ent brightness grey dots, depending on the
strength of the reflected signal.  onography Color Doppler and
S
A further development of the method is Power Doppler
3D ultrasound, which generates spatial still Color Doppler (synonyms: color-coded
images. For this purpose, in addition to the Doppler sonography; color-coded duplex
scan in one plane, the angle of the sound is sonography; FKDS) is a further develop-
swiveled in order to obtain image informa- ment of Doppler sonography. The image is
tion in the 3rd plane. If not only a still image color-coded with the measured flow veloci-
is generated, but the examination is per- ties and flow directions. The following
formed in real time, a 4D ultrasound is cre- applies by definition:
ated with time as the 4th dimension.
>>Blood flow toward the transducer is
Sonography Doppler coded red; blood flowing away from the
In 1842, the physicist Christian Johann transducer is coded blue. Faster blood
Doppler described the Doppler effect named flow is shown lighter than slower flow. In
after him. When the sound source and reflec- the image on the right, a corresponding
tor move towards each other, the sound waves coding is shown with an indication of
are bundled and reach the receiver at a higher the measured flow velocity.
frequency. You already know the principle:
you can hear whether the sirens of an ambu- For example, it is important to detect the
lance are coming towards you or moving away! direction of flow in subclavian-steel syn-
This effect is used for Doppler sonography. drome, in which flow reversal of the associ-
The effect is strongly angle-dependent ated vertebral artery occurs due to stenosis
(. Fig. 8.3). If the angle between the sound of the subclavian artery (. Fig. 8.4).
source and the reflector is 90°, no signal can be Clinically, affected patients usually have diz-
obtained. The smaller the angle between sound ziness, especially during physical exertion
source and reflector, the smaller the error! and strain of the corresponding arm.
Sonography
79 8
8.2 Design and Operation
of a Sonography Device

A modern ultrasound scanner (. Fig. 8.5)

consists of the following components:
55 Control computer
55 Monitor
55 Keyboard
55 Transducers
55 Printer or connection to the PACS for
image documentation
vertebral artery
The most important elements are the vari-
ous transducers, which are sensitive and
should therefore not be dropped or handled
with aggressive cleaning agents. Depending
on the device class, the prices for such trans-
ducers can correspond to a small car.
Therefore, in case of doubt, it is also worth
taking a look at the operating instructions.

..      Fig. 8.4 Flow reversal in subclavian steal syn-

drome. (From Hartmann et al. 2014)

Power Doppler is an amplitude-coded

Doppler method. In contrast to FKDS, it
does not detect flow velocities, but the quan-
tity of moving particles. The power Doppler
can therefore also detect much slower flows.
The use of ultrasound contrast agents
can enhance the visualization of blood flow.
The field of application of contrast-­
enhanced sonography is primarily the dig-
nity assessment of space-occupying lesions,
in particular of the liver, or during cardiac
ultrasound for the detection of an open
foramen ovale, i.e. a pathological connec- ..      Fig. 8.5 Ultrasound device. (From Hartmann
tion between the right and left atrium. et al. 2014)
 80 C. Vockelmann and M. Kahl-Scholz

..      Fig. 8.6 Transducer variants. (From Hartmann ..      Fig. 8.7 Reverberation

et al. 2014)
Good coupling between the transducer
8.2.1 Transducers and the skin is important for ultrasound
examinations. An insufficient coupling leads
8 The transducers (. Fig. 8.6) are subdivided to artefacts, the so-called reverberations and
according to the propagation of the sound an insufficient image quality. For this rea-
waves into son, ultrasound gel is applied to the trans-
55 Linear transducers: The sound waves prop- ducer and also the patient’s skin, which
agate in parallel, which has the advantage improves the connection between the trans-
of geometrically accurate imaging. ducer and the skin.
55 Convex transducers (curved array): The By the way: Reverberations (. Fig. 8.7)
sound waves spread out like a fan. A also occur with intestinal air or with patho-
larger area can be imaged. logical air accumulations intraabdominal.
55 Sector transducers: The sound wave prop- If the ultrasound is used in a sterile envi-
agation is fan-shaped and radial. Typical ronment, e.g. during an operation, gel must
application is cardiac ultrasound with a also be filled into the sterile cover used for
transcostal access path between the ribs. the transducer (in the case of pocket
Doppler, sometimes also a sterile glove). In
these cases, the sterile tube is coupled to the
Sonography Pocket Doppler patient using saline solution or skin disinfec-
A special form is the so-called pocket tant spray, for example.
Doppler, in which the ultrasound probe For endosonography, there are other
looks like a thick pen. It is mainly used in special transducers that are designed for
vascular diagnostics to measure occlusion the corresponding application. These
pressure. Here, for example, the blood flow include endosonography of the pancreas,
over the dorsalis pedis artery is derived from the heart, the prostate and the internal
the foot and at the same time a blood pres- female genitals.
sure cuff is inflated on the lower leg. As soon
as the sound of pulsating blood disappears,
the blood pressure cuff is slowly released
again. The blood pressure reading at which
8.2.2 Where to Press…
the sound reappears is the occlusion pres-
sure. The value is lowered in the event of
Each sonography device is designed slightly
stenosis or occlusion of the leg arteries.
differently depending on the manufacturer.
Nevertheless, we would like to introduce you
Sonography
81 8
to the most important operating elements, 55 The power mode is often marked with
which are actually always present: “PW” and is also designed as a rotary
55 Before starting the examination: Enter knob.
the patient’s name, usually on the top 55 New and especially larger devices often
right of the keyboard, often marked with also have a touchscreen for operation.
“ID”. In radiology, the devices are usually
linked to the RIS, so in these cases you
select the patient’s name from a work list.
55 The selection keys for the various organ 8.3 Possibilities and Limits
programs are usually located in the upper of Ultrasound Diagnostics
row of the keyboard and are marked
“Preset”. Ultrasound diagnostics is the primary diag-
55 If multiple transducers are available, nostic imaging method for abdominal com-
they can be changed by pressing a but- plaints, vascular diseases and for diagnosing
ton, often labeled “Probe”. cardiac function. Exceptions are highly
55 A button shows the outline of a body. acute diseases, e.g. polytrauma patients. In
This displays the so-called body marker these cases, a computer tomography can
in the image, which is used to document provide an accurate diagnosis in a very short
the section plane in the image. time, while sonographic clarification requires
55 The often somewhat larger “Freeze” or sufficient time, depending on the experience
“FRZ” button (usually on the bottom of the examiner. For an ultrasound diagno-
right of the device) is used to freeze the sis of the entire abdomen without significant
image for saving. peculiarities, even the experienced examiner
55 In the lower part of the keyboard there is needs 10–15 min. In principle, one can
usually a knob labeled “Gain” or examine almost everything with ultrasound,
“Depth” which is used to adjust the over- especially when it comes to children. Thus,
all gain. fractures can also be detected with sonogra-
55 The depth compensation has a similar phy (. Fig. 8.8).
function, but it controls the gain for the
different image depths separately. The
depth control is a slider that is placed in
several rows, usually in the upper right
corner.
55 Often the focus can be shifted with a tog-
gle switch. This achieves an optimal
image at a certain depth.
55 The trackball is used to move markers or
measuring points. You can find these via
buttons, which are usually marked with
crosses or dots.
55 Devices with color duplex function have
a (rotary) knob, usually marked with col-
ored dots, or a “Color” or “CDI” button,
which can be used to set the color duplex
or to amplify it by rotation. ..      Fig. 8.8 Fracture in the child on sonography
 82 C. Vockelmann and M. Kahl-Scholz

>>However, the result is more dependent

on what the examiner sees and docu- 3. What is the meaning of the red and
ments as an image than with any other blue coding in color Doppler or a
procedure. lighter or darker display?
4. What is the pocket Doppler and
where is it used?
Practice Questions 5. In which clinical situations is sonog-
1. What is the piezoelectric effect? raphy mainly used?
2. Please briefly explain the meaning of
A-, M- and B-mode. Solutions 7 Chap. 27

8
 83 9

Contrast Agent
Martina Kahl-Scholz

Contents

9.1 X-ray Contrast Medium – 84

9.1.1 Classification of X-ray CMs – 84

9.2 MR Contrast Medium – 89

9.2.1 Gadolinum – 90

9.3 Sonographic Contrast Agent – 91

9.4 Contraindications – 91

9.5 Side Effects – 91

9.6 Pregnancy and Breastfeeding – 92

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 84 M. Kahl-Scholz

Contrast media (CM) are important in

X-ray diagnostics in order to make certain
tissues, but also pathological processes, e.g.
tumors, visible and to be able to assess them
better. They are divided into different classes
(positive/negative, water-soluble/insoluble,
ionic/non-ionic, monomer/dimer) and used
for different examinations. In addition to
this aspect, however, the chapter also deals
with the most common side effects that can
be triggered by CM.

9.1 X-ray Contrast Medium

..      Fig. 9.1 Hemangioma of the liver with contrast
Contrast media (CM) are used in radiology enhancement
to better highlight tissue structures and thus
make them assessable. Since certain organs case of the hemangioma by the so-called
(e.g. the abdominal organs) have a similar rosette phenomenon, . Fig. 9.1).
density, they would be difficult to distin-
9 guish in imaging without CM. >>Tasks of contrast agents
In addition, the aim of using X-ray con- 55 Contrast enhancement in fabrics that
trast media is to achieve better imaging otherwise differ little or not at all in
while at the same time being well tolerated density
by the patient. –– Improvement of the assessability
Good imaging is dependent on of functional processes (e.g. blood
55 a high contrast, flow, excretion, etc.)
55 a detailed representation,
55 a long enough contrast display depend-
ing on the examination. 9.1.1 Classification of X-ray CMs
Good tolerance of the contrast agent means Contrast media can reduce the absorption
that the CM of X-rays (so-called negative X-ray contrast
55 does not negatively affect any physiologi- media) in order to differentiate from the sur-
cal processes/functions, rounding tissue, or increase it (so-called pos-
55 does not penetrate the blood-brain bar- itive X-ray contrast media).
rier or cell membranes, X-ray contrast media are therefore
55 can be quickly and completely excreted divided into two main groups:
again, 1. Substances with lower density than the
55 does not result in any undesirable side environment to be imaged = negative
effects. contrast media (gases, water, methyl cel-
lulose, sorbitol, mannitol)
The enhancement, i.e. the accumulation of 2. Substances with a higher density than
CM in the organs or tissues, is dependent on the environment to be depicted = positive
the respective organ or tissue structure and contrast media (differentiation into
in part allows conclusions to be drawn about water-soluble, water-insoluble and oil-­
a specific structure in the body (e.g. in the containing)
Contrast Agent
85 9
Contrast Media Negative (sugar alcohol, sugar substitute) or manni-
Negative contrast agents (. Fig. 9.2) used tol belong to the negative CM.
in X-ray diagnostics include gases, i.e. car-
bon dioxide (CO2), nitrogen dioxide (NO2), >>Sorbitol intolerance should be clarified
noble gas and simply: air (e.g. for imaging before using Sorbitol!
the stomach and intestines). But also water
(or water-mannitol solutions), methyl cellu- Side effects of Mannitol may include:
lose, paraffin suspensions and sorbitol 55 Disturbances of the fluid and electrolyte
balance
55 Hypotension
55 Allergic reactions
NO2 55 Cardiac arrhythmias
55 Vertigo
CO2
Similar to methyl cellulose, carbon dioxide
Gase
is used, for example, in gastrointestinal diag-
Noble nostics, e.g. for double-contrast examination
Methyllcellulose of the stomach and for imaging in virtual
Negative KM Air
colonoscopy (. Fig. 9.3a, b). It is generally
better absorbed in the intestine than room
Sorbitol
air and thus, as studies have shown, better
tolerated by the patient.
Water CO2 can also be used in intra-arterial
angiography of the kidneys, the lower
extremity and in the diagnosis of dialysis
..      Fig. 9.2 Negative contrast agents. (From Hart- shunts as a contrast medium with very few
mann et. al 2014) side effects. Patients with an intolerance to

a b

..      Fig. 9.3 Virtual colonoscopy in 3D a and 2D b reconstruction. A pedunculated polyp was seen (arrow).
(From Mang et al. 2008)
 86 M. Kahl-Scholz

iodine-containing contrast media and arthrographies (contrast medium-supported

patients with renal insufficiency are of par- radiological joint examination).
ticular benefit. However, CO2 must not be
used in angiography of the thorax, upper  ontrast Media Positive
C
extremities or supraaortally, as this can trig- Water-Soluble Contrast Media
ger serious neurological complications, in Containing Iodine (. Fig. 9.4)
the worst case accompanied by strokes. Iodine-containing, water-soluble contrast
media are used for the imaging of
55 Vessels (angiography, phlebography),
Double Contrast—What Does that
55 Renal pelvic calices and urinary tract
Mean?
(e.g. MCU, cystography),
Double contrast means performing fluo-
55 Gastrointestinal tract (oral),
roscopy with a positive CM (usually bar-
55 Bile ducts (e.g. ERCP, PTCD).
ium, section water-insoluble contrast
media) and a negative CM (e.g. cellulose,
Especially in computed tomography (specif-
water, CO2). The negative CM provides
ically: CT angiography, CT coronary angi-
better distension (widening, expansion)
ography) they are often used. They are also
of the bowel and distribution of the posi-
used in myelography.
tive CM, resulting in better contrast of
the bowel folds. This technique (the best
z Why Iodine?
9 known method is the enteroclysma, i.e.
Iodine-containing CMMs are used because
the contrast enema according to Sellink)
iodine as a chemical element has a high con-
is no longer frequently performed, as
trast density as well as a relatively low toxic-
other imaging methods (especially mag-
ity and forms a strong bond with the other
netic resonance imaging) are now pre-
chemical structures of the contrast agent
ferred for the desired visualization.
complex.

Room air is used (partly supplementary) for z Triiodobenzoic Acid (Renal)

imaging the gastrointestinal tract (e.g. colon These are contrast media that are largely
double contrast examination) and for excreted through the kidney by glomerular

monomer

Ionian

dimer
Trioiodobenzoic
acid (suitable for the
kidneys = nephrotropic)
monomer

nonionic
Positive KM Water-soluble
dimer

Trioiodaminobenzoic
acid ester (bile-permeable Ionian dimer
= hepatotropic)

..      Fig. 9.4 Positive, water-soluble contrast agents. (From Hartmann et. al 2014)
Contrast Agent
87 9
filtration (therefore renal = nephrotop). A z Contrast Media Ionic
small part is also excreted via the liver-­ Ionic contrast agents carry a salt group in
biliary system and the intestine. their chemical structure, which gives them
Triiodobenzenes produce a well-­an ionic charge. They have a high osmolality
contrasted representation and are classified (number of osmotically active particles in a
into ionic and non-ionic CMs, whereby ionic solution) and a higher plasma protein bind-
CMs are no longer used in practice because ing. This also makes them less well toler-
they have a higher side-effect potential ated, in contrast to non-ionic CM
(. Table 9.1). (. Table 9.1). The BfArM (Federal Institute
for Drugs and Medical Devices) declared in
>>If the limit is exceeded or if liver func- 2000 on the i.v. application of certain ionic
tion is impaired, the CM is excreted via contrast media:
the kidneys (renal insufficiency)!
»» Ionic high-osmolar contrast media
exhibit a higher chemotoxicity and a
In the case of a pathological restriction of
higher osmotoxicity than the low-osmo-
liver metabolism, special attention should be
lar non-­ ionic contrast media preferred
paid to a particularly gentle slow infusion.
today. Chemotoxicity and osmotoxicity
cause a variety of undesirable effects on
different organs and organ systems,
..      Table 9.1 Comparison of ionic and respectively. The intravascular applica-
non-ionic contrast mediaa tion of ionic contrast media is associated
with a significantly higher risk of trigger-
Ionian Nonionic
ing a contrast medium side effect in all
Osmo- High (hence also Low (hence patient groups compared to the applica-
lality “high osmolality “low osmolar tion of non-ionic monomeric contrast
CM”; the CM”) media.
osmolality largely
determines the side Ionic CMMs are hardly ever used in X-ray
effect spectrum) diagnostics, especially as i.v. CMs
Load- Electrically Not (. Fig. 9.5)—their use should be well
ing charged electrically weighed up with regard to possible risks and
charged pre-­existing underlying diseases (morbidi-
Solubil- Only sufficiently Water ties) of the patients.
ity soluble as salt soluble due
(meglumine salts > to hydro- z Contrast Media Non-Ionic
sodium salts) philic side As the name suggests, non-ionic CMs have
chain groups
no ionizing group, but a hydrophilic (i.e.
Protein Approx. 10 Approx. 1.5 water-loving) group that ensures solubility.
Binding Since they have a lower osmolality than
Side Total: 12.66 Total: 3.13 ionic CM (but still twice as high as that of
effectsa plasma), they are also referred to as low-­
Heavy: 0.22 Heavy: 0.04 osmolar CM (. Table 9.1). Because of this
property, they are also associated with side
Very heavy: 0.04 Very heavy:
0.004% effects much less frequently.
Intravenous iodine-containing contrast
aModified after Katayama study, Japan, 1986– media are eliminated renally. Only a small
1988 proportion is excreted hepatically via the
bile. This proportion may cause you to see
 88 M. Kahl-Scholz

z Monomers and Dimers

Both ionic and nonionic contrast agents
have monomeric and dimeric variants. The
difference lies in the chemical structure: the
number of benzene rings in dimeric non-
ionic CMMs is two, in monomeric nonionic
CMMs only one—due to the more complex
structure, dimeric nonionic CMMs are also
more viscous, i.e. more viscous, and must
therefore be warmed up before application,
as the viscosity decreases with increasing
temperature.

>>CM are before their use in a heat cabinet

to reduce the viscosity. Due to the vis-
..      Fig. 9.5 More strongly contrasted colon (right)
cosity, the CM can only be injected with
after rectal filling with diluted contrast medium, orally
given CM (loops of small intestine) is more diluted increased force. Therefore, errors can
due to fluid retention in the intestine in case of bride- occur with CM pumps when they are
nileus in the right lower abdomen cold. Therefore, care must be taken to
ensure that a heat sleeve is used.
9
Dimeric ionic contrast agents, on the other
hand, have two acid groups, for example.

Water-Insoluble Contrast Media

z Barium Sulphate
Barium sulphate (BaSO4) is used in the diag-
nosis of the gastrointestinal tract as an
orally administered CM (. Fig. 9.7).
However, today it is only used in very rare
cases.
Since barium sulfate is hypotonic to
blood plasma, it can cause dehydration in
the intestine.
It must not be used in cases of suspected
ileus (intestinal obstruction), perforation or
suture insufficiency, dysphagia (risk of aspi-
ration!) or other serious illnesses.

Contrast Media Containing Oil

..      Fig. 9.6 Intravenous pyelogram (IVP) 12 min z Oils
after CM administration Oils that have been iodized are used in lym-
phography. However, they are difficult to
contrast of the gallbladder one or two days degrade in the body and produce by-­
after intravenous contrast administration products, and are therefore associated with
(. Fig. 9.6). many disadvantages and side effects. Since
Contrast Agent
89 9

a b

..      Fig. 9.7 Coronary reconstruction with elongated better from the diluted barium sulfate in the other
foreign body in the terminal ileum (arrow); in the intestinal loops due to its higher density. (From Fabel
selected bone window, the foreign body stands out 2006)

raphy (. Fig. 9.8), but due to the severe side

effects, this is now only performed with
water-soluble non-ionic contrast media.

>>The amount of CM to be administered

depends on the examination, the weight
of the patient and the iodine concentra-
tion of the CM. In CT, concentrations of
400 mg iodine/ml are often administered.
Thus, if a patient is injected with 100 mL
of CM, he or she will receive 40 g of
iodine! The daily requirement of an adult
is 180–200 μg per day.

9.2 MR Contrast Medium

The functioning of MRI is related to relax-

ation times as already shown. The signal
..      Fig. 9.8 Myeolography with oily CM. (From strength of the tissue is significantly influ-
Hartmann et al. 2014) enced by the T1 and T2 relaxation time. The
use of contrast agents increases the signal
water-soluble contrast media would diffuse difference between the tissues and thus the
too quickly in the lymphatic system, and image contrast.
thus no good imaging of the lymphatic ves- To achieve this, substances with a large
sels is possible, there is no alternative. In the magnetic moment (many unpaired electrons
past, iodinated oils were also used in myelog- on the outermost shell) are used, which
 90 M. Kahl-Scholz

accelerates the ambient relaxation (decay of 9.2.1 Gadolinum

magnetizations) in the environment.
Gadolinum complexes are commonly used Gadolinum is the “all-rounder” among the
MR contrast agents in this context. MR contrast agents, has seven unpaired
electrons and greatly reduces the relaxation
>>The amount of relaxation time reduc- time (in T1-weighted sequences with signal
tion is called relaxivity. It is a measure of enhancement). However, the free paramag-
the effectiveness of an MR contrast netic ions are very toxic. Therefore, the MR
agent. contrast agents used are derivatives of gado-
linum (. Fig. 9.10). These include:
Since the effect is stronger in T1 measure-
ments, CM are mainly used in such z Non-Specific Gadolinum Complexes
sequences. 55 Are excreted via the kidney,
MR-CM can be used as positive (“whit- 55 distribute only in the extracellular space
eners”) and negative (“blackers”) depending (no penetration of the blood-brain bar-
on the measurement in which they are used. rier),
Since they shorten the relaxation times in 55 have an HWZ of 90 min,
both T1 and T2 time, they can lead to differ- 55 are not metabolized or bound to pro-
ent image effects. teins,
55 The shortening of the T1 time leads to a 55 have a high stability.
9 faster reconstruction of the longitudinal
magnetization and thus to a signal >>The accumulation of gadolinium in a tis-
amplification (white). sue depends on the general condition of
55 The shortening of the T2 time leads to a the patient (fever), the waiting time after
faster decay of the transverse magnetiza-
tion and thus to a signal drop (black)
(. Fig. 9.9).

..      Fig. 9.9 Magnetic resonance cholangiopancreati-

cography (MRCP) with negative contrast of the stom-
ach with 100 mL of pineapple juice immediately before
the examination. Note the signal-elevated distal loops
of small bowel and the pineapple juice signal-extin- ..      Fig. 9.10 Imaging of a neuroectodermal tumor in
guished stomach. The contrast is due to the high man- a 5-year-old girl using gadolinum MR. (From Choi
ganese and iron content of the pineapple juice 2005)
Contrast Agent
91 9
the injection and the dose (“much helps 55 Anaphylactoid reaction to the iodine-­
much”). The contrast medium may containing CM to be used
“behave differently” in a patient with 55 Certain thyroid carcinomas
fever than in patients without fever. This
may play a role in the findings. Relative Contraindications
55 Heart failure
MR contrast media are generally well toler- 55 Severe hepatic dysfunction
ated. Side effects occur in only 1–2% of 55 Hematological diseases (Waldenström’s
examinations, mainly affecting the kidney. disease)
In a few cases, allergic reactions have also
been reported. >>After CM injection, thyroid scintigraphy
is not informative!
>>The edema signal in STIR or TIRM
sequences is masked by CM administra-
tion, so these sequences must be per- 9.5 Side Effects
formed before contrast administration.
Adverse reactions caused by CM may be
dose-dependent or dose-independent
9.3 Sonographic Contrast Agent (. Table 9.2).
Among other things, vasodilatation may
Contrast agents used in sonography perform occur, which causes a drop in blood pressure
their function by increasing the reflection of (hypotension). Histamines released from
ultrasound waves—this results in a stronger mast cells are responsible for an immediate
signal response, which can be read on the allergic reaction and in turn lead to vasodi-
ultrasound screen as higher contrast. lation of the small peripheral vessels. This is
The imaging of contrast microbubbles the cause of a possible circulatory shock.
in diagnostic sonography is based on exci- Furthermore, an involvement of the coagu-
tation of the microbubbles in the sound lation system and the CNS is discussed.
field, whereby the microbubbles start to
oscillate.
..      Table 9.2 Undesirable direct side effects/
>>The higher the intensity of the irradiated reactions to CM
ultrasonic waves, the stronger the reac-
Dose-dependent Dose-­
tion of the microbubbles (up to bubble
response independent
destruction). response

Response Direct (local) Systemic

9.4 Contraindications type effect on organs response
and tissues as
well as organ
The most important contraindications are systems
given in the following overview:
Pathologi- Chemotoxic Anaphylac-
cal process tic
z Contraindications for CM Application
Absolute Contraindications Symptoms Sensation of Nausea,
warmth/cold, vomiting,
55 Severe kidney dysfunction not previously reddening of the urticaria,
requiring dialysis skin, headache itching
55 Manifest hyperthyroidism
 92 M. Kahl-Scholz

Many patients assume that a CM reac- child, depending on the planned examina-
tion is accompanied by an iodine allergy— tion. In certain emergency situations, it is
but an iodine allergy would not be nevertheless unavoidable to perform an
compatible with life, since we need iodine as examination on a pregnant patient. There
an indispensable component of our human are no precise data on the extent to which
metabolism. CM is transferred to the fetus and exposes it
in this case.
>>An adverse CM reaction is not based on About 1% CM is found in the mother’s
an iodine allergy, but is due to an intoler- milk. That this amount has a harmful effect
ance of the CM complex. on the infant has not yet been proven. The
current recommendation does not call for
Locally, especially with iodine-­ containing any special measures. Nevertheless, a
contrast media, pain, damage to the vessel 24-hour breastfeeding break can be consid-
walls, vasodilatation (→ drop in blood pres- ered.
sure) may occur.
Practice Questions
>>Low osmolar CMs are generally better
1. Which negative and positive contrast
tolerated than high osmolar ones, non-­
media are used in radiology?
ionic ones better than ionic ones.
2. What factors influence the accumula-
9 Special caution and close scrutiny of the use
tion of gadolinum in tissues?
3. What is meant by “double contrast”?
of CM is required in patients with:
4. What are absolute, what are relative
55 Status after severe CM reaction
contraindications for the administra-
55 Allergies
tion of CM?
55 Bronchial asthma
5. What should be considered during
55 Kidney disease
breastfeeding with regard to the
55 Thyroid disorders
administration of CM?

Solutions 7 Chap. 27
9.6 Pregnancy and Breastfeeding

Pregnancy is a relative contraindication for

an X-ray examination. The radiation expo-
sure is relatively high for the unprotected
 93 10

Radiotherapy
Guido Heilsberg

Contents

10.1 Possibilities and Principles of Radiooncology – 94

10.1.1  rachytherapy – 94
B
10.1.2 Particle Therapy – 94
10.1.3 Therapy Concepts in Radiooncology – 94
10.1.4 Fractionation – 95

10.2 Irradiation Planning – 95

10.2.1 Further Processing – 96

10.3  esign and Function of Radiooncological

D
Irradiation Equipment – 96
10.3.1 L inear Accelerator – 96
10.3.2 Dose Distribution in Tissue – 97
10.3.3 Irradiation Techniques – 97
10.3.4 Irradiation Variants – 99
10.3.5 X-ray Therapy Equipment – 99

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 94 G. Heilsberg

Radiation therapy, also known as radioon- 10.1.2 Particle Therapy

cology or radiotherapy, is a medical spe-
cialty that deals primarily with the treatment In particle therapy, the Linear Energy
of malignant tumors with the aid of ionizing Transfer (LET), i.e. the energy transfer of
radiation. a particle, plays a decisive role. The radia-
tion quality and the relative biological
effectiveness (RBE) depend on the LET of
10.1 Possibilities and Principles the respective radiation. A distinction is
of Radiooncology made between loosely ionizing radiation
(low LET) and densely ionizing radiation
10.1.1 Brachytherapy (high LET); a high LET therefore has a
higher biological effectiveness than a low
In contrast to “teletherapy”, in which the LET.
radiation hits the body externally and over a Protons belong to the low-LET radiation
distance, the distance between the radiation group and their relative biological effective-
source and the body in brachytherapy is less ness is 1.1, which is approximately the same
than 10 cm. as that of photons and gamma rays, whose
Application: Intracavitary (the radionu- RBE is 1. Heavy ions with a high LET have
clide is placed in a body cavity for a short a RBE of 2–4. The dose is expressed in Gray
time), interstitial (the radionuclide is placed equivalent (GyE) or in RBE (relative bio-
temporarily or permanently in the tissue), logic effectiveness).
contact therapy (radionuclide is placed in a Acceleration takes place via the cyclo-
10 carrier that remains on superficial tissue for tron and the synchrotron.
a certain time).
Indication for intracavitary brachyther-
apy is the vaginal application for irradiation 10.1.3 Therapy Concepts
of the vaginal stump in corpus carcinoma. in Radiooncology
However, it is also possible for small superfi-
cial carcinomas in the esophagus or other Radiation is also used to treat benign dis-
cavities. The transport of the radioactive eases, but it is mainly used to treat cancer
substance to the target site is carried out with the aim of curation or palliation. It
remotely from a lead-resorber in the so-­ can be used as the sole form of treatment or
called afterloading procedure. For this pur- in combination with chemotherapy, anti-
pose, the lead resor is connected via one or body therapy or hormones (“primary” or
more tubes to the applicator, which in turn is “definitive”) and in combination with sur-
introduced into the body cavity. For the tem- gery (pre- or post- or intra-operative radio-
porary method of interstitial therapy, more therapy).
or less flexible plastic tubes several millime-
ters thick are pulled through the tissue intra- z Radiotherapy Alone
operatively with a sharp metal needle. Over Radiotherapy alone is more often used in
a period of several days, these cavities are palliative situations. Only in smaller and
filled several times with radioactive material, radiosensitive tumors is radiotherapy a
usually 192 iridium by afterloading. The curative therapy.
technique is used for ENT tumors, large soft
tissue tumors or as an interstitial boost for Radiotherapy in Series Radiotherapy can be
anal carcinoma and breast-conserving given either in one series without any change
breast carcinoma. in the irradiated volume or in several series.
Radiotherapy
95 10
The number of series and their target struc- z Palliation
tures depend on the disease, the pre-treatment For palliative treatment, a therapy regimen
and also the individual situation. must be individually tailored to the patient’s
situation and the therapy goal.
Boost Irradiation The boost is applied to a
macroscopic tumor or to an area with an
increased risk of recurrence. 10.2 Irradiation Planning
It is possible to perform the boost
sequentially, i.e. following the irradiation As soon as all important information about
series, or during the irradiation series either the cancer such as TNM stage, histology,
concomitantly or as a simultaneously inte- receptor status, etc. is available, the patient is
grated boost (SIB). presented to the interdisciplinary tumor
Radiotherapy can also be combined with board and the therapy concept is deter-
other treatments (multimodal): mined. The radiation oncologist discusses
55 Chemotherapy: e.g. for squamous cell the recommended procedure, the therapy
carcinoma and its side effects with the patient. In a
55 Antibodies: e.g. for ENT tumor for physical examination, the doctor himself
which chemotherapy is contraindicated gets an idea of the extent of the tumor and,
55 Hormones: e.g. for prostate carcinoma during the discussion, assesses whether the
55 Surgery; preoperative (“neoadjuvant”) radiotherapy can be carried out on an out-
with the aim of tumor reduction; post- patient basis, which positioning on the treat-
operative or adjuvant; intraoperative. ment table is possible or advisable and
whether certain preparations are necessary,
e.g. implantation of markers in the target
10.1.4 Fractionation organ or dental rehabilitation in the case of
treatment in the mouth and throat area. In
The standard regimens are 5 × 2 Gy/week addition, it is clarified to what extent the
and 5 × 1.8 Gy/week (normofractionation). patient is ready for the therapy.
The irradiation ordinance includes the
z Hypofractionation following aspects:
This is the reduction of fractions with a 55 Intention (curative, palliative)
simultaneous increase in individual doses. 55 Definition of the target volume
Advantages: shorter treatment time. 55 Definition of organs at risk (OAR)
55 Radiation type: photons or electrons
z Hyperfractionation 55 Beam energy: Example six or 15 MV
This is the increase of fractions in a unit of photons, fouror 18 MeV electrons
time. It is used if, for example, a radiation 55 Irradiation technique: standing field/
session is cancelled. The single dose to be multi-field irradiation, IMRT, stereo-
made up is often applied before the week- therapy, brachytherapy etc.
end, i.e. on Friday as the second session of 55 Single and total dose
scheduled radiotherapy. The idea is that the 55 Fractionation
normal tissue will have recovered from the 55 Positioning and positioning aids for the
sublethal (almost fatal) radiation damage by patient
Monday. 55 Name, first name, date of birth and diag-
Dose-scaled, accelerated hyperfraction- nosis of the patient
ation is used for tumors with a high cell divi- 55 Irradiating institution, name and signa-
sion rate. ture of attending specialist, date
 96 G. Heilsberg

Storage is an important preliminary mea- energy. It is called ultra-hard X-rays. It

sure so that the irradiation can always be makes it possible to reach deeper tumors—
applied in a reproducible manner. in contrast to conventional X-ray therapy,
55 It must be as comfortable as possible. which has a superficial effect (7 Chap. 2).
55 The planned irradiation technique must The accelerator arm (gantry) rotates in one
also be taken into account. plane around the treatment table. Its posi-
55 It must be possible to reproduce it tion is specified as the gantry angle.
exactly. The section in which the electrons are
generated is called the electron gun. The
acceleration of the electrons is achieved by a
10.2.1 Further Processing 1–2.5 m long accelerator tube, which the
electrons have to pass through. Here an
MRI and/or PET-CT slices are superim- alternating voltage with high frequency pre-
posed on the planning CT images (= fusion, vails. The tube ends in the beam head. There,
matching) and thus support the determina- the electron beam is deflected by means of
tion of the contours. magnets in a circular motion through 270°.
The target volume results from: As a result, the previously different energy
55 Tumor volume: Tumor, possibly with levels of the individual electrons are brought
lymph node metastases or distant metas- into line with each other, and the beam
tases. becomes more homogeneous.
55 Clinical tumor volume (CTV): macro- When the accelerated electrons collide
scopic tumor + the region with scattered with the target, high-energy photons are
10 tumor cells.
55 Planning Target Volume (PTV): CTV.
produced and the target is strongly heated
during this process. A water pipe and a cop-
per block are integrated in the machine for
From many years of experience, the dose cooling. The resulting photons pass through
values for the individual organs are known, the primary collimator, which is used to
the exceeding of which threatens a func- absorb photons that are not moving in the
tional impairment. In so-called dose volume direction of the useful beam. In this case,
histograms, the organ volumes that receive a the primary collimator is a lead funnel,
certain dose are represented graphically. which absorbs the rays on the walls that are
not directed at the patient and therefore
>>In an emergency, extensive radiation have no therapeutic effect. In the further
planning is not necessary. course of the beam there is a balancing filter
made of metal (photon balancing body),
which homogenizes the photon radiation. A
10.3 Design and Function further element is the electron catcher
of Radiooncological (beamstopper or beamhardener). It
Irradiation Equipment intercepts the soft (low-energy) radiation
­
components (“hardening”).
10.3.1 Linear Accelerator During treatment with electrons, the
radiation emerges directly (without a brake
The classic treatment device is the linear target). Instead of hitting the compensating
accelerator. It consists of an X-ray machine body, the electrons hit a micrometer-thick
with an accelerating tube as an additional metal foil (scattering foil), which expands
device that provides the rays with higher the beam to an enlarged diameter.
Radiotherapy
97 10
The two transmission ionization cham- 10.3.2 Dose Distribution in Tissue
bers measure the absorbed dose in monitor
units (ME, “MU”). Deep Dose Profile
The field to be irradiated is projected Electrons and photons both belong to par-
onto the patient’s surface by means of a mir- ticle radiation (fast-moving atoms, ions or
ror in the irradiator head using a light elementary particles with rest mass), but
source. The position of the light source has they have different weights and behave dif-
the same distance to the skin or surface as ferently as to when and to what extent they
the brake target. It indicates the focus-to-­ release their energy. Diagrams with so-called
skin distance (FHA). depth dose curves (. Fig. 10.1) characterize
Four tungsten or lead blocks (apertures) the dose progression in tissue.
delimit the four field edges (collimators), Decisive for the depth dose curve are: the
their four apertures are movable, and the beam modality (high energy photons reach
field lengths and field widths (X1, X2, Y1, deeper volumes), the beam energy (higher
Y2) are defined above them. energies penetrate deeper), the field size, the
Before the first session and at certain focus-skin distance and the material irradi-
intervals during the treatment, it is checked ated.
and documented whether or not radiation is
actually administered exactly as specified in z Photons and Electrons
the calculated plan. If this verification When it hits the skin or surface, the photon
recording takes place directly before the beam emits about 70–80% of its dose. It
radiation and any necessary corrections are penetrates further into the tissue on its path
made immediately, this is known as IGRT and regains energy through the secondary
(image-guided radiotherapy). Computer electrons.
programs help to measure (match) the dis-
tance from given structures (e.g. bone con- >>The higher the energy of the photon
tour, trachea, teeth) in advance. An beam, the less dose the skin receives and
additional metal clip (marker) in the tissue the deeper the dose maximum lies in the
allows the target volume to be defined more tissue.
clearly. Newer linear accelerators have a
cone beam CT. Electrons also develop their dose maximum
under the skin, but they subsequently have a
Respiratory Gated Radiotherapy different behavior than photons, because
With respiratory control, only a narrow cra- after penetrating the skin they maintain the
nial and caudal safety margin is required for direction of their movement and penetrate
irradiation of lung tumors, since the respira- deep into the tissue (one reaches deeper PTV
tory tumor movement does not have to be with them).
taken into account. Similarly, the method
spares the heart in left-sided breast cancer. It
is only irradiated in inspiration. 10.3.3 Irradiation Techniques
z Gating or Breath Hold Technique z Isocentric and Isocentric Irradiation at
The above-mentioned technique is called the Linear Accelerator
gating (gate: the gate that opens and closes). The isocenter is the point located on the cen-
A simpler method is breath-hold radiation, tral beam at a distance of 100 cm from the
which is preferably used for left-sided breast target. It is where the axes of the gantry, col-
cancer to protect the heart. limator and table meet. The patient is posi-
 98 G. Heilsberg

Photon and Electron Beam %DD’s

6 MV
100.0 10 MV
18 MV
6 MeV
80.0 9 MeV
12 MeV
14 MeV
60.0 16 MeV
%DD

20 MeV

40.0

20.0

0.0
0.0 5.0 10.0 15.0 20.0 25.0 30.0
Depth (cm)

..      Fig. 10.1 Depth dose profile for 6–18 MeV electrons and 6–18 MV photons. Y-axis: Dose in percent, x-axis:
Tissue depth. (From Purdy et al. 2012)

10 tioned in the planning CT in such a way that The simplest technique is the standing
the isocenter is in the middle of the target field, where the field size, the hearth depth
volume. If this is sometimes not successful, and the energy are fixed.
the planning computer calculates how far Counterfields
and in which directions the patient must be A standing field is not suitable for target
moved with the table during the initial settingvolumes located deeper in the body.
(off-set) in order to meet the specification. Counterfields (opposing single fields) halve
the radiation exposure of healthy tissue.
z Coplanar Irradiation Multi-Field Technique—Conformal
Normally, the central beams of all fields are Irradiation
placed in a plane that is typically transverse A common technique is the multi-field
to the patient’s axis (coplanar irradiation). method. This brings the isodoses closer to
Stereotaxy, on the other hand, is a non-­ the PTV, so that the healthy tissue can be
coplanar procedure (. Fig. 10.2), which is better protected.
why the table must be partially realigned
during a session. z IMRT
IMRT (intensity-modulated radiotherapy)
z Isodoses is another method of conformal irradia-
Isodoses are points with the same dose (con- tion. Here, either the sliding window tech-
nected by lines, they are called isodose nique (irradiation while the MLC are
curves). moving) or the step-and-shoot technique
(with irradiation interruption) are used.
z Simple Techniques This allows the dose to be varied from point
Standing Field to point.
Radiotherapy
99 10

..      Fig. 10.2 Non-coplanar stereotaxy using ten fields compared to coplanar VMAT

z VMAT of radiosurgery when the dose (12–25 Gy) is

Volumetric Modulated Arc Therapy applied all at once. High targeting accuracy
(VMAT) is borrowed from the IMRT tech- is extremely important, especially for brain
nique: the number of small dose-modulated radiation (e.g., for acoustic neuroma,
fields irradiated in gantry positions increases, meningioma). The Cyberknife is used to
the gantry moves in a circle or semicircle, compensate for the movements of the
and the irradiation time is shortened. patient or the target volume.

10.3.4 Irradiation Variants 10.3.5 X-ray Therapy Equipment

z Tomotherapy For radiotherapy in the kV range, a conven-

The tomotherapy device is a combination of tional X-ray apparatus is used, but with
linear accelerator and computer tomogram. higher voltage than in diagnostics (30–
The advantages are that several volumes can 200 kV).
be irradiated in one procedure and that long In many forms of heel pain (achillo-
volumes can be achieved. In addition, the dynia, fasciitis plantaris, heel spur) and
adjacent tissue is optimally spared in the other inflammatory degenerative diseases,
case of shell-shaped target volumes. such as tennis elbow (epicondylitis humero-
radialis), there is an inflammation of the
z Stereotactic Radiotherapy soft tissues (connective tissue, ligaments,
Stereotaxy is the term used to describe tendons) with the classic features of pain,
radiotherapy that is applied in a spatially redness and swelling in addition to the (age-
targeted and highly precise manner. The related) signs of wear and tear. In these
treatment is carried out via numerous, very cases, X-ray therapy with small individual
small radiation fields of the linear accelera- doses between 0.5 and 1 Gy and total doses
tor in noncoplanar arcs. In the actual stereo- of about 6 Gy, also called stimulation radia-
taxy (Stereotactic Radiotherapy, SRT), tion, is effective.
treatment is administered 3–5 times, each Basaliomas and spinaliomas whose sur-
time with high individual doses. One speaks gical removal would produce cosmetically
 100 G. Heilsberg

unattractive results (e.g. on the nose, lip) or

would be associated with functional limita- 3. What are the different forms of
tions (e.g. on the eye) can be successfully brachytherapy?
treated with conventional therapy. 4. What is “boost therapy”?
5. Explain the terms tumor volume, clin-
ical target volume, and planning tar-
Practice Questions get volume.
1. What is IMRT and VMAT?
2. What happens during stereotaxy? Solutions 7 Chap. 27

10
 101 11

Nuclear Medicine
Ursula Blum

Contents

11.1 Imaging and Therapeutic Options – 103

11.1.1 S cintillation Counter: Scanner, Gamma Camera,
Gamma Probe – 103
11.1.2 Semiconductor Cameras – 103
11.1.3 PET – 103
11.1.4 Hybrid Systems – 104
11.1.5 Therapy Options – 104

11.2 Radiation Protection – 106

11.2.1  ot Laboratory – 106
H
11.2.2 Investigation Area – 107
11.2.3 Leaving the Department – 107

11.3 Detection of Radioactivity – 107

11.3.1 Scintillation Detectors – 107

11.4 Image Formation Systems – 110

11.4.1 Gamma Camera – 110

11.5 Radionucleotides in Medical Application – 113

11.5.1 Diagnostic Imaging – 114

11.6 Radiopharmacology – 114

11.7  uality Assurance Measures

Q
of Radiopharmaceuticals – 114
11.7.1  adioisotope Purity – 115
R
11.7.2 Chemical Purity – 115
11.7.3 Radiochemical Purity – 115
11.7.4 Specific Activity – 116

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
11.7.5 S tability – 116
11.7.6 Microbiological Purity – 116

11.8 Contamination and Decontamination Measures – 116

11.8.1  ontamination – 116
C
11.8.2 Decontamination – 116
Nuclear Medicine
103 11
Nuclear medicine is like X-ray—only the The radioactive radiation hits a scintilla-
other way round. In nuclear medicine, it is tion crystal (usually a thallium-enhanced
the patient who radiates and not the device— sodium iodide crystal). This produces a flash
or, to put it more technically, the emission of light in the crystal which strikes a photo-
rays of the applied radioactive substances cathode. An electron is released. This is sub-
are used for imaging. Here, molecular meta- sequently amplified by a secondary electron
bolic processes can often be made visible. multiplier (SEV, or photomultiplier, PM).
The voltage increases from dynode to dyn-
Beta and alpha emitters are used in nuclear ode, so that a large number of electrons
medicine therapy. Many therapies are very (amplification approx. 105–109) strike the
specific. anode. Amplification and discrimination
take place, and images are generated by
means of a connected EDP. To avoid stray
radiation as far as possible, a collimator is
11.1 Imaging and Therapeutic usually placed in front of the crystal.
Options
11.1.2 Semiconductor Cameras
11.1.1 Scintillation Counter:
Scanner, Gamma Camera, Semiconductor cameras are currently only
Gamma Probe available as special cameras (e.g. heart,
chest). The radiation is collected directly by
The principle of image generation or radio- the semiconductor (e.g. cadmium-zinc-­
activity detection is the same for the gamma telluride) and converted into electrical
scanners, the gamma camera and the charge. The detectors are significantly
gamma probe. With the scanner systems no smaller than those of a “normal” gamma
longer in use today, the organ to be exam- camera, and examination times can be sig-
ined was scanned line by line, and the image nificantly reduced due to the good energy
was often created using a directly connected resolution.
plotter. The gamma camera replaced the
scanner. Almost all examinations are per-
formed with the gamma camera. They are 11.1.3 PET
available as special shield-nozzle cameras,
as single-­head, two-head and three-head When a positron emitter decays, a positively
systems. Single images of regions (e.g. thy- charged antiparticle (=positron) is formed.
roid, kidney, lung) can be produced, as well This then meets an electron in the body. This
as whole-­body images (bone scintigraphy, produces the so-called annihilation radia-
inflammation scintigraphy) and tion; a pair of γ-quanta with an energy of
3-­dimensional images using SPECT (single 511 keV is always formed. The γ-quanta are
photon electron computed tomography, e.g. emitted at an angle of 180° to each other.
in heart or brain diagnostics). Only when both γ-quanta hit the detection
Gamma probes are very small measuring crystal, they are detected as true radiation
devices that are used especially in the oper- by the device and further processed as true
ating room for the detection of sentinel signal. This nearly simultaneous impinge-
lymph nodes. Other possible applications ment of the radiation is called coincidence.
are the intraoperative detection of parathy- Due to the various other factors, such as the
roid glands. Here, the radiation is converted temporal impingement of the radiation and
into an acoustic signal. the local registration of the radiation,
 104 U. Blum

3-dimensional cross-sectional images are ical data set. In this case, all examinations
generated. A spatial assignment of the accu- can be performed. SPECT-CT is used in
mulation is sometimes difficult, since not all conventional nuclear medical diagnostics
anatomical structures can be clearly distin- (e.g. heart, brain, bones), PET-CT or PET-­
guished from each other on the basis of their MRI mainly for oncological questions.
metabolism.
A PET device usually consists of many
small detection crystals (bismuth germanate, 11.1.5 Therapy Options
BGO or lutetium oxyorthosilicate, LSO)
arranged in a ring and in series. Several crys- Almost all nuclear medicine therapies are
tals are amplified via an SEV. performed on an inpatient basis for reasons
The examination is performed in 2D or of radiation protection. Exceptions to this
3D technique with attenuation correction. are radiosynoviorthesis (RSO, section
2D technique means that only coincidences Radiosynoviorthesis) and palliative pain
within one collimator row are detected; in therapy for bone metastases.
the 3D technique, these are detected across
all collimator rows. This means that the 3D Radioiodine Therapy
technique is significantly more sensitive than Usually, radioactive iodine (131I-NaI) is
the 2D technique, whereas the 2D technique taken in capsule form. Less frequently, it can
provides very homogeneous images. be administered in liquid form or injected
An attenuation correction is always nec- intravenously. The radioactive iodine is dis-
essary. Different tissues cause different tributed according to the physiological
attenuation of the passing radiation. In the iodine metabolism. It is absorbed through
case of pure PET systems, the attenuation the gastrointestinal tract into the blood,
correction is carried out by means of a so-­ then into the thyroid gland. Here it is
11 called transmission measurement. An exter- absorbed into the active thyroid tissue.
nal radiation source (68 Gy rod source) is Depending on the disease, different doses
used and an exposure is started. The tomo- are reached in the target tissue.
gram created in this way is then overlaid In the case of malignant diseases of the
with the emission data from the PET exami- thyroid gland, radioiodine therapy can be
nation. This procedure must be carried out used to eliminate the remaining tissue or to
for each bed position and thus considerably treat metastases.
extends the time the patient is in the device. The patient will be hospitalized for at
In the hybrid devices, the attenuation correc- least 48 h. The time of discharge depends on
tion is performed by the CT or MRI data the legally prescribed residual activity in the
set. body. If necessary, the patient should still
comply with some radiation protection mea-
sures after discharge (e.g. restricted contact
11.1.4 Hybrid Systems with radiation-sensitive persons, external
radioactivity measurements), these will be
SPECT-CT, PET-CT, PET-MRI: Here, the communicated to the patient on discharge.
nuclear medicine systems are combined with
the respective radiological device. The com- Radiosynoviorthesis (RSO)
bination allows a reliable anatomical assign- RSO is a targeted treatment of chronic
ment of the enrichments. Pure PET systems inflammation of the synovium (synovitis).
have become rare. The hybrid devices can Different substances are available for differ-
always provide attenuation correction of the ent joints. There is proven success in
nuclear medicine data through the radiolog- ­rheumatic joint diseases and psoriatic arthri-
Nuclear Medicine
105 11
131
 I-MIBG (Meta-Iodo-Benzyl-­
tis, among others. RSO is also used for acti-
vated arthrosis or for irritation after Guanidine) Therapy
implantation of artificial joints. The follow- Special tumors can accumulate MIBG. These
ing are used: tumors are then amenable to MIBG therapy.
55 90Yttrium: Knee joint These include, for example, malignant pheo-
55 186Rhenium: Shoulder, elbow, hip, hand chromocytoma, malignant paraganglioma,
and ankle joints carcinoids, medullary thyroid carcinoma
55 169Erbium: Finger and toe joints, meta- and neuroblastoma.
carpophalangeal and metatarsophalan- Several medications can interfere with
geal joints MIBG uptake and should be suspended
according to half-life. Both pheochromocy-
>>The application is strictly intra-articular toma and paraganglioma can release cate-
under X-ray control (exception: knee cholamines, so these patients may require
joint). Incorrect injection leads to tissue medication with α- and β-blockers.
necrosis of the affected area.
>>The therapy is carried out via a slow
The treated joint should be immobilized for intravenous infusion, during which
48 h. blood pressure and heart rate should be
monitored.
 alliative Pain Therapy for Bone
P
Metastases
Skeletal metastases that accumulate in skel- Peptide Therapy
etal scintigraphy can be treated with various Neuroendocrine tumors show an increase in
radioactive substances. The indication is somatostatin receptors. These receptors can
usually made interdisciplinary with all treat- be used to detect neuroendocrine tumors by
ing physicians and after exhaustion of con- scintigraphy. Tumors that show a corre-
servative pain therapy. sponding accumulation are amenable to
Possible substances for therapy are the peptide therapy. Here, 90Yttrium-­
emitters 89strontium, 153samarium, 186rhe- 177
DOTATOC or Lu-DOTATOC are used.
nium, 188rhenium and 32phosphorus. All
substances are applied intravenously. After  elective Internal Radiotherapy
S
administration, the patient should be moni- (SIRT)
tored for 2–3 h. A scintigraphy can be per- SIRT can be used to treat inoperable pri-
formed after the administration of samarium mary liver tumors or inoperable metastases
or rhenium. of other tumors. In this procedure, small
The α-emitter 223Ra-radadium dichlo- glass or synthetic resin particles—marked
ride was newly approved (November 2013) with 90Y—are injected intra-arterially into
for the treatment of bone metastases in the liver. The microspheres have a diameter
prostate cancer. This preparation is also of 20–30 μm (glass microspheres) or
administered intravenously. 20–60 μm (resin microspheres).
Prior to treatment, selective liver angiog-
Radioimmunotherapy raphy occludes all vessels leading to extrahe-
In radioimmunotherapy, antibodies (here patic tissues (e.g. stomach, intestine) and a
CD20 surface antigen) are radioactively distribution scintigram with 99mTc-MAA is
labelled. The 90yttrium-labelled ibritu- performed. This scintigraphy is used to
momab tiuxetan (Zevalin®) is approved for exclude extrahepatic accumulations and to
the treatment of B-cell lymphomas. calculate the liver-lung shunt.
 106 U. Blum

z Liver-Lung Shunt 11.2.1 Hot Laboratory

This refers to vascular connections between
the lungs and liver, through which the micro- In the hot laboratory, the radioactive sub-
spheres also reach the lung tissue and lead to stances are stored, prepared and portioned.
tissue damage (radiation pneumonitis). A Usually, the highest radioactivity is to be
shunt >20% represents a contraindication to expected here.
therapy, from a shunt volume of 10% the
dose is adjusted. Generator
In each hot lab there are at least two 99molyb-
denum generators with different activity.
11.2 Radiation Protection Each generator has its own shielding. 99Mo
decays with a HWZ of 65.9 h to 99mtechne-
In a nuclear medicine practice or depart- tium. This is dissolved out of the generator
ment, different areas are defined. There is using sterile saline solution.
the monitoring area (effective dose >1 mSv/
year) and the control area (effective dose Lead Castle (Screening Wall)
>6 mSv/year). There are no restricted areas The structure of a lead castle is regulated in
(local dose rate >3 mSv/h). The controlled DIN 25407. It is the direct preparation area
area may only be entered with restrictions. of the radiopharmaceuticals.
The controlled area usually contains the A lead castle consists of individual lead
hot laboratory, the camera rooms, the decay bricks that can be variably combined. In
room and a waiting area (incl. WC) for part, the building blocks are encased in
patients to whom the radioactive substance stainless steel to prevent liquids from seep-
has already been applied. The control area ing into the joints. In addition, a component
is entered and exited via a sluice with mea- with a lead glass pane is placed on top to
11 suring devices for the detection of radioac- protect the sensitive eye lenses from the
tivity. emitted radiation. Additional spacers and
shielding are used within the lead castle.
>>For work in the controlled area, the “5
A’s of radiation protection” apply in Spacers
principle: According to the square law of distance, the
55 Distance: Always keep as much dose per area decreases with the distance to
distance as possible from the radia- the radiation source due to the divergence of
tion source. the radiation. Thus, you only get a quarter
55 Shielding: If possible, radioactive of the dose if you double the distance to the
materials should be shielded (tung- radiation source. With a spacer (a kind of
sten, lead glass, Plexiglas). pliers for medicine vials), you can quickly
55 Length of stay: Any unnecessary stay increase the distance from 0 cm (vial in your
should be avoided and any stay hand) many times over.
should be as short as possible.
55 Activity: As little as possible, as much Syringe Shields
as necessary (ALARA principle: As Each drawn up syringe is clamped into a
Low As Reasonably Achievable). shield. For gamma emitters (99mTc etc.)
55 Avoid ingestion: Avoid incorporation these are usually made of tungsten with a
of radioactive material. lead glass insert.
Nuclear Medicine
107 11
For beta emitters (e.g. radiosynoviorthe- to the radioactive aerosols used. For this
sis, palliative pain therapy), shields made of reason, as few staff as possible should be
Plexiglas are used. Depending on the radio- present in the room. Care should be taken
nuclide used, the syringe in combination that, if possible, the aerosols or the patient’s
with nitrile gloves may also provide ade- breathing air (“para-breathing”) does not
quate protection (169Er). escape.

Transport Equipment >>In a nuclear medicine department it is

The radiopharmaceutical is usually applied in mandatory that all radiopharmaceuti-
the application room. In order to keep trans- cals are labelled and shielded (lead cas-
port distances as short as possible, the appli- tle, transport containers, etc.). On each
cation rooms are often set up directly next to syringe it must be indicated at least
the hot lab and connected to each other by an which nuclide it contains, when which
airlock. The airlock is also shielded. activity was raised.
For all other routes within the depart-
ment, suitable lead transport containers
must be used. These come in different sizes 11.2.3 Leaving the Department
depending on whether you need to transport
a single syringe or a larger container (e.g. for Each time they leave the controlled area,
waste disposal). employees must check that they are free of
radioactive contamination. A contamina-
Waste Containers tion monitor at the entrance or exit of the
Strict waste separation takes place in a hot controlled area is used for this purpose. This
lab. A distinction is made between contami- has various detectors to check not only the
nated waste (including questionable con- hands, but also shoes and clothing.
tamination) and safely non-contaminated The results of the measurement must be
waste. documented and must be within specified
The contaminated waste is collected and tolerance limits. In the event of contamina-
stored in special lead-lined containers. tion, this must be detected, documented
and, if possible, removed. If this is not com-
Decay Space pletely possible, further measures may have
In the decay room, all radioactive waste is to be taken.
stored until it can be disposed of in accor-
dance with the clearance limit. >>If the necessary radiation protection
measures are observed and implemented,
the occupational radiation exposure per
11.2.2 Investigation Area year is about 1–3 mSv.

In the examination rooms, the patient is the

largest source of radiation. To protect the 11.3 Detection of Radioactivity
staff, there are mobile radiation protection
walls that can be moved around the room 11.3.1 Scintillation Detectors
like a screen. Protective gloves must be worn
when handling blood samples (e.g. for renal A medium with a high atomic number Na/
scintigraphies). OZ 53 is used in the so-called scintillation
If a pulmonary ventilation scintigraphy detector. Scintillation detectors emit the
is performed, there is an increased risk due excitation energy produced by the passage
 108 U. Blum

of photons or electrons in the form of low energy can be measured, because at high
light. Such a scintillation detector is the energy pulses of the neighboring sample
core of the gamma camera, which records flow into the measurement.
the distribution of an applied activity in
the patient. Liquid Scintillators
Low-energy beta particles cannot be mea-
Probe Measuring Station sured by solid-state scintillators due to their
A simple scintillation detector used in short range. Detection is possible with the
in vivo diagnostics is the so-called probe aid of liquid organic scintillators (e.g. 3H,
measuring station. The NaJ crystal con- 14C, 90Sr). The dissolved scintillator converts

tained here is only equipped with a single, the resulting electrons into light. They are
relatively large collimator. This has the task measured by two PMPs.
of protecting the detector from ambient
radiation. A probe measuring station is used Gas Ionization Detectors
to determine the percentage activity uptake A gas in a chamber (air, noble gases such as
of an applied radiopharmaceutical at differ- He, Ar, Kr, Xe) is used as a medium with a
ent times. The up-take measurement is of low atomic number. When a gamma ray hits
particular importance, for example, for the the gas ionization chamber, the gas is ion-
planning of a radioiodine therapy. ized by releasing the electrons. A positively
charged gas molecule remains on one side
Gamma Probe and a free electron on the other side. When
The scintillation detector of the gamma high voltage is applied, these charge carriers
probe is particularly small at 10–20 mm, are transported to the negatively charged
which is surrounded by a lead collimator. cathode or the positively charged anode. A
The gamma probe is used, for example, for current flows which can be measured. The
11 the preoperative or intraoperative detection working range of the ionization chamber is
of the sentinel lymph node. This can be defined depending on the high voltage
detected with the aid of an acoustic signal or applied. In the so-called recombination
a visual display. range, the charge carriers escape measure-
ment because negative and positive parti-
Borehole Logging Station cles recombine. In the saturation range,
Another scintillation detector is located in a which follows the recombination range in
so-called borehole measuring station, which terms of voltage, the applied high voltage is
is used for the detection of low activities. so high that no more recombinations can
Thus, allergens or hormone levels can be take place; every charge carrier is registered.
determined via antigen or antibody reac- Ionization chambers operate in this range.
tions (IRMA/RIA) in patient serum or urine If the high voltage is increased further, the
by measuring radioactive compound com- primary generated electrons are accelerated
ponents. Since very small amounts of activ- so strongly that they ionize further atoms.
ity are involved, the detector encloses the An electron avalanche is created which is
sample in a U-shape. The sample volume is proportional to the primary event (working
chosen in such a way that it can be com- range of the proportionality counter tubes).
pletely sunk into the central bore. This If the high voltage is increased further into
allows all outgoing quanta to reach the the so-called trigger range, a single primary
detector. It is encased in lead to protect it electron can lead to the ionization of the
from ambient radiation. Only tracers with entire chamber volume, which is important
Nuclear Medicine
109 11
in the detection of minute amounts of evaluation of the personal dosimeter worn
activity in radiation protection. on the front of the torso is carried out once
a month by the responsible central personal
Activimeter dosimetry office.
A cylindrical ionization chamber is the
basic component of the so-called active Ring Dosimeter
meter. The activity to be applied is mea- Another dosimeter used in routine nuclear
sured with the aid of the active meter. The medicine is the ring dosimeter, which deter-
activity is inserted into the chamber. Thus, mines the radiation exposure of the hand
the same measurement geometry is always and is used in the hot laboratory. The ring
given. The chamber should be protected contains a thermo-luminescence detector, a
from contamination. The surrounding lead substance (e.g. calcium fluoride contami-
shielding protects the measuring chamber nated with manganese) which stores the
from incident background radiation, which absorbed radiation energy. The crystal is
would lead to a falsification of the measure- heated once a month by an appropriate eval-
ment. Activitmeters can measure different uation point. This causes the stored energy
nuclides. The response is very wide in a to be emitted in the form of visible light.
measuring range up to 200 GBq and in an The ring is used in addition to the film
energy range from 35 KeV to 3 MeV. Daily dosimeter.
checks of the activimeter including the zero
effect and the sensitivity are carried out. In Electronic Dosimeters
addition, semi-annual linearity checks are Electronic dosimeters are immediately read-
required. Measuring systems in radiation able. They display the measured values digi-
protection. tally and give an acoustic warning when the
According to the recommendation, every set dose or dose rate is exceeded. They con-
employee working in the monitoring or con- tain special photodiodes which convert the
trolled area is obliged to determine the per- energy of the incident photons into electric
sonal dose equivalent at a representative current. The measured values should be
point of the body surface. documented every working day.

Personal Dosimeter Whole Body Counter

The monitoring of radiation exposure can Whole-body counters are used for the detec-
be performed, for example, by a film dosim- tion of incorporated radiation, with the aid
eter when dealing with photon, electron or of which the nuclide present in the body can
neutron radiation. Such a dosimeter consists be identified and the amount of activity
of a two-part sliding shadow cassette con- present can be determined. Whole-body
taining absorbers of different atomic num- counters contain scintillation and also semi-
bers (e.g. aluminum, copper, lead). The conductor detectors to increase the detec-
absorbers on the front and back are differ- tion sensitivity. Semiconductors are
ently shaped and offset so that, when evalu- crystalline substances, e.g. germanium or
ating the blackening of the films inside, it is silicon contaminated with lithium, which
possible to determine with varying sensitiv- insulate at low temperatures but become
ity from which direction the radiation expo- conductors when energy is applied. They are
sure occurred. Due to the different density characterized by good energy resolution,
of the absorbers, when radiation passes but are less sensitive than scintillation detec-
through, its energy can be determined. The tors. Because of the extremely high
 110 U. Blum

s­ ensitivity of a whole-body counter, shield- Collimators

ing against ambient radiation is extremely A prerequisite for the correct spatial analy-
costly. sis of the incident gamma quanta is the use
of a so-called collimator. It ensures that
Contamination Measuring only gamma quanta of a certain flight direc-
Equipment tion are allowed to pass through and con-
The contamination measuring instruments sists of many lead septa, which are separated
used in routine nuclear medicine are from each other by small holes.
equipped with ionization detectors operat-
ing in the proportionality or trigger range. If >>The thickness of the lead septa depends
input events are high and easily detectable, on the energy of the radionuclide used.
they can be recorded with the proportional-
ity counter tube proportional to the input If they are too thin, gamma quanta can pen-
event (application in contamination meters etrate the lead (septa penetration), if they
and portable site dosimeters). Smaller activ- are too thick, too many gamma quanta are
ity contaminations are detected with the absorbed, the count rate decreases. While
Geiger-Müller counting tubes operating in septa that are too thin lead to a deteriora-
the trigger range (application in portable tion of the spatial resolution, the use of a
local and electronic personal dosimeters). collimator with septa that are too thick can
Increasingly, contamination meters are also be compensated by extending the acquisi-
equipped with scintillation detectors. They tion time.
can be used to detect contamination with The imaging properties of a collimator
alpha, beta and gamma radiation. depend on its geometry and its distance
from the source, i.e. the patient. The geom-
etry of a collimator depends on the ratio
11 11.4 Image Formation Systems hole size/sept length. The divergence angle α
is the reference quantity and indicates the
11.4.1 Gamma Camera maximum angle at which gamma quanta
can still just penetrate the bores.
The gamma camera is a detector system that The following applies:
reproduces the activity distribution in the 55 long septa/small holes/small divergence
patient as a two-dimensional image (scinti- angle/high spatial resolution,
gram). Depending on the tracer used, the 55 short septa/large holes/large divergence
recorded scintigram provides information angle/low spatial resolution.
about blood flow, storage, metabolism and
receptor density of an organ system. Single The spatial resolution is also dependent on
images with constant activity distribution the distance between the patient and the col-
(static images) or dynamic image series can limator. The greater the source-detector dis-
be acquired, in which the activity distribu- tance, the poorer the imaging quality.
tion changes constantly during the acquisi-
tion period. >>The collimator must always be moved as
The measuring head of the gamma cam- close as possible to the patient.
era consists of a collimator, the sodium
iodide crystal used to convert the gamma In patients suffering from claustrophobia,
quanta into light, and the photomultipliers an optimal quality of the image can almost
connected to it via a light-conducting layer, always be achieved by intensive ­education
which convert the light into electrical sig- about the importance of being close to the
nals. collimator.
Nuclear Medicine
111 11
The sensitivity of a collimator is and 42 × 31 cm for a three-head system. The
described by the ratio of outgoing to CFOV (central field of view) is the actual
detected quanta. The more quanta reach the imaging area, which is 75% of the
detector, the higher the sensitivity of the col- UFOF. Under the influence of photon radi-
limator. It is influenced by the hole size, the ation, individual molecules of the crystal
number of holes and the septa length. structure are excited. When these fall back
The following applies: to the ground state, the excitation energy is
55 large bores/short septa/high sensitivity, emitted in the form of light. The brightness
55 small bores/long septa/low sensitivity. of the light is proportional to the absorbed
photon energy, and the amount of light is
However, the spatial resolution decreases proportional to the number of events that
with increasing bore size and shorter septa. occur. The high atomic number of NaJ
implies a good absorption behavior. The
>>Spatial resolution and sensitivity are crystal must be adapted to the energy of the
competing properties. A collimator with radionuclide used. If it is too thin, many
good spatial resolution has low sensitiv- quanta leave the crystal unattenuated, the
ity, one with high sensitivity has poor probability of detection decreases. If it is
spatial resolution. too thick, multiple absorption occurs. The
thickness is 9.53 mm for the main use of
The collimator most commonly used in rou- 99mTc.

tine applications is the parallel-hole collima-

tor, whose septa are perpendicular to the Photomultiplier
detector plane. A number of photomultipliers (PMP) are
With converging collimators, the septa coupled to the crystal without reflection via
diverge conically (as seen from the patient). a translucent silicone layer. These have the
This results in a magnification of the object. task of converting the resulting scintillation
The diverging collimator reduces the size light into electrically measurable pulses.
of the object. It is used when the dimensions PMPs are vacuum tubes on which a thin
of the object are larger than the field of view metal layer = cathode is vapor-deposited.
of the camera. The septa converge conically Electrons are released from it when the
(as seen from the patient). scintillation light hits it. The number of elec-
The rarely used Pinehole collimator trons is proportional to the amount of light
works on the principle of the pinhole cam- emitted from the crystal. By applying a high
era. It has only one hole and magnifies the voltage, the released electrons are acceler-
image to the maximum. The resolving power ated onto sheets (dynodes) and release sec-
is excellent, the sensitivity very low because ondary electrons, each of which is
of the one hole. accelerated again onto the next dynode. The
partial voltage is applied to the dynodes in
>>Collimators weigh between ten and such a way that from cathode to anode each
100 kg. If the collimator is changed, its dynode is positive to the previous one. The
attachment to the measuring head must high voltage between each dynode must
be conscientiously checked to prevent remain the same to maintain proportional-
any risk to the patient. ity to the incident scintillation light. An
­avalanche of electrons finally arrives at the
Sodium Iodide Crystal anode located at the end of the accelerating
The field of view of the thallium-doped path. Each PMP is associated with a pream-
sodium iodide crystal (UFOF, useful field of plifier which converts the incoming charge
view) is 54 × 40 cm for single-head cameras pulses into voltage pulses, the magnitude of
 112 U. Blum

which is in turn proportional to the absorbed 128 × 128, 256 × 256, 512 × 512. However,
quantum energy. each detector needs a certain time to process
The linear amplifier connected to it lin- the absorbed quanta. Another signal cannot
early exponentiates the voltage pulses. The be accepted during this time, it escapes the
shape of the signal duration is shortened in measurement (dead time). The resulting
order to be able to receive further signals as count rate losses increase as the amount of
quickly as possible. activity increases.

Gamma Spectrum SPECT

If we now assume 99mTc, all measured pulses SPECT (Single Photon Electron Computed
would have to be registered with the energy Tomography) cameras usually consist of
of 141 KeV, given proportionality. Due to two to three measuring heads running on a
voltage fluctuations, inhomogeneities of the ring system. To determine the three-­
crystal, scattering of the incoming photons dimensional image of the nuclide distribu-
etc., a relatively broad energy distribution tion in an object, two-dimensional image
around 141 KeV arises. Scattered quanta data are acquired with a gamma camera.
release a pulse of lower energy than those The measurement is repeated at different
absorbed via a photoelectric effect, a pulse projection angles, with the camera rotating
spectrum is obtained. Radionuclides can stepwise around the object. Each of the
have one or more energy peaks, e.g. 111In acquired scintigrams represents a two-­
(171 KeV and 215 KeV). dimensional projection of the three-­
dimensional nuclide distribution. Here, all
Measuring Head Electronics object points (3D) are reproduced in a 2D
The resulting signals are located in the mea- image of the object oriented parallel to the
suring head via a special resistor network. It detection surface of the camera. By back-­
11 divides the output signal of each PMP into projection, a three-dimensional image of the
four location signals: x+, x−, y+, y−. The nuclide distribution can be generated from
PMP closest to the absorption site registers this set of 2D images. Thus, in this type of
the most light quanta and provides the high- image reconstruction, the 2D image data is
est output pulse. All PMPs further away back-projected onto the object volume
from the absorption site register correspond- (hence the name of the method) by mapping
ingly less light, and the output pulse is lower the intensity of each pixel as a line perpen-
(distance-squared law). The sum signals x+, dicular to the detection surface back in the
x−, y+, y−, are supplied from the spatial sig- object volume. The depth information is of
nals of all existing PMPs, which generate a course lost in the process. It can be recov-
signal via two differential amplifiers x and y. ered by combining images taken at different
The sum of the resulting output pulses angles. This type of unfiltered back projec-
forms the Z signal, which corresponds to the tion of the raw data leads to smearing of the
height of the absorbed energy. This is for- image, which is why filters are used to
warded to the pulse height analyzer and improve the image quality (filtered back
only if it is within the set energy window x projection). This method must also be con-
and y are forwarded to the connected elec- sidered an approximation, since the attenua-
tronics for registration and the content of tion of gamma radiation due to photoelectric
the corresponding pixel of the image matrix effect and scattering as it passes through the
increases by one. The more decays are object is not included. These effects are
detected at one and the same location, the taken into account in the iterative recon-
larger the number of pixels in the associated struction procedures, in which measured
matrix. Common matrix sizes are 64 × 64, projections are compared with projections
Nuclear Medicine
113 11
calculated by means of correction factors. moving change in activity in the patient can-
Through repetitions in which these correc- not be recorded with a SPECT camera.
tion factors are refined further and further,
the three-dimensional nuclide distribution
that would correspond to the 2D projections 11.5 Radionucleotides in Medical
measured by the camera is determined. The Application
acquired scintigrams are displayed on a
monitor of the computer system, stored on Various radioactive substances are used in
hard disk, and, if desired, output via a con- medicine (. Table 11.1). A distinction is
nected documentation system. A suitable made between substances used for diagnos-
software enables the evaluation and post-­ tic imaging, for therapeutic purposes and for
processing. laboratory chemical diagnostics.
When displaying the tomograms, there is In laboratory chemical diagnostics, in
a time window of about 30 min between the addition to radioactive substances (predom-
first and the last acquisition, so that a fast-­ inantly 125I) in the RIA (radioimmunoassay)

..      Table 11.1 List of some common radioisotopes. (Modified according to Nuclear Medicine, 4th
edition, Kuwert)

Isotope Application Radiation, keV HWZ Production

[99mTcO4]TcO4 Diagnostics γ, 140 6.01 h Generator

[123I] Diagnostics γ, 159 13.3 h Cyclotron

[124I] PET β+, 188 4.18 d Cyclotron

[131I] Therapy β−, 191 8.02 d Reactor

γ, 364
[111In]3+ Diagnostics γ, 171, 245 2.80 d Cyclotron

[90Y]Y3+ Therapy β−, 934 2.67 d Generator

[89Sr]2+ Therapy β−, 583 50.5 d Reactor

[186Re]ReO 4
Therapy β−, 359 3.72 d Reactor
γ, 137
[188Re]ReO4 Therapy β−, 795 17 h Generator
γ, 155
[88Sm]3+ Therapy β−, 203, 228 1.93 d Reactor
γ, 103
[18F]F PET β+, 242 109.8 min Cyclotron

[11C]CO 2
PET β+, 385 20.4 min Cyclotron

[13N]NH 3
PET β+, 491 10 min Cyclotron

H2 15O PET β+, 735 2 min Cyclotron

HWZ Half-life, Tc Technetium, TcO4 Pertechnetate, I Iodine, In Indium, Y Yttrium, Sr Strontium, Re

Rhenium, Sm Samarium, F Fluorine, C Carbon, CO2 Carbon dioxide, N Nitrogen, NH3 Ammonia, H2O
Water
 114 U. Blum

or IRMA (immunradiometric assay), other, the eluate can be injected immediately (e. g.
non-radioactive substances are also used; in thyroid examination) or it is processed by
particular, enzymes in the enzyme immuno- means of commercially available labelling
assay (EIA) or enzyme-linked immunosor- kits mainly by chemical reduction to com-
bent assay (ELISA), fluorescent or plex compounds.
luminescent substances should be men- The marking devices are usually supplied
tioned here. The laboratory chemical meth- as powder in a small sealed glass vial. They
ods will not be discussed further here. are stored according to the manufacturer’s
instructions. They consist of a small propor-
tion of a reducing agent (tin[II] salts) and an
11.5.1 Diagnostic Imaging excess of the complexing agent (chelating
ligand). The complexing agent has been
The most commonly used radioactive sub- developed for the respective examination,
stance in imaging is 99mtechnetium (99mTc). e.g. the phosphonate compounds for bone
It has a physical half-life of 6.01 h. It decays scintigraphy. The ligands are freeze-dried
into 99technetium, emitting γ-radiation with (lyophilized) and packed in a protective
an energy of 140 keV. atmosphere (nitrogen or argon). All kits are
99mTechnetium is produced in a genera- sterile and pyrogen-free.
tor system. In the system 99molybdenum Radioactive labelling with the eluate is
(HWZ 65.9 h) is firmly bound as sodium carried out according to the manufacturer’s
molybdate (Na2 99MoO4). This decomposes instructions. Often the labelling can be car-
to sodium pertechnetate (Na 99mTcO4), ried out at room temperature within a few
which is dissolved out of the generator sys- minutes. The resulting radiopharmaceutical
tem using sterile physiological saline and a can be used within the specified expiry time.
vacuum container.
11 A generator can be used for approx. one
week. The yield of radioactive technetium 11.7  uality Assurance Measures
Q
decreases in the course of the week. of Radiopharmaceuticals
The obtained 99mtechnetium (99mTcO4)
can either be used directly (e.g. in thyroid Radiopharmaceuticals are subject to vari-
diagnostics) or it is combined with inactive ous quality criteria. These are laid down in
substances in labelling kits. the European Pharmacopoeia (Ph. Eur.)
Other generator systems include the and the German Medicines Act. These
188tungsten/188rhenium generator, the include:
68germanium/66gallium generator, or the
55 Radioisotope purity,
90strontium/90yttrium generator.
55 Chemical purity and identity,
Positron emitters are required in PET 55 Radiochemical purity,
diagnostics. These have different half-lives. 55 Specific activity,
18F-compounds such as the 18F-FDG are
55 Stability,
available from commercial suppliers. 55 Microbiological purity.

The quality criteria must always be fulfilled.

11.6 Radiopharmacology The responsibility for the individual sub-­
items differs in some cases.
In routine diagnostics, the 99mTcO4− labelled 55 Ready-to-use radiopharmaceuticals:
radiopharmaceuticals in particular play a These are not modified by the user, but
major role. The use of 99mTc is simple. Either only applied (e.g. injection solutions,
Nuclear Medicine
115 11
capsules). Quality assurance is the sole are e.g. self-produced cyclotron products
responsibility of the manufacturer. The or radioactively labelled patient parts
user should check the information on the (e.g. platelets, erythrocytes).
supplied product with the accompanying
note as well as the activity.
55 Kit preparations. The manufacturers are 11.7.1 Radioisotope Purity
responsible for the ingredients of the kits.
The ingredients are guaranteed sterile In practice, this includes testing the so-called
and pyrogen-free. In addition, controls of molybdenum breakthrough. Each
the preparation are carried out by means 99Mo/99mTc generator must be tested before

of sample generators and sample kits. the first application in order to exclude any
possible invisible leakage (e.g. due to trans-
In the respective department, the manufac- port damage) of 99Mo into the eluate.
turer, according to the law the doctor, is Here the generator is eluted normally.
responsible for the preparation of the radio- Afterwards, the eluate is measured without
pharmaceutical and its properties. Errors shielding and with an appropriate lead
can occur during all preparation steps. The sheathing on all sides (6 mm lead) in the
main disturbing factors are free pertechne- activimeter in the technetium window. The
tate and reduced Tc colloid. lead sheath shields the low-energy radiation
55 Self-produced radiopharmaceuticals: the of the 99mTc (141 keV) and only 65% of the
entire responsibility lies with the manu- higher-energy 99Mo (739 keV). The quotient
facturer. These radiopharmaceuticals Q must be <0.04%.

EluatmessungmitAbschirmung  MBq 
Q 100
EluatmessungohneAbschirmung  MBq 

>> The activimeter, formerly also called desired chemical form to the total radioac-
curiemeter, is a measuring device that indi- tivity of the radionuclide in the radiophar-
cates the activity of a measured sample. maceutical is referred to as radiochemical
purity.
The main causes of contamination lie in
11.7.2 Chemical Purity the preparation. In addition to an undesir-
able oxygen supply (e.g. leaky stopper, aera-
This refers to the proportion of the desired tion cannula), an excessively high amount of
substance in the total substance mixture. In radioactivity can also lead to poor labelling
the monographs on radioactive medicinal yield (a lot does not always help a lot). Also
products, the requirements for chemical “old” eluates or the first eluate after a longer
purity are laid down by specifying limits for elution break (e.g. weekend, holidays) have
the chemical impurities. an influence on the radiochemical purity.
Chemical purity must be guaranteed by Other causes of contamination are techni-
the manufacturer. cal, such as chemical instabilities or autora-
diolysis.
To determine the radiochemical purity,
11.7.3 Radiochemical Purity the individual components are separated
chromatographically and measured.
The ratio, expressed as a percentage, of the Another possibility is a solid phase extrac-
radioactivity of the radionuclide in the tion in cartridge form.
 116 U. Blum

11.7.4 Specific Activity Contamination is not necessarily directly

detectable, since radioactivity cannot be per-
The specific activity is characteristic for each ceived by the human senses. The handling of
isotope and results from the measure the all open radioactive substances must there-
ratio of the activity to the mass. fore be done very carefully.
Contamination hazards exist in all work
steps, starting with the elution of the genera-
11.7.5 Stability tor, kit preparations, preparation of the
patient dose up to the application.
The stability of the radiopharmaceutical The patient is also a possible source of
depends on various factors. Particularly in contamination. These include, in particular,
the case of high-energy therapeutic sub- incorrect inhalation of radioactive sub-
stances, changes can occur as a result of the stances (e.g. lung ventilation examination),
radiation, so that these substances must be uncontrolled excretion of substances in the
consumed relatively quickly after production. case of various incontinence diseases with
possible contamination of objects (chairs,
toilet, door handles) as well as due to con-
11.7.6 Microbiological Purity tact with all excretions of the patient (e.g.
urine, stool, saliva, stomach contents,
Every radiopharmaceutical should be free blood).
of bacteria if possible. Due to the sometimes Contamination checks must be carried
only short half-lives of various substances, out at each workplace at least once a day
the exact status can sometimes only be when handling open radioactive substances,
determined after the radioactivity has sub- and immediately if contamination is sus-
sided. A rapid test, the so-called Limulus pected. The corresponding results must be
11 amoebocyte lysate test (LAL test), is pre- recorded.
scribed for the 18FDG, for example. In this When leaving the controlled area, the
test, the sample is combined with the lysate. personnel must carry out a contamination
If endotoxins are present in the sample, this check, e.g. by means of a hand-foot clothing
becomes visible by means of various meth- monitor or hand monitor in the personnel
ods. Only after receipt of the result may the airlock. The measurement results are to be
injection solution be released for consump- recorded.
tion. The release is to be checked by the Items leaving the controlled area (e.g.
applying physician. cleaning utensils, litter, wheelchair) must
also be checked and the results recorded.

11.8 Contamination
and Decontamination 11.8.2 Decontamination
Measures
This refers to the removal of (hazardous)
11.8.1 Contamination impurities, in this case radioactive sub-
stances.
This refers to (unintentional) contamination The primary goal is to reduce radiation
of the environment (including the air), exposure to the body; other goals are to pre-
objects or persons with radioactive sub- vent the spread of contamination and to
stances. prevent incorporation.
Nuclear Medicine
117 11
z Contamination: What to Do? sonnel, therefore appropriate
55 Blocking the contamination area protective clothing is mandatory
55 Contact another person. If this is not –– Absorbing liquids with absorbent
possible, clearly mark the contamination material from the outside to the inside
area, avoid carry-over –– Wet wipe if necessary (from the out-
55 In case of possible personal contamina- side to the inside)
tion: decontamination as quickly as pos- –– If necessary, further physical mea-
sible sures (scraping, grinding, brushing)
55 Remove contaminated work clothing –– Non-removable contaminations are
without further contamination of other covered (adhesive foil) and marked
areas –– In case of contamination of work
55 Localization of contaminated skin areas equipment with short-lived sub-
as precise as possible stances, wait for decay time (in decay
55 Multiple dry decontamination of the room, marked)
skin by means of adhesive film, this leads 55 Clarification of the cause of contamina-
to a removal of >90% of the activity tion
55 Wash with plenty of lukewarm water 55 Documentation of contamination
and decontaminant, dry with disposable
towels
55 Success control by means of monitor, if
Practice Questions
contamination is still detectable → wash
1. Name the 5 As of radiation protec-
thoroughly again using a soft brush
tion.
55 Lack of decontamination success: Repeat
2. What do you do in case of contamina-
all points. If the effect is <10% and the
tion with 99mTc?
contamination <10 Bq/cm2, further
3. Name the major components of a
­measures can be dispensed with. Other-
gamma camera.
wise, the radiation protection officer
4. Name the most important (most com-
must initiate further measures
mon) nuclear medicine therapy—
55 Special measures appropriate to the sit-
naming benign as well as malignant
uation: e.g. hair washing; eye and
diseases.
mouth rinsing, if necessary venous sta-
5. What is the difference between X-ray
sis and wound rinsing in the case of
examinations and nuclear medicine
skin injury
examinations?
55 Only after personal contamination has
6. Which radioactive radiation do you
been ruled out should the area be
know? Name one possible application
approached:
in each case.
–– Determination of the location and
7. What do you mean by coincidence?
extent of contamination of surfaces
8. What is a SPECT examination?
and objects: Any decontamination
should not increase the risk of con-
Solutions 7 Chap. 27
tamination and incorporation of per-
 119 12

Emergencies and Extreme

Situations
Christel Vockelmann and Martina Kahl-Scholz

Contents

12.1 Extreme Situations – 120

12.1.1  olytrauma – 120
P
12.1.2 Anaphylactoid Reaction – 120
12.1.3 C T-Guided Puncture – 120
12.1.4 Seizure During Stent Angioplasty – 121

12.2  ontrast Agent Incident and Emergency

C
Medication – 121
12.2.1 Side Effects – 121

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 120 C. Vockelmann and M. Kahl-Scholz

In this chapter, some extreme situations that examined in the CT. Bony injuries, organ
can be encountered in everyday clinical and vascular injuries can be detected and
practice will be briefly addressed and pre- assessed very quickly so that further mea-
sented. These include, of course, emergen- sures can be initiated immediately.
cies, such as those that can occur in the form
of a KM intolerance or a seizure.
12.1.2 Anaphylactoid Reaction

12.1 Extreme Situations You are a few years in the profession and
have performed at least 5000 CT examina-
In everyday professional life, one often tions with contrast agent. A few patients
encounters extreme situations. For some, have complained of a few spots at most
this starts with the oncological patient hav- after the examination. Then comes the next
ing a tracheostoma or discovering only one CT. An outpatient in whom you have per-
leg when “uncovering” a patient lying in formed a CT angiography of the pelvic-leg
bed, and for others with small babies suffer- vessels. You look at the images while the
ing from cancer or patients covered in blood patient sits in the waiting room. The MTRA
being admitted after a traffic accident. The notices that the patient is relatively pale. She
extreme situations are individual to each calls her. The patient is already cold sweaty
examiner and can be psychologically stress- and shows red pustules and dyspnea. They
ful. However, it is very important to dis- recognize that there is an allergic reaction
tance oneself mentally as much as possible and call the anesthetist from the intensive
in order to be able to do the best possible for care unit. He now quickly injects the medi-
the patient quickly and effectively. Here we cation against the anaphylactoid reaction.
go into a few examples: Fortunately, the rapid intervention
helped. The next day you can already see the
patient again in front of the hospital.
12 12.1.1 Polytrauma

The definition of a polytrauma is a mul- 12.1.3 CT-Guided Puncture

tiple, life-threatening injury caused by an
accident. Here, very good interdisciplinary Mr. Müller has a pulmonary nodule. This
cooperation and organization is essential for is to be punctured in the CT. You routinely
the patient. The procedures and protocols run through your program. The needle is
differ depending on the hospital. It is always placed and a sample obtained. However,
important to have a clear organization. In the patient was relatively restless, so that
any emergency, it must be clear who is “in the access route was difficult. You note: A
charge” in order to treat quickly and effec- pleural effusion has formed. Probably an
tively. And in the case of an emergency on intercostal artery is injured. You ask the
the street or at the airport, this can also be MTRA to connect KM and run an angio
you as a PJ’ler or radiologist, who then has in the aortic program over the area. CT
to give clear instructions to bystanders and shows the findings—there is bleeding from
passers-by so that the patient is well cared the intercostal artery and the patient gets a
for as quickly as possible. In the hospital, haemothorax (. Fig 12.1). You call the sur-
the initial measures are well organized in the geon. Fortunately, the patient is stable until
shock room, then the patients are usually the surgeon takes him to the OR.
Emergencies and Extreme Situations
121 12
Rivotril to treat the seizure and instruct to
let CT know. The fears are confirmed. The
patient presents with a large ICB (intrace-
rebral hemorrhage). The neurosurgical col-
leagues are called in, but surgical therapy
does not seem advisable. In the next few
hours the patient is in intensive care. His
condition does not improve, however, and
he dies a few days after the operation.

12.2  ontrast Agent Incident

C
and Emergency Medication

12.2.1 Side Effects

Adverse reactions caused by KM may

be dose-dependent or dose-independent
(. Table 12.1).
Among other things, vasodilatation may
occur, which causes a drop in blood pressure
(hypotension). Histamines released from
mast cells are responsible for an immediate
allergic reaction and in turn lead to vasodi-
Thickness: 15.00 mm Location R 627.70 mm
lation of the small peripheral vessels. This
..      Fig. 12.1 CT angiographic evidence of arterial is the cause of a possible circulatory shock.
bleeding from the intercostal artery into the pleural
space

12.1.4  eizure During Stent

S ..      Table 12.1 Adverse direct side effects/
reactions to KM
Angioplasty
Dose-dependent Dose-­
(See also section on seizures). response independent
A patient has a high-grade restenosis response
of the carotid artery. As almost every day
in angiography, a stent angioplasty is to Response Direct (local) Systemic
type effect on organs response
be performed in this patient. Everything is and tissues as
going as usual. The wire has successfully well as organ
passed the stenosis, and the initial dilatation systems
went smoothly. Blood pressure is rather high Pathologi- Chemotoxic Anaphylac-
throughout the procedure, up to blood pres- cal process tic
sure values of about 180 mmHg systolic.
Symptoms Sensation of Nausea,
But the patient says that’s always the case. warmth/cold, vomiting,
Then the stent is released, angiographically reddening of the urticaria,
the stenosis is completely eliminated. At that skin, headache itching
point, the patient starts seizing. You ask for
 122 C. Vockelmann and M. Kahl-Scholz

Furthermore, an involvement of the coagu- –– Use of a low osmolar and viscous KM

lation system and the CNS is discussed. –– Use as little KM as possible!
Many patients assume that a KM –– Repeated KM administration should
reaction is accompanied by an iodine be avoided at all costs!
allergy—but an iodine allergy would not be
compatible with life, since we need iodine as Hyperthyroidism and Thyrotoxic
an indispensable component of our human Crisis
metabolism. If iodine-containing contrast medium is
used (e.g. in the course of an angiography),
>>An adverse KM reaction is not based on the iodine plasma level is increased due to
an iodine allergy, but is due to an intoler- cleavage of the iodine nucleotide. A nor-
ance of the KM complex. mal healthy thyroid gland can adapt to the
increased iodine load. However, if autono-
Locally, especially with iodine-­ containing mous production or an immune disease of
contrast media, pain, damage to the vessel the thyroid gland is already present, hyper-
walls, vasodilatation (→ drop in blood pres- thyroidism and even a thyrotoxic crisis may
sure) may occur. occur.
The frequency with which hyperthyroid-
>>Low osmolar CMs are generally better ism occurs depends on several factors:
tolerated than high osmolar ones, non-­ 55 Severity of iodine deficiency prior to
ionic ones better than ionic ones. iodine exposure,
55 Extent of exposure to iodine,
 ontrast Induced Nephropathy
C 55 Frequency of functionally autonomous
(CIN) cells in the thyroid gland,
Contrast-induced nephropathy is defined 55 Age of patients.
as a deterioration of renal function (symp-
tomatic by pathological creatinine values z Symptoms of Hyperthyroidism Include
12 3–10 days after the application of KM) 55 Weight loss (despite sufficient food
after the administration of iodine-contain- intake)
ing, intravasally applied contrast media. It 55 Accelerated pulse
occurs in 7–10% of patients, with patients 55 Sweating
with pre-existing renal insufficiency or dia- 55 Hypertension
betes mellitus with renal insufficiency being 55 Nervousness, restlessness
particularly at risk. In this group of patients, 55 Sleep disorders
contrast media should not be administered 55 Possible goiter
if possible. However, if it cannot be avoided
for compelling diagnostic reasons, the fol- z Symptoms of Thyrotoxic Crisis Include
lowing aspects should be taken into account: 55 Stage 1 (lethality less than 10%): Extreme
55 Before the examination, the patient sinus tachycardia (>150/min) or tachyar-
should be sufficiently hydrated, i.e. sup- rhythmia with existing atrial fibrillation,
plied with fluid (i.v. hydration with iso- heart failure; high fever; gastrointestinal
tonic NaCl solution is optimal). and neurological symptoms, exsiccosis,
55 Nephrotoxic substances should be dehydration
avoided as concomitant therapies or dis- 55 Stage 2: Clouding of consciousness
continued if necessary. 55 Stage 3 (lethality: over 30%): Uncon-
55 During the investigation: sciousness
Emergencies and Extreme Situations
123 12
In patients at risk, perchlorate (irenate) is
..      Table 12.2 Risk classification of gadoli-
used prophylactically before and 1–2 weeks num contrast agents in relation to the
after the examination with a thyrostatic. development of NSF. (According to EMEA)
Perchlorate decreases iodine uptake into the
thyroid gland. Risk class Contrast agent

Prophylaxis with Perchlorate High risk Optimark, Omniscan, Magnevist,

z
Gado-MRT-Ratiopharm
Example of Prophylactic Treatment of
Iodine-Induced Hyperthyroidism Medium Vasovist, Primovist, Multihance
risk
55 2–4 h before KM administration 25
drops of Irenate (perchlorate) Low risk Gadovist, ProHance, Dotarem
55 3 × 15 drops of Irenat/day for one week
55 Check TSH basal, T4, T4 after three and
six weeks 55 Cerebral seizures possible after 15–45 s
55 Pupil dilation and loss of light reaction
Example of Treatment in Manifest Hyper- after 30–60 s
thyroidism and Vital Indication
55 2–4 h before KM administration 25 z Resuscitation
drops of Irenate (perchlorate) 55 Cardiac massage: Find a hard surface, if
55 3 × 15 drops of Irenat/day for two weeks not already available → pressure point in
55 20 mg/day Favistan (thiamazole) for two the middle of the chest (lower half of the
weeks sternum) → compression depth approx.
4–5 cm → 100 compressions
 ephrogenic Systemic Fibrosis
N 55 Ventilation: after the first 30 compres-
(NSF) sions (frequency 100–120/min) → first
This form of fibrosis can occur (very rarely) ventilation cycle of approx. 1 s with ven-
in patients who already have stage 4 or 5 renal tilation twice
failure and are undergoing testing with gad- 55 Continue as above in the ratio 30 (car-
olinum. Why it occurs is not yet fully under- diac compressions):2 (ventilations)
stood. It may become symptomatic in the 55 Special features:
period from 2 days to 18 months after expo- –– in pregnant women from the 20th
sure to gadolinum-containing BM. There week of pregnancy, lift the pelvis to
are prophylactic measures that can be taken the right and move the uterus to the
to reduce the risk of NSF. These include: left during positioning before chest
55 If KM administration is diagnosti- compressions
cally essential in high-risk patients, then –– for children, five ventilations initially;
cyclic gadolinum KM or KM with a if only one caregiver is present, 30
low risk classification should be used (cardiac compressions):2 (ventila-
(. Table 12.2). tions); for the 2-helper method, 15
55 The lowest possible dose should be (cardiac compressions):2 (ventila-
aimed for and repeated administration tions)
should be avoided at all costs.
z Emergency Medication
Circulatory Arrest 55 Suprarenin® (adrenalin 1:1000): dilute
z Symptoms 1 mL (1 mg) with 9 mL physiological
55 Lack of (carotid) pulse saline solution
55 Respiratory arrest, gasping possibly after 55 Glucocorticoids (e.g. dexamethasone
15–40 s 40–100 mg, prednisolone 200–500 mg)
 124 C. Vockelmann and M. Kahl-Scholz

55 H1 and H2 antagonists z Status Epilepticus

55 Atropine 0.5 mg 55 If a tonic-clonic seizure lasts longer than
55 Midazolam 5 mg five minutes or if an entire series of sei-
55 i.v. narcotics zures occurs without the patient regain-
55 Crystalloid solutions ing consciousness in the meantime, this
55 Colloidal volume substitutes is referred to as status epilepticus. The
danger here is an undersupply of oxygen
Seizures (hypoxia) and dangerous cardiovascular
A seizure does not have to occur as a side stress.
effect, but it can occur at any time due to an
existing underlying disease (epilepsy, brain kAcute Therapy for Status Epilepticus
tumors, metastases, scarring in the brain, 55 Oxygen supply, blood pressure control,
etc.), e.g. also in the MRI or CT during the if possible ECG and blood sugar control
examination procedure. 55 Benzodiazepines i.v., e.g. 2–4 mg loraze-
There are various forms of seizures, of pam (alternatively diazepam 10–20 mg
which the grand mal seizure and status epi- or clonazepam 1–2 mg)
lepticus are the most relevant in emergency 55 If there is no effect after five minutes, the
medicine. administration is repeated
55 Phenytoin and valproate are reserve
z Grand Mal Seizure drugs that are only given if the status epi-
This type of seizure is divided into different lepticus cannot be terminated even by
phases: administration of benzodiazepines.
55 Preconvulsive phase with general symp-
toms such as headache, fatigue, halluci-
nations
Practice Questions
55 Convulsive phase (tonic stage) with fall,
1. A patient suddenly becomes cold
loss of consciousness, apnoea, tongue
12 bite, extensor tonus
sweaty and develops dyspnea after a
CT scan with KM. What is your first
55 Convulsive phase (clonic stage) with
thought?
rhythmic contractions of the muscula-
2. What can extreme sinus tachycardia,
ture, enuresis, tongue biting, cyanosis
high fever; gastrointestinal and neuro-
55 Postconvulsive/postictal phase followed
logical symptoms indicate?
by a brief comatose state, twilight, con-
3. What can be done prophylactically to
fusion.
prevent hyperthyroidism from iodine-
containing KM?
This is the most common type of seizure you
4. What are the resuscitative measures in
will encounter. The most important treat-
case of circulatory arrest?
ment measure here is to prevent injury to the
5. How is status epilepticus defined and
patient, e.g. by falling off the examination
what is dangerous about it?
table. A biting wedge or similar is no longer
used today. In the case of a short-lasting sei-
Solutions 7 Chap. 27
zure, acute drug therapy is not usually nec-
essary. It is important that you get support
from the doctor in charge.
 125 13

Legislation
Christel Vockelmann

Contents

13.1 Basic Law (GG) – 126

13.2 Patients’ Rights Act – 127

13.2.1 Reconnaissance – 127

13.3 Data Protection – 128

13.4 Atomic Energy Act (AtG) – 128

13.5 X-ray Ordinance (RöV) – 129

13.6 Radiation Protection Ordinance (StrSchV) – 129

13.7 Radiation Protection Areas – 129

13.8 Occupationally Exposed Persons – 131

13.9 Technical Knowledge – 132

13.10 Justifying Indication – 132

13.11 Medical Devices Act (MPG) – 132

13.12 Maternity Protection Act (MuSchG) – 133

13.13 Working Time Act – 133

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 126 C. Vockelmann

Due to the manifold dangers of ionizing 55 Standards or rules of technology are not
radiation, several laws and regulations play binding. They serve as proof of safety.
an important role. In addition to the national
requirements, European and international The laws that are important for the applica-
requirements must also be observed. The tion of ionizing radiation to humans are
laws that are important for the application arranged hierarchically. In the Federal
of ionizing radiation to humans are arranged Republic of Germany, the Basic Law (GG)
hierarchically. In the Federal Republic of is the supreme law (7 Sect. 13.1). The
Germany, the Basic Law (Constitution, GG) Atomic Energy Act (AtG) (7 Sect. 13.4) is
is the supreme law (7 Sect. 13.1). The subordinate to the Basic Law. The Radiation
Atomic Energy Act (AtG) (7 Sect. 13.4) is Protection Ordinance (StrSchV) (7 Sect.
subordinate to the Basic Law. As of 2016, 13.6) and the X-Ray Ordinance (RöV)
the Radiation Protection Ordinance (7 Sect. 13.5) are subordinate to the Atomic
(StrSchV) (7 Sect. 13.6) and the X-ray Energy Act. In order to transpose the
Ordinance (RöV) (7 Sect. 13.5) are subordi- Euratom Directive 2013/59/Euratom into
nate to the Atomic Energy Act. The German law, the Radiation Protection Act
Radiation Protection Act (StrlSchG) will (StrlSchG) is expected to enter into force in
probably enter into force in 2018, replacing 2018 and replace RöV and StrSchV. In terms
the X-ray Ordinance and the Radiation of content, both ordinances will be largely
Protection Ordinance, but will ultimately reflected in the new law.
correspond to a large extent to the content
of the X-ray Ordinance and the StrlSchV.
13.1 Basic Law (GG)
Due to the manifold dangers of ionizing
radiation, several laws and regulations play Articles 1 to 19 of the Basic Law set out the
an important role. In addition to national fundamental rights that every person, and in
requirements, European and international particular every citizen, has.
regulations must also be observed. First of » Article 2 Basic Law
all, however, it is important to differentiate
13 between the various terms.
1. Everyone has the right to the free devel-
opment of his personality, provided that
55 Laws are binding on everyone and are he does not infringe the rights of others
established by the parliamentary legisla- and does not offend against the constitu-
ture. The Basic Law can serve as an tional order or the moral law.
2. Everyone has the right to life and physical
example. integrity. The freedom of the person is
55 Legal ordinances are also binding on inviolable. These rights may be interfered
everyone, the obvious example for us with only on the basis of a law.
being the X-ray ordinance. They are
issued by the executive, i.e. the govern- This means that medical treatment or a
ment, on the basis of laws. An amend- diagnostic measure is only permissible with
ment, e.g. adaptation to changed the patient’s consent. The patient may
conditions, is possible more quickly than revoke the consent at any time.
with laws.
55 Guidelines do not represent binding >>Treatment without consent is an interfer-
requirements, but are applied for con- ence with the physical integrity of the
crete implementation. patient.
Legislation
127 13
This is where the Criminal Code (StGB) tions of the contrast medium. Nevertheless,
comes into play: the physician should discuss the examina-
tion with the patient, provided the patient is
» § 223 Criminal Code bodily injury
responsive, in order to learn about possible
1. Whoever physically abuses another per- contraindications.
son or damages his or her health shall be
punished by imprisonment for not more
than five years or a fine. >>In the case of patients for whom infor-
2. The attempt is punishable. mation is not feasible due to their physi-
cal or mental situation, the legal
representative must be informed of the
13.2 Patients’ Rights Act planned measures.

The Patients’ Rights Act is part of the Here, too, the urgency and danger of the
German Civil Code (BGB). The law came planned measures must be taken into
into force on 20 February 2013 and is account and, if necessary, a telephone expla-
intended to create transparent regulations nation, if possible with fax confirmation by
for patients and doctors, particularly in the the caregiver, is also possible.
areas of information, documentation and
rights of access. For imaging procedures, the Duties/Rights During
necessary documentation was already stipu- the Practical Year
lated in detail in RöV and StrSchV before A recent ruling by the Karlsruhe Higher
the Patients’ Rights Act came into force. For Regional Court has declared the provision
practice, the Patients’ Rights Act results in a of information by PJ students to be legal
number of important requirements, in par- under certain conditions. They must be
ticular for information. familiar with the examination or interven-
tion and be able to assess the risks. The par-
ticipation in clarification discussions and, in
13.2.1 Reconnaissance the next step, the clarification under the
supervision of the training physician is the
Informing patients is a medical activity and prerequisite for PJ’ler to be allowed to clar-
cannot be delegated to non-medical staff. ify independently, provided that they can
The physician providing the information call a doctor for this at any time and should
must have a corresponding level of knowl- also point out to the patient that he or she
edge about the intervention or measure can always speak to a doctor as well.
about which he is providing the information. The patient must be offered a copy of the
In practice, this means that a physician can written copies of the information and should
explain an appendectomy if he has at least confirm receipt or refusal of the copy, pref-
assisted in the procedure and has experience erably in writing. The patient’s signature
with possible complications and their treat- confirming receipt of the copy must not, of
ment. The extent of the explanation depends course, already be on the copy.
on the urgency and danger of the interven-
tion. In the case of an emergency CT scan >>The patient may revoke his or her con-
for a suspected perforated aortic aneurysm, sent at any time; an intervention or
the patient does not need to be informed in examination against the patient’s express
detail in writing about possible complica- will is not permitted.
 128 C. Vockelmann

What Must Be Disclosed? around openly or pass it on. Electronic doc-

The patient should be informed about the uments such as patient files or X-ray images
planned measures in such a way that he/she must not be freely accessible, but must be
can decide for him/herself whether the password-protected. As a doctor, you are
planned procedure makes sense for him/her only allowed to see information about
(self-determination information). To this patients you are treating. The patient decides
end, the patient must be informed about the to whom information about his or her state
risks of the planned treatment, but also of health may be disclosed. Without the
about the risks that may arise if the measure patient’s consent, the X-ray results of an
is not carried out. examination, for example, may not be passed
The actual treatment information on to the referring physician or general prac-
includes the specific treatment (e.g. com- titioner. In order to make it possible to work
puter tomography) with possible risks (e.g. sensibly here, this passing on of information
contrast agent incident with anaphylactic to the referring physician is often regulated
shock). In the end, it is not the frequency of in the treatment contract that the patient
risks that is important, but the consequences. concludes with the hospital. The consulta-
Thus, possible lethal complications should tion of other specialist groups also requires
be mentioned, even if their probability of the patient’s consent. In the case of emer-
occurrence is very rare but possible. gency consultations, such as the consultation
Information should also be provided on of a neurosurgeon in the event of intracere-
possible alternatives to the proposed proce- bral hemorrhage, you may, however, act in
dure, especially if there are in fact approxi- the presumed interests of the patient.
mately equivalent procedures. The same applies to the information of
relatives. The spouse does not generally have
Information Requirements a right to information, but in an emergency
The doctor is obliged to inform the patient you may assume that the patient agrees to
about the disease, the planned therapy and his or her spouse being informed about the
also the probable development of the state state of health.
of health. The storage of external X-ray examina-
13 If the doctor recognizes that the treat- tions also falls within the scope of data pro-
ment costs are not fully covered by the tection. Here, too, you need the patient’s
health insurance, the patient must be consent.
informed in writing about the costs incurred. Electronic data transmission must be
A typical example of this are IGel services encrypted. An example of such encrypted
(individual health services) or also a planned sending of X-ray images is the operation of
dental prosthesis. teleradiology home offices. Here, there must
be a secure connection between the teleradi-
ologist’s home computer and the hospital so
13.3 Data Protection that the images cannot be intercepted and
the information misused.
Information about a person’s state of health
is very sensitive data that must be handled
responsibly. Even as a medical student, you, 13.4 Atomic Energy Act (AtG)
as well as the nursing staff and medical tech-
nical assistants (MTA), are subject to medi- The content of the X-ray and Radiation
cal confidentiality. Therefore, you must not Protection Ordinances is based on the regu-
leave information about patients lying lations of the EURATOM Directives and
Legislation
129 13
the Atomic Energy Act, which regulates the Ordinance (StrlSchV), is an ordinance
peaceful use of nuclear energy and protec- within nuclear law. The legal basis for it is §
tion against the dangers of nuclear energy. 54 of the Atomic Energy Act. The StrlSchV
As you can guess from the name, was last amended in 2011; the original ver-
EURATOM stands for an organization in sion dates from 1976.1 The purpose of the
Europe. The European Atomic Energy ordinance is described in § 1:
Community (Euratom) was founded in 1957
by the Treaty of Rome at the same time as »» The purpose of this Regulation is to lay
down the principles and requirements for
the European Economic Community, now
precautionary and protective measures
renamed the European Community (EU),
applicable to the use and exposure to
by France, Italy, the Benelux countries and
radioactive substances and ionizing radia-
the Federal Republic of Germany.
tion of civil and natural origin in order to
protect man and the environment against
the harmful effects of ionizing radiation.
13.5 X-ray Ordinance (RöV)
The StrlSchV applies in areas in which
The Ordinance on Protection against radioactive substances are worked with. In
Damage Caused by X-rays, the full title of addition to nuclear medicine in the field of
the X-ray Ordinance, came into force in its medicine, this also affects, for example, the
original version in 1973. The last amend- personnel of nuclear facilities.
ment has been valid since 01 November Medical personnel are partly subject to
2012. A core statement of the X-ray both the X-ray Ordinance and the Radiation
Ordinance is the requirement to avoid any Protection Ordinance.
unnecessary exposure to radiation for
humans and the environment. It also regu-
lates quality requirements and necessary 13.7 Radiation Protection Areas
quality controls by users and medical
authorities. The medical authorities are The radiation protection areas (. Fig. 13.1,
institutions located at the respective state . Table 13.1) are regulated in § 19
medical associations that monitor the qual- RöV. These areas describe the working areas
ity assurance of medical radiation applica-
tions. Comparable institutions exist as dental
Monitoring area
authorities for the dental field. The X-ray Effective dose > 1 mSv/year
Ordinance regulates areas with X-ray radia-
tion with a limit energy of more than 5 keV
and less than 1 MeV. The handling of radio- Kontrollbereich
active substances and ionizing radiation not Effective dose > 6 mSv/year
covered by the X-ray Ordinance is regulated
by the Radiation Protection Ordinance.
Restricted area
Local dose rate > 3 mSv/h

13.6 Radiation Protection

Ordinance (StrSchV)

The Ordinance on Protection against

Damage Caused by Ionizing Radiation, ..      Fig. 13.1 Radiation protection areas. (From Hart-
abbreviated to Radiation Protection mann et al. 2014)
 130 C. Vockelmann

.       Table 13.1 Radiation protection areas

a b

Radiation protection area Dose

Restricted area >3 mSv/h

Control area >6 mSv/a
Monitoring area >1 mSv/a

..      Fig. 13.2 Radiation warning sign. a Currently

used and b future internationally used radiation warn-
in which ionizing radiation may occur. A ing sign. (From Hartmann et al. 2014)
residence time of 40 h in a week and 50 weeks
in a calendar year serves as the basis for often encounter the radiation warning sign.
defining the areas. The sign currently used in Germany, the
This classification is not relevant for black propeller on a yellow triangle
patients. (. Fig. 13.2a), will be replaced internation-
ally in the future by a red triangle with a
z Restricted Areas deterrent symbol. Here, a skull and cross-
These exist in radiation therapy and in bones and a departing human are found
nuclear facilities. In radiotherapy, the radia- below the propeller (. Fig. 13.2b).
tion bunker or the after-loading room is a Before you are allowed to work in the
restricted area when the linear accelerator is controlled area, you must be instructed by
radiating or the radiators are extended in the radiation protection officer. This instruc-
after-loading. Only the patient may be in the tion must be repeated annually. You must
room at this time. Persons holding or assist- tolerate this instruction. Only if you are pre-
ing the patient as well as medical personnel vented from doing so, the instruction can be
are not allowed to be there and the area given in writing in exceptional cases.
must be marked with a light signal (restricted X-ray rooms belong to the controlled
area—no access). Outside the actual irradia- areas during admission or fluoroscopy, oth-
13 tion, the restricted area becomes a con- erwise to the monitoring area. In the case of
trolled area. X-ray equipment in intensive care units or
mobile C-arms, there is of course no spa-
z Control Areas and Supervised Areas tially identifiable controlled area. Here, a
These are available in every X-ray, radio- controlled area of 1.5 m applies by defini-
therapy or nuclear medicine department. tion for mobile X-ray exposure devices or
If you enter a controlled area for occupa- 3 m or 4 m for C-arms, depending on the
tional reasons, you belong to the group of image converter size. Marking is not required
occupationally exposed persons. Persons for this, provided that it is ensured that unin-
under the age of 18 are only permitted volved persons do not enter the area unin-
access for training purposes. For pregnant tentionally.
employees, it must be ensured that the uter- If you work in the controlled area, you
ine dose is less than 1 mSv until the end of are required to determine your body dose.
the pregnancy. For this purpose, you must wear an appro-
Control areas must be marked. This priate X-ray badge. You are also obliged to
marking must contain at least the words wear appropriate protective clothing (lead
“No access—X-ray” or, in nuclear medicine, apron, thyroid protection) in the controlled
“Controlled area”. In addition, you will area. This obligation does not apply in
Legislation
131 13
nuclear medicine, as here a lead apron would larly on board aircraft. Two categories are
make the radiation longer-wave and thus distinguished, depending on the potential
absorbable. radiation exposure. The dose limits are to be
However, the obligation for protective understood as an “or” rule, i.e. it is suffi-
clothing and personal dosimetry with deter- cient, for example, to reach the organ dose
mination of the body dose does not only of the eye lens in order to belong to category
concern employees. The body dose must A (. Table 13.2).
also be determined immediately for persons The results of the Federal Office for
who are “in the controlled area for reasons Radiation Protection show that the radia-
other than their (…) examination or treat- tion exposure of the vast majority of medi-
ment”. For this purpose, for example, rod cal personnel is less than 1 mSv/year. For
dosimeters are used which can be read after flying personnel, on the other hand, the
the examination. This dose must also be average radiation exposure is 2–3 mSv/
documented. year.
The monitored area is characterized by a If there is actually a radiation exposure
dose rate of more than 1 mSv/year. Persons of more than 20 mSv/year, an official permit
who permanently stay in these areas also can be issued in individual cases allowing a
belong to the group of occupationally radiation exposure of up to 50 mSv/year.
exposed persons.
>>However, according to Directive 96/29/
EURATOM, the radiation exposure
13.8 Occupationally Exposed may not exceed 100 mSv in five consecu-
Persons tive years.

In addition to medical personnel, occupa- In Germany, approx. 360,000 persons are

tionally exposed persons also include per- currently monitored. In 2007, there was a
sonnel of nuclear facilities and, in the radiation exposure of more than 20 mSv
meantime, airline personnel who are regu- effective dose in 11 cases.

.       Table 13.2 Persons exposed to radiation

Category A Category B

Medical examination Annual By order of the Authority

Effective dose >6 mSv/calendar year >1 mSv/calendar year
Organ dose eye lens >45 mSv/calendar year >15 mSv/calendar year
Organdosis skin, hands, forearms, feet, ankles >150 mSv/calendar year >50 mSv/calendar year
 132 C. Vockelmann

Basic course, usually with

4 hours of theoretical
instruction
Application for a
Acquisition of Specialized
certificate of knowledge
periods of expertise knowledge
at the medical association
4-hour practical
instruction by
radiologists in the clinic

Special course

..      Fig. 13.3 The path to expertise. (From Hartmann et al. 2014)

13.9 Technical Knowledge whether the question cannot be answered by

another examination with lower radiation
The X-ray and Radiation Protection exposure.
Ordinances stipulate that the medical use of In order to be able to establish the justi-
X-rays may only be ordered or carried out fying indication, the physician must be in
by doctors who have the appropriate spe- possession of the corresponding specialist
cialist qualifications. For this purpose, you knowledge. For example, a doctor with
must attend radiation protection courses emergency specialist knowledge may order
and perform a specified number of examina- an X-ray of a patient’s ankle following supi-
tions under supervision. In addition to the nation trauma. However, he may not order
overall specialist qualification in X-ray diag- an X-ray of the lung with the question of
nostics, there are also specialist qualifica- metastases in a tumor disease. This requires
tions in CT, skeletal diagnostics, emergency a thoracic specialist qualification or a gen-
diagnostics, interventions and much more eral specialist qualification.
(. Fig. 13.3). In order to retain your spe-
cialist knowledge, you must attend an update >>Questions such as progress monitoring
13 course in accordance with RöV and possibly are not sufficient to establish a justifiable
also StrlSchV (for nuclear medicine and indication.
radiotherapy as well as MTRA) every five
years at the latest.

13.11 Medical Devices Act (MPG)

13.10 Justifying Indication
You will encounter the MPG in your work
Examinations may only be performed if a every day. It stipulates that only appropri-
competent physician has provided the “justi- ately tested medical devices may be used.
fying indication” according to § 23 RöV or § X-ray devices also fall under this regulation,
80 StrlSchV. It must be assessed whether the as do perfusers or pressure syringes. In order
benefit of the planned examination out- to be allowed to operate these, you must be
weighs the risk of radiation exposure and instructed in the respective device.
Legislation
133 13
13.12  aternity Protection Act
M daily working time, minimum rest breaks
(MuSchG) and protective regulations on night work.
The law is binding for employers and
The Maternity Protection Act is intended to employees. There are regulations on work-
protect the health of mother and child. This ing hours on weekdays, weekly working
includes, among other things, that pregnant hours and on-call duty.
women are not allowed to work at night.
Working in the controlled area is possible Practice Questions
under certain conditions, as mentioned 1. What must the doctor explain?
above. Contact with potentially infectious 2. What is regulated by the X-ray
material must be avoided. Therefore, you Ordinance and what by the Radiation
must not draw blood or place venous Protection Ordinance?
accesses during pregnancy. 3. What is meant by “justifiable indica-
tion”?
4. Does pregnancy under the Maternity
13.13 Working Time Act Protection Act preclude working in
the radiological field?
This regulates occupational health and
safety under public law. Among other things, Solutions Chap. 27
there are limits on the maximum permissible
 135 II

Disease Patterns
Contents

Chapter 14 Neurology – 137

Christel Vockelmann, Ursula Blum,
Martina Kahl-Scholz and Guido Heilsberg

Chapter 15 Head/Neck – 161

Martina Kahl-Scholz, Christel Vockelmann,
Ursula Blum and Guido Heilsberg

Chapter 16 Gynecology – 171

Carla M. Kremers, Guido Heilsberg, Ursula Blum,
Christel Vockelmann and Martina Kahl-Scholz

Chapter 17 Respiratory System – 191

Martina Kahl-Scholz, Christel Vockelmann
and Ursula Blum

Chapter 18 Gastrointestinal Tract – 217

Christel Vockelmann, Ursula Blum,
and Guido Heilsberg

Chapter 19 Urogenital – 253

Carla M. Kremers, Guido Heilsberg, Ursula Blum,
Christel Vockelmann and Martina Kahl-Scholz

Chapter 20 Musculoskeletal Diseases – 279

Mirja Wenker, Christel Vockelmann, Ursula Blum
and Guido Heilsberg

Chapter 21 Cardiovascular Diseases – 307

Mirja Wenker, Ursula Blum,
and Christel Vockelmann
Chapter 22 Endocrinological System – 327
Martina Kahl-Scholz, Christel Vockelmann,
Ursula Blum, and Guido Heilsberg

Chapter 23 Lymphatic System – 339

Martina Kahl-Scholz, Christel Vockelmann,
Ursula Blum, and Guido Heilsberg

Chapter 24 Pediatrics – 351

Esther Münstermann and Christel Vockelmann
 137 14

Neurology
Christel Vockelmann, Ursula Blum, Martina Kahl-Scholz
and Guido Heilsberg

Contents

14.1 Anatomical Structures – 138

14.2 Disease Patterns – 138

14.2.1 I ntracranial and Spinal Hemorrhages – 138
14.2.2 Ischemic Diseases – 141
14.2.3 Intracerebral Tumors – 143
14.2.4 Cerebrospinal Fluid Circulation Disorder – 146
14.2.5 Intracranial Extraaxial Tumors – 146
14.2.6 Cystic Intracranial Lesions – 147
14.2.7 Chronic Inflammatory CNS Processes: Multiple Sclerosis – 147
14.2.8 Acute Inflammatory CNS Processes – 149
14.2.9 Epilepsy – 149
14.2.10 Phacomatoses – 150
14.2.11 Neurodegenerative Diseases – 151

14.3 Diagnostics – 152

14.3.1  iagnostic Radiology – 152
D
14.3.2 Nuclear Medicine – 153
14.3.3 Valence – 156

14.4 Therapy – 157

14.4.1 I nterventional Radiology – 157
14.4.2 Radiotherapy – 158

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 138 C. Vockelmann et al.

The brain controls all important functions, and right internal carotid arteries and the
from motor skills and sensory perception to right and left vertebral arteries. The verte-
vital processes such as breathing, heartbeat bral arteries form the basilar artery, which in
and digestion. It is a complicated system of turn feeds the cerebral arterial circle (also
neurotransmitters and neuroreceptors. The known as the circle of Willis) inside the skull
spinal cord is, so to speak, the connection (frequent location of aneurysms, etc.). The
between the central switching station “brain” term carotid T for the intracranial part of
and the other parts of the body such as the the internal carotid artery with its branching
neck, trunk and extremities. into the middle cerebral artery and anterior
cerebral artery is commonly used in clinical
practice and is particularly important in the
14.1 Anatomical Structures acute diagnosis of stroke. The intracranial
vessels are divided into segments M1 to M4
Christel Vockelmann for the middle cerebral artery or P1 to P4 for
the posterior cerebral artery (each to the
The anatomical structures of the neurologi- next vessel division), and A1 (to the anterior
cal system include the neurocranium with its communicating ramus) and A2 for the ante-
various parts, the myelon as well as the cra- rior cerebral artery.
nial nerves (central nervous system, CNS) Brain and spinal cord are surrounded by
and the peripheral ganglia and nerves cerebrospinal fluid, which is formed by the
(peripheral nervous system, PNS). choroid plexus.
The imaging of the CNS plays a major The spinal cord is about 45 cm long and
role, therefore we will limit ourselves here to extends to the 1st/2nd LWK. Like the cere-
the brief imaging of the brain (encephalon) brum, it is divided into the grey and white
and spinal cord (medulla spinalis). matter, which carry different nerve fibers.
The cerebrum (telencephalon) forms the The spinal nerves, which are responsible for
largest part of the brain and is structurally the nervous supply of the neck, trunk and
characterized by the two hemispheres, sev- the arms and legs, branch off from the spi-
eral furrows (sulci) and convolutions (gyri). nal cord.
Other parts are the diencephalon with thala-
mus, subthalamus, hypothalamus, pituitary
gland and epiphysis as well as the mesen- 14.2 Disease Patterns
14 cephalum, cerebellum, pons and the medulla
oblangata, which merges into the myelon. Christel Vockelmann
The boundary between the latter two struc-
tures is at about the level of the foramen 14.2.1 Intracranial and Spinal
magnum. Important in the context of imag- Hemorrhages
ing are the basal ganglia (also called the
truncal ganglia), which include the putamen Intracranial and intraspinal hemorrhages
and pallidum (together Nucl. lentiformis) are described according to their localization.
and Nucl. caudatus. between the aforemen- Epidural hemorrhages can be localized both
tioned nuclei is found the capsula interna, intraspinally and intracranially between the
laterally to it the capsula externa, the stria- cranial bone or vertebral body and the dura
tum and the capsula extrema, in each of mater. In the skull in particular, the cause is
which important pathways run. often a calvaria fracture, which leads to a
The brain is supplied by numerous blood rupture of the meningeal artery and can
vessels. The four main arteries are the left thus progress rapidly.
Neurology
139 14
>>Because of its space-occupying nature
and potentially rapid progression, epi-
dural hematoma is a neurologic or neu-
rosurgical emergency.

Subdural hemorrhages (SDH = subdural

hematoma) often occur post-traumatically
between the dura mater and the arachnoid
with any necessary relief. In older people in
particular, even a trivial trauma is sufficient
to lead to rupture of the bridging veins
(. Fig. 14.1).
Subarachnoid hemorrhage (. Fig. 14.2)
can occur with aneurysm rupture.

>>A history of falls should not deter one

from looking for an aneurysm in the
basal cisterns in a SAB, as the patient
may have fallen due to the aneurysm
rupture. ..      Fig. 14.2 Subarachnoid hemorrhage on CT scan

An important sign is the accumulation of Intracerebral hemorrhage (ICB), when

blood in the basal cisterns with punctum localized in the basal ganglia (. Fig. 14.3)
maximum around the aneurysm. Another or pons, is usually hypertensive in origin;
cause is a post-traumatic SAB, which is then when localized elsewhere, reasons for ICB
not localized basally. must be sought. Possible causes are:
55 Arteriovenous malformations,
55 Cavernomas,
55 Intracerebral tumors or metastases,
55 Sinus vein thrombosis (bleeding in the
neighborhood of the thrombosed sinus).

. Table 14.1 shows the main distinguishing

features.

z Clinic
Epidural and subdural hematomas become
clinically obvious mainly because of increas-
ing headache; a history of trauma and pos-
sibly medication with anticoagulants or
antiplatelet agents suggest hemorrhage.
SAB is characterized by a thunderclap head-
ache of unknown severity. Typically, aneu-
rysm ruptures affect younger people who
report physical exertion before symptom
onset. ICB results in neurological deficits
..      Fig. 14.1 Subdural hematoma on multiple CT similar to ischemic stroke, matching the
scans affected portion of the neurocranium.
 140 C. Vockelmann et al.

a b c

..      Fig. 14.3 Intracerebral hemorrhage on CT. a Basal ganglia on left. b Basal ganglia on right. c Pons

.       Table 14.1 Differentiation of hematoma localization

Epidural Hematoma Subdural Hematoma Subarachnoid Hemorrhage

Anamne- Acute trauma Often insidious onset with Thunderclap headache after
sis trauma that has already physical exertion
occurred some time ago
Patients Any age Rather older patients Often younger patients
concerned
Localiza- Often temporoparietal Frontoparietal, often Basal cisterns → aneurysm
tion along the falx or rupture, parietal/occipi-
tentorium tal → rather traumatic
Form Biconvex, does not Concave crescent-shaped, Along the gyri and sulci of
exceed the cranial exceeds the cranial sutures the brain surface
sutures, does not respect
the falx

14
z Diagnostics entrapment or hemorrhage infiltration into
CT the ventricular system. In these cases,
The method of first choice is the cranial ­neurosurgical relief must be performed.
CT, with which an acute hemorrhage can be Spinal hemorrhages are usually poorly
sensitively detected or excluded. In case of recognizable on CT; in this case, MRI is nec-
SAB in the basal ganglia, CT angiography essary at an early stage with appropriate
should be performed immediately to detect sequence selection (hemorrhage-sensitive
an aneurysm. With increasing duration of sequences, T1s fat-saturated).
SAB, vascular spasms occur, which make Intracranial hemorrhages change their
aneurysm detection difficult or impossible. characteristics on imaging over the course
MRI of days and weeks (. Table 14.2). Because
MRI is necessary in the further work-up of the changes with T1-weighted signal
of atypical ICB with then blood-sensitive enhancement on MRI, an MRI should be
sequences and angiographic procedures. It is performed within a maximum of three days
important to detect CSF congestion, e.g., for atypical intracerebral hemorrhages to
due to dilatation of the temporal horns by detect contrast enhancement.
Neurology
141 14

.       Table 14.2 Temporal changes in imaging

CT MRI Compared to White Matter

T1w T2w T2*w

Peracute Hyperdens (cA. 50 HU) Isointens Slightly hyperintense Slightly

(0–24 h) hypointense
Acute Hyperdens (cA. 50 HU) Slightly Greatly hypointense Hypoin-
(1–3 days) hypointense tens
Early subacute Slowly deflating Strongly Strongly hyperinten- Hypoin-
(3–7 days) hyperintensive sive tens
Late subacute Increasingly isodens Strongly Strongly hyperinten- Hypoin-
(7–14 days) hyperintensive sive tens
Chronic Hypodense to Central isoin- Central slightly Greatly
(>14 days) liquorisodense. If tense, slightly hyperintense, margins hypointense
applicable calcifications hypointense rim strongly hypointense

14.2.2 Ischemic Diseases z Diagnostics

CT
A lack of blood supply to the brain is the An acute stroke is, comparable to a heart
most frequent cause of stroke, accounting attack, an absolute emergency that requires
for about 70%. The incidence is 130/1,00,000 immediate imaging. In this case, the native
inhabitants. After myocardial infarction and cranial CT is the first elementary compo-
tumor disease, stroke is the third most fre- nent due to its speed and high availability. If
quent cause of death. The cause is often there is no hemorrhage (hyperdens with den-
arteriosclerotic vascular disease of the extra- sity values around cA. 50 HU) and no
cranial vessels supplying the brain, followed demarcated infarct (hypodense, missing
by embolic occlusions. In younger patients, gray-white differentiation, edema), an intra-
inflammatory changes of the vessels or sinus venous lysis therapy is started directly in the
vein thrombosis may lead to stroke. appropriate clinic. Time is brain! Every min-
Ischemic myelon infarction is rare over- ute saved improves the patient’s prognosis.
all. A typical cause may be aortic dissection. Perfusion Imaging
Myelon infarction is feared as a complica- The native CT is usually supplemented
tion after surgical or interventional proce- by perfusion imaging (section computed
dures on the aorta. tomography) with which large infarct areas
that can no longer be saved even by immedi-
z Clinic ate therapy and areas that are threatened but
A classic symptom is brachiofacial hemipa- can still be saved can be detected, even if no
resis of the contralateral half of the body. infarct is yet demarcated in the native image.
Dizziness and visual disturbances or cranial CT Angiography
nerve failures may also be symptoms of an The third pillar is CT angiography to
acute stroke. Prodromes are, for example, find intra- or extracranial occlusions. Acute
amaurosis fugax or TIA symptoms, i.e. a thrombotic occlusion of the middle cerebral
transient ischemic attack. artery or internal carotid artery is recana-
 142 C. Vockelmann et al.

lized by interventional techniques similar to nial vessels. Border zone infarcts are local-
those used in myocardial infarction (Sect. ized in the transition zones between the
14.4.1). supply areas and are hemodynamically
MRI caused. Lacunar infarcts are of microangio-
Diagnosis of ischemic diseases of the pathic origin (. Fig. 14.5).
neurocranium and myelon is performed in
MRI. The classic constellation here is sig-
nal enhancement in diffusion weighting
with signal depression in ADC, which is
already present in the peracute stage. With
increasing time, edema with signal enhance-
ment in T2w sequences then develops
(. Fig. 14.4).
This edema has its peak approximately
between the 3rd to 5th day. In the further
course, the necrosis zone is organized with
glioses and cystic formations. This process
can be well traced on imaging with a regress-
ing diffusion disorder and increasing glioses
(CT: hypodense to the parenchyma; MRI:
hyperintense in the FLAIR, T1 hypoin-
tense) and cystic formations (CT and MRI
liquorisodense and -isointense, respectively,
. Fig. 14.4).
The localization and extent of an infarct
allow conclusions to be drawn about its gen- ..      Fig. 14.5 Anterior border zone infarct on the left
esis. Thus, territorial (embolic) infarcts are and posterior border zone infarct on the right in the
assigned to the supply area of the intracra- native CT scan

14

..      Fig. 14.4 CT-native and CT-A with blunted basal ganglia (caput nucleus caudatus and putamen/pallidum
on the left with occlusion of the middle cerebral artery in the M1 segment—arrow)
Neurology
143 14
14.2.3 Intracerebral Tumors

The classification of brain tumors is based

on the WHO classification (. Table 14.3).
This reflects the degree of malignancy of the
tumors.
In addition, there are other tumors, some
of which have typical localizations and age
peaks. In the end, the clear image-­
morphological assignment is often not suc-
cessful.
In adults, metastases occur more fre-
quently than brain tumors (. Fig. 14.7).
Here, in addition to intracerebral metasta-
sis, meningeal carcinomatosis or intramedul-
lary metastasis is increasingly common.
Characteristic imaging shows melanoma
metastases and frequently also metastases
of renal cell carcinoma, both of which can
..      Fig. 14.6 Glioblastoma (coronary T1, contrast
be delineated hyperdense on CT and native enhanced)
T1-weighted hyperintense on MRI.

..      Table 14.3 Classification of brain tumors

according to WHO

Grade Description Example

I Benign tumors Craniopharyngeoma,

that can pilocytic astrocy-
potentially be toma or neurinomas
cured by and schwannomas
surgical
removal
II Infiltrative Oligodendroglioma,
tumors, diffuse growing
histologically astrocytoma
benign,
frequently
recurrent
III Malignant Anaplastic
tumors with astrocytoma, plexus
reduction of carcinoma
survival time
..      Fig. 14.7 Cerebral metastases bds. with annular
IV Very Glioblastoma enhancement and finger-shaped edema in contrast-­
malignant (. Fig. 14.6), enhanced CT
tumors with a medulloblastoma
significant
reduction in z Clinic
survival time The symptomatology of cerebral masses
depends on the localization of the finding.
 144 C. Vockelmann et al.

For example, a mass in the frontal brain may this can also be performed as part of a com-
be accompanied by a change in the patient’s plementary MRI diagnosis. The finger-­
personality. Other symptoms are stroke-like shaped edema can also be delineated on
symptoms or a seizure. MRI. To allow contrast passage through
Cerebral metastasis can also be the first the blood-brain barrier, imaging should be
symptomatic manifestation of a tumor, and performed no earlier than 5 min after con-
the first look should then be at the lung as trast administration. On the basis of the
the most common organ of origin. localization, the age of the patient, any cal-
In contrast, in the absence of a tumor cifications in the CT and the contrast
history, a primary tumor is more likely to be medium accumulation, a tentative diagnosis
assumed in the case of a myelon mass; if of the type of mass can be made. If neces-
myelon metastases occur, the tumor is usu- sary, this can be reinforced by MR spectros-
ally already known. copy, but ultimately a definite statement
about the type of tumor is not always pos-
z Diagnostics sible. Cerebral metastasis is indicated by the
CT presence of several contrast-enhancing
Often the first diagnosis is a cranial CT lesions.
scan due to stroke-like symptoms or a sei- An important differential diagnosis
zure. Here, a hypodense “finger-shaped” (. Table 14.4) to intracerebral tumor is
edema can be detected, which mostly abscess, which is classically characterized by
respects the cortex. The space-occupying marked hyperintense signaling in the diffu-
character can be delimited by a constriction sion.
of the cerebrospinal fluid spaces.
MRI >>Signal enhancement of a space involve-
Further imaging then requires the ment in the diffusion weighting is indica-
administration of a contrast agent, although tive of an intracerebral abscess!

14
 Neurology

.       Table 14.4 DD of selected brain tumors

Frequent localization Frequency of all Age and gender distribution Tumor Imaging
primary brain grading
tumors

Astrocytoma Supratentorial 9% 30–60 LJ II + III With increasing de-differentiation, increasing

M>w KM enhancement, surrounding finger-shaped
edema
Glioblastoma Cerebral hemispheres, 20% 50TH–70TH LJ IV Severe KM enhancement, garland-shaped,
multiforme (=astro- bars (butterfly M>w extensive necrosis and hemorrhage
cytoma grade IV) glioblastoma)
Oligodendroglioma Frontal brain, basal 4% 40TH–60TH LJ II + III In 2/3 of the cases, extensive scaly calcifica-
ganglia M>w tions, little surrounding edema, KM uptake
depending on the grading (II or III)
Ependymoma Proximity to the <0.5% Children and adolescents, Variable Inhomogeneous KM enhancement, no
ventricular system 30–40 LJ perifocal edema; caution: drip metastases
Primary CNS – Rarely For immunocompetence On CT often hyperdense due to cell richness,
lymphoma 50–60th year, for immuno- on MRI isodense in T1w and T2w with
incompetence earlier homogeneous KM enhancement
Pilocytic astrocytoma Infratentorial 0.3% 1st-2nd cent of life; m > w Large cystic tumor portion with vigorous
KM-absorbing node
Medulloblastoma Infratentorial Rarely 1st decade of life IV Inhomogeneous tumor of the cerebellum,
hemorrhages, frequent infiltration of the
145

ventricular system, drip metastases

Colloid cyst Third ventricle, <2% Mostly between 20 and 40 Benign CT: Hyperdense, smooth bordered in 3rd
foramen monroi… LJ, m > w ventricle; variable on MR, T1w usually
hyperintense, usually no enhancement
14
 146 C. Vockelmann et al.

14.2.4 Cerebrospinal Fluid z Clinic

Circulation Disorder Mostly incidental finding. Symptoms usu-
ally occur only with very large meningiomas.
Common to all cerebral space-occupying Acoustic neuroma is characterized by tinni-
lesions is the risk of cerebrospinal fluid cir- tus, dizziness and a disturbance in sound
culation disturbance, i.e. congestion of the perception.
ventricular system. This can be caused supra
as well as infratentorially by an entrapment z Diagnostics
of the parenchyma at the tentorium, falx or CT
foramen magnum. Obstruction of interven- Classical is besides the convex contour
tricular foramen or aqueduct in hemorrhage to the cranial dome with a protrusion to the
also results in CSF circulatory obstruction. dura, the so-called dural tail, a very strong,
early and homogeneous contrast enhance-
z Clinic ment. The blood supply of a meningioma is
The classic symptom is headache. Often the via branches of the external carotid artery,
examination of the fundus of the eye reveals and the contrast enhancement does not
a congestion papilla. have to cross the blood-brain barrier. In
addition, meningiomas are frequently calci-
z Diagnostics fied.
CT/MRI Meningiomas can occur anywhere on the
The most important imaging procedure meninges, although spinal meningiomas are
is the CT. Further clarification takes place in very rare (. Fig. 14.8).
the MRI. In both procedures, the widening A special case of meningioma is malig-
of the cerebrospinal fluid spaces and, if nec- nant meningioma, which exerts pressure on
essary, the cause for this can be detected. the adjacent brain parenchyma and becomes
symptomatic accordingly.
>>An early sign of a cerebrospinal fluid cir- Acoustic neuromas show a strong con-
culation disorder is a widening (>3 mm) trast enhancement of the partly very small
of the temporal horns. tumors. Larger findings may lead to a wid-
ening of the internal acoustic meatus with
an “ice cream cone”-like configuration of
Intracranial Extraaxial the tumor.
14 14.2.5
Tumors
>>In the case of space occupying lesions in
the cerebellopontine angle, three diagno-
In addition to cerebral tumors (synonym:
ses must be considered: meningioma,
intraaxial tumor), meningioma is a frequent
acoustic neuroma (=wannoma) and epi-
finding in neurocranial imaging. This usually
dermoid tumor. The differential diagno-
benign tumor originates from the meninges
sis is made in MRI with KM sequences
and displaces the adjacent brain parenchyma.
and diffusion weighting (the epidermoid
Other extraaxial rare tumors are the epi-
shows a strong diffusion restriction with
dermoid, schwannomas especially of the
signal enhancement).
vestibulocochlear nerve (“acoustic neu-
roma”) or tumors of the pituitary gland.
Neurology
147 14
z Diagnostics
CT/MRI
CT and MRI with liquorisodense
and -isointense imaging, respectively. The
arachnoid cyst displaces the adjacent brain
parenchyma without signal alterations. No
contrast enhancement.
Neuroepithelial cysts are often located
supratentorially adjacent to the lateral ven-
tricles.

14.2.7  hronic Inflammatory CNS

C
Processes: Multiple Sclerosis

The most common chronic inflammatory

CNS disease is multiple sclerosis (MS).
Often optic neuritis is the first symptom
with no pathological findings on imaging.
..      Fig. 14.8 Cuneiform wing meningioma on the left MS is a demyelinating disease in which MS
with strong contrast enhancement on CT plaque forms with destruction of myelin due
to etiologically unclear inflammation. The
disease mostly affects younger patients
14.2.6 Cystic Intracranial Lesions between 20 and 40 years of age. In most
cases, the disease progresses in relapses.
As with tumors, it must first be decided Glucocorticoids are used as therapy during
whether the finding is intrecerebral or intra- the relapse.
cranial but not originating in the brain. The
most common lesion is the arachnoid cyst, a z Clinic
cyst often in the middle cranial fossa that In about 1/4 of the cases, optic neuritis (“The
displaces the brain but is not space-­ patient sees nothing, the doctor sees noth-
occupying. More rarely, cysts are intracere- ing!”) is the initial symptom. Sensory distur-
bral, such as a neuroepithelial cyst. In this bances, weakness of the extremities or even
case, the presence of a cystic mass or a cere- a loss of sensitivity in the supply area of the
bral infection must always be considered in trigeminal nerve are further symptoms.
the differential diagnosis. Virchow-Robin
spaces are protrusions of the subarachnoid kDiagnostics
space around vessels, which appear as intra- CT
cranial cysts. The most frequent localization In addition to imaging, CSF puncture is
is the basal ganglia, where the cysts develop obligatory in the suspected diagnosis of
along the lenticulostriatal branches of the MS. The CT shows hypodense areas of the
middle cerebral artery. Differential diagnosis white matter only in advanced disease, which
is a lacunar infarction in the basal ganglia. are not distinguishable from a pronounced
microangiopathic damage of the brain.
z Clinic MRI
Most often it is an asymptomatic incidental MRI of the neuroaxis shows typical
finding. Large arachnoid cysts may occasion- changes, but imaging alone cannot prove
ally cause intracranial pressure symptoms. MS. Typical findings are highly oval T2w
 148 C. Vockelmann et al.

hyperintense demyelinating foci periventricu-

larly, which then show a cockscomb-like
appearance in the sagittal image. Other typi-
cal findings include juxtacortically located
lesions and distribution supra- and infraten-
torially (this includes a spinal manifesta-
tion). The lesions are T1w frequently
hypointense (so-called “black holes”)
(. Fig. 14.9). Temporal dissemination (cor-
responding to the relapsing course of the dis-
ease) can be evidenced by KM-receiving
lesions (typically not completely annular but
horseshoe-­shaped) or new lesions at least one
month after symptomatology (. Table 14.5).
An important differential diagnosis in a
clinic similar to MS is acute disseminated
encephalomyelitis (ADEM), which causes
similar lesions in the CNS, but here all ..      Fig. 14.9 Sagittal flair with hyperintense demye-
linating foci around the corpus callosum
lesions have the same stage.

..      Table 14.5 McDonald criteria for spatial dissemination (at least three criteria for radiological
diagnosis)

At least nine 2w At least one infratentorial At least one At least three periventricular
hyperintense lesion (also located in the juxtacortical lesions and evidence of temporal
lesions myelon) lesion dissemination

Dissemination
over time
KM-absorbing focus at least three months after Evidence of a new lesion T2w, at least 30 days after
initial symptoms symptomatology
14
Neurology
149 14
14.2.8  cute Inflammatory CNS
A
Processes

This includes the following processes:

55 ADEM: Rare disease with symptoms
typical of MS, but monophasic.
55 Encephalitis: Infection of the brain with
various pathogens. Occurs frequently as
meningoencephalitis derived from inflam-
matory processes, e.g. of the sinuses or
mastoids. Typical manifestation in herpes
encephalitis (type I, herpes simplex) in the
temporal lobes and the limbic system.
Important differential diagnosis for this is
paraneoplastic limbic encephalitis with a
similar pattern of distribution. This ..      Fig. 14.10 Cerebellitis with hyperintense, rela-
occurs most frequently in bronchial carci- tively symmetrical signal elevations in the flair in the
noma as the primary tumor. cerebellum bds
55 Abscess: circumscribed melting inflam-
matory process, often derived from in the CSF. Imaging often shows normal
sinusitis or due to hematogenous dissem- findings on MRI in encephalitis. If changes
ination. Common in immunocompro- are detectable, it is often edema with signal
mised patients. elevations T2w and possibly KM enhance-
ment. If there are corresponding changes in
Ultimately, almost all pathogens can also the limbic system, herpes simplex encephali-
affect the CNS. These include, for example, tis or limbic encephalitis must be consid-
neurocysticercosis due to infestation with ered. Parasitic infections often show
the pork tapeworm, toxoplasmosis and calcifications in later stages. A cerebral
tuberculosis. It is important to assess all abscess shows a marginal KM enhancement
clinical and imaging findings in order to with central fluid. For the differential diag-
arrive at the correct diagnosis. nostic differentiation from a tumor the dif-
fusion is important, which shows a strong
z Clinic diffusion restriction with a strongly hyperin-
The classic symptom of meningitis is neck tense signal.
stiffness combined with headache. Other
symptoms depend on the severity and local-
ization of the disease. Immunocompromised 14.2.9 Epilepsy
patients in particular are more frequently
affected by encephalitis. Epilepsy is characterized by the repeated
occurrence of seizures. If these seizures are
z Diagnostics primarily generalized and affect the whole
MRI (. Fig. 14.10) brain, there are often genetic causes. In the
In the case of encephalitis or meningoen- case of focally initiated seizures, there is
cephalitis, the cerebrospinal fluid (CSF) often local damage to the brain. Therefore,
puncture is a very important diagnostic tool it is important to know the possible localiza-
for detecting cells and possibly also a germ tion of the damage during imaging.
 150 C. Vockelmann et al.

Tumors, infarcts or bleeding can be the nervous system. They are based on certain
cause of epilepsy. More difficult to detect genetic defects, which are often inherited in
are anlage disorders. The most common are an autosomal-dominant manner. The most
heterotopia, i.e. scattered grey matter that common is neurofibromatosis type 1
has not migrated to the cortex, and focal Recklinghausen’s disease). Typical are café-
dysplasia, a developmental disorder with a au-­lait spots of the skin and neurofibromas,
blurring of the medullary-cortical boundary especially optic gliomas. In neurofibromato-
or disturbances in the grey matter. Another sis type 2, the leading feature is acousticus
disorder in the setting of epilepsy is hippo- schwannomas. Bilateral acoustic schwanno-
campal sclerosis (also known as ammonic mas are sufficient to establish a diagnosis of
horn sclerosis). Etiologically unclear, the neurofibromatosis type 2. Tuberous sclerosis
disease leads to nerve cell destruction of the (Bourneville-Pringle disease) also belongs to
hippocampus. the phacomatoses. Classically, subependy-
mal nodules, cortical tuberosities, hypomel-
z Clinic anotic patches of the skin as well as
Depending on the location of the damage, angiomyolipomas of the kidney and also
the picture of epilepsy is very diverse. From rhabdomyomas of the heart as well as giant
the classic seizure with twitching of extremi- cell astrocytomas are found. These are
ties to sensory disturbances and absences, mostly located in the area of the foramina
other symptoms can also occur in the course monroi and belong to WHO grade I tumors.
of a seizure. Sturge-Weber syndrome is an angiomatosis,
mainly in the supply area of the trigeminal
z Diagnostics nerve. Such angiomas are also found intra-
CT cerebrally. Another phacomatosis is Von
CT is the rapidly available method for Hippel-Lindau disease. The disease is char-
the first seizure that can rule out bleeding or acterized by cerebral hemangioblastomas.
a tumor as the cause. In addition, renal cell carcinomas, but also
MRI renal cysts, pheochromocytomas and cyst-
Further imaging takes place in the adenomas of the testis occur frequently in
MRI. Causes, such as old infarcts or tumors, these patients.
are often already clear after computed
tomography. In the case of malformations z Clinic
14 such as heterotopia or focal dysplasia, thin-­ Neurofibromatosis type 1 and also Sturge-­
slice sequences are required both T1w and Weber syndrome and tuberous sclerosis
as flair sequences in order to be able to are usually manifested in childhood.
detect the malformation here. Neurofibromatosis type 2 and Von Hippel-
Hippocampal sclerosis can be well delin- Lindau disease are often diagnosed in young
eated in coronal images as a reduction in vol- adulthood. The clinic is characterized by the
ume of a hippocampus with enlargement of skin changes and the corresponding affected
the adjacent temporal horn. In addition, structures of the nervous system.
there is a signal enhancement in T2w or bet-
ter flair sequences. z Diagnostics
MRI
Neurofibromas, which include optic glio-
14.2.10 Phacomatoses mas and acoustic schwannomas, can be
homogeneously delineated on MRI with a
Phacomatoses are neurocutaneous syn- strong KM enhancement. Large acoustic
dromes, i.e. diseases involving the skin and neuromas lead to a dilatation of the internal
Neurology
151 14
acoustic meatus. The image occasionally diseases present a relatively typical pattern
resembles an ice cream cone in large acous- of findings on MRI, so that MRI is per-
tic neuromas. formed as standard for the clarification of
neurodegenerative diseases (. Fig. 14.11).
Important differential diagnostic criteria are
14.2.11 Neurodegenerative shown in . Table 14.6.
Diseases
>>Every dementia should be clarified once
The brain is subject to a natural aging pro- with a sectional image diagnosis of the
cess with a degradation of brain substance neurocranium, in order to exclude e.g.
as well as iron deposition in the basal gan- tumors or a normal pressure hydrocepha-
glia. However, certain neurodegenerative lus as a cause.

..      Fig. 14.11 Diffusion enhancement (right image) in the basal ganglia in Creutzfeldt-­Jakob disease, for com-
parison normal findings on the left

.       Table 14.6 Differential diagnosis of different neurodegenerative diseases

Clinic Diagnostics

M. Alzheimer Short-term memory impairment, no Temporally accentuated atrophy, atrophy

delirium, existing > six months, of the hippocampus
onset at mean 70th year
Vascular dementia Abrupt onset, history of stroke, Pronounced microangiopathy, infarcts
other neurological deficits with involvement of both thalami and/or
temporomesial structures
Multisystem Parkinson-like symptoms, additional Atrophy putamen and/or olivopontocer-
atrophy e.g. orthostatic dysregulation, ebellar, hot cross bun sign (hyperintense
micturition disorder, impotence cross figure in bridge foot in T2w)
Frontotemporal Behavioral problems, change of Unilateral frontotemporal atrophy
lobar degeneration character

(continued)
 152 C. Vockelmann et al.

.       Table 14.6 (continued)

Clinic Diagnostics

Normal pressure Triad of gait disorder, dementia and Dilatation of the ventricular system;
hydrocephalus urinary incontinence sample liquor puncture
M. Parkinson Onset with unilateral rigor, tremor Mostly normal findings; possibly changes
and hypokinesia in the iron content of the substantia
nigra, atrophy of the hippocampus
Creutzfeld-Jakob Rapid dementia, myoclonia… Flair and diffusion with signal enhance-
disease ment of the basal ganglia and/or cortex
Progressive Parkinson’s-like symptoms Mesencephalic atopy (Mickey mouse
supranuclear character)
paralysis
Huntington’s chorea Excessive movements (choreatic Bilateral atrophy of the nucl. caudatus
hyperkinesia) (coronary T1w), also putamen and
globus pallidus
Wernicke’s Brain-organic psychosyndrome, Atrophy or KM uptake of the corpora
encephalopathy unsteadiness of gait and stance, eye mamillaria
movement disorders

14.3 Diagnostics increasingly, to treat these interventions.

Coils, i.e. small metal spirals, are used to fill
14.3.1 Diagnostic Radiology aneurysms.

Computed Tomography (CT)

Sonography
CT is the method of choice for almost all
Sonography is used in newborns as the pri-
emergency indications for imaging of the
mary diagnostic tool for assessing the neu-
neurocranium. CT can reliably detect or rule
rocranium. In adults, access for the sound
out hemorrhage. Also, most tumors that
waves through the cranial dome is very lim-
have become symptomatic can already be
14 ited. Here, sonography is used as transcra-
detected with a CT. Since the lenses of the
nial Doppler sonography for the assessment
eye are very sensitive to radiation, the layers
of the intracranial vessels, often supple-
in the CT of the head are angulated at the
mented by CT or MR angiography.
base of the skull. This ensures that the lenses
of the eye are not in the direct radiation
Conventional X-ray Diagnostics field.
Conventional X-ray diagnostics of the brain In acute stroke, a so-called lysis protocol
skull are no longer performed. One of the is generally used today. First, a native CT of
last indications is the position control of a the head is performed. After exclusion of
valve in certain VP shunts before or after hemorrhage, intravenous lysis therapy can
MRI examinations. be initiated if indicated. In addition, a CT
perfusion and a CT angiography of the
Fluoroscopy/Angiography supra-aortic vessels are performed. In the
Angiographic examinations are used to clar- case of large infarctions, the CT perfusion
ify intracerebral vascular processes such as can be used to estimate how much infarction
AV malformations or aneurysms and, is imminent and how much tissue can still be
Neurology
153 14
saved. This is achieved by evaluating the search for a focus in epileptic seizures or
repeated images of the brain during a con- the identification of the speech or visual
trast medium run, which allows parameters center before a planned operation.
such as blood volume and blood flow in the There are 99mTc-ECD (ethyl cysteinate
various parts of the brain to be calculated. dimer) and 99mTc-HMPAO (hexamethylpro-
CT angiography then reveals stenoses or penylene aminooxime) available. Both sub-
occlusions of the vessels so that, if neces- stances are almost equivalent.
sary, therapy can also be initiated immedi- ECD is used in questions about surviv-
ately with interventional reopening of the ing brain tissue after a cerebral infarction
vessels. because it does not accumulate in brain cells
that are still perfused but dead. Another
Magnetic Resonance Imaging (MRI) domain of ECD is inflammation diagnos-
MRI with its high soft tissue contrast is ide- tics. In addition, the contrast between gray
ally suited for clarifying the neurocranium. and white brain matter, especially in the
Here, the examination protocol, which temporal lobe, is better than with HMPAO.
always consists of several sequences, must Other possibilities for the determination
be adapted to the question. When asking for and visualization of rCBF lie in PET.
fresh infarcts, a diffusion measurement must For this purpose, 15O labelled water
be performed. For the question of old (H215O) or 15O-butanol can be used.
infarctions, T2w sequences are performed, However, these products have a very short
which are susceptible to susceptibility arti- half-­life of 2 min, so that a cyclotron must
facts (T2* or SWI). Sagittal flair sequences, be available in the immediate vicinity.
with which the configuration of the demye- Since rCBF is associated with regional
linating foci can be well delineated, are help- sugar metabolism, 18F-FDG can also be
ful in the clarification of MS. Contrast used.
medium, which is detectable in T1w Normal findings depend on the age of
sequences, is required for the clarification of the patient. Normally, the accumulation in
tumors and metastases, but also inflamma- the gray matter is 2–3 times higher than in
tory processes. the white matter.
In epilepsy diagnostics, the radiophar-
maceutical is injected during the seizure
(under EEG monitoring, if possible within
14.3.2 Nuclear Medicine 10 s), and the image is then recorded in the
phase after the seizure. During the seizure,
Ursula Blum
the focus is stronger than the surrounding
brain tissue (hyperperfused), while in the
Brain seizure-free interval it is usually weakened
Blood Flow, Regional Cerebral Blood (hypoperfused).
Flow (RCBF) In the case of reduced cerebral perfu-
Regional cerebral blood flow (rCBF) can be sion in the context of a TIA (transient isch-
visualized using various tracers. The ques- emic attack) or a PRIND (prolonged
tions range from focal imaging in epilepsy, reversible ischemic neurological deficit),
psychiatric diseases, a statement about the there are usually no conspicuous findings in
perfusion reserve of the brain in previous cross-­
­ sectional imaging. In the perfusion
TIA’s to brain death diagnostics. examination, a reduction in cerebral perfu-
Different areas of the brain are of par- sion in the affected section of the brain can
ticular interest for different questions, e.g. already be detected.
 154 C. Vockelmann et al.

If vasoconstriction in the brain is sus- kForms of Dementia, Localization in the

pected, the examination can be performed Cerebrum
with additional application of Diamox
– Alzheimer’s Bitemporal and/or
(1000 mg over 5 min i. v.). This reveals the
dementia: biparietal
so-called perfusion reserve of the brain.
Diamox dilates the arterioles, and perfusion – Lewy body Similar to Alzheimer’s
dementia: disease, additional visual
therefore increases significantly in a healthy
cortex
state of the vessels. If vasoconstriction is
present, the vessels are already maximally – Fronto-­temporal Frontotemporal
dementia:
dilated, so that increased perfusion cannot
occur in these regions. The examination – Vascular Multiple circumscribed
should be performed at the earliest 24 h after dementia: defects
a basic scintigraphy.
Dementia is characterized by reduced In brain death diagnostics (. Fig. 14.12),
blood flow in different regions of the the patient is placed directly on the camera
brain. and injected. This is followed by the creation

..      Fig. 14.12 Brain

death diagnosis HIRNPERFUSIONSZINTIGRAPHIE
Tc99m Neurolite

70 sec. p.i
Trunc
Trunc

14

35 min. p.i
Trunc Trunc
Neurology
155 14
of a dynamic sequence, as well as static Brain Tumors
images of the skull, thorax (including thy- Brain tumors (gliomas) are characterized by
roid and stomach) and, if necessary, a an increase in amino acid transporters.
SPECT. These can be visualized with radioactively
In these patients, the blood-brain barrier labeled amino acids.
is non-functional. There is no accumulation Three tracers are currently used,
in the brain at all. 11C-­methionine (MET), 3-123I-iodine-α-
The marking must be checked for qual- methyl-­ L-tyrosine (IMT) and
ity. This check should be carried out accord- 18F-­ethyltyrosine (FET). All tracers have not

ing to the kit manufacturer’s specifications yet been approved in Germany.

(e.g. thin layer chromatography). Indications include biopsy planning,
The images of the thorax must not show determination of the exact extent of the
any major accumulations in the thyroid tumor, therapy monitoring and recurrence
gland or stomach. These images also serve diagnosis (differentiation between necrosis
as a quality control, but are not sufficient as and tumor).
the sole quality control. A statement on the degree of malignancy
is not possible. The differentiation between
Neurodegenerative Diseases tumor and non-malignant changes or radio-
z Receptor Scintigraphy necrosis can be made by establishing quo-
Receptor scintigraphy is used in the diagno- tients. Here, the uptake in the tumor tissue is
sis of Parkinson’s disease. Especially in the significantly higher than in the other tissues
early stages of the disease, clinical differen- (depending on the tracer cA. 1.5 to 2.2 times
tiation from other diseases may be difficult. increased), in the context of therapy control,
Receptor scintigraphy can be used to distin- the quotient should fall by >10%.
guish idiopathic Parkinson’s disease (PD)
from atypical PD syndromes such as multi- z Meningiomas
system atrophy (MSA), progressive supra- Due to the somatostatin receptors, which
nuclear gaze palsy (PSP), and corticobasal are detectable in many meningiomas, these
degeneration (CBD). This distinction is changes can be detected with a somatostatin
important for the treatment of the disease receptor scintigraphy (111-In-Oxin). Here,
and the prognosis of the patient. the differential diagnosis to an acoustic neu-
SPECT tracers such as 123I-benzamide roma is in the foreground.
(IBZM) and 123I-ioflupane (FP-CIT), which
are commercially available in Germany, are CSF Space
used. CSF scintigraphy allows statements to be
Another decision option is the determi- made about the distribution, circulation,
nation of rCBF by means of 18F-FDG-PET, and any leaks or fistulas that may be pres-
which can accurately separate the diseases in ent. In addition, a statement about the func-
one examination (Hellwig, Meyer). tion of existing shunt systems is also
PET tracers are 18F-DOPA and possible.
18F-­Fallypride.
CSF scintigraphy is performed after ster-
The tracers differ in the binding site on ile puncture of the CSF space, usually the
the receptor system. lumbar region. Only very rarely is the punc-
 156 C. Vockelmann et al.

ture performed suboccipitally. The patient tamponade activity/blood activity quotient

should remain in bed after the puncture. is calculated. If this quotient is >2, a fistula
If leakage is suspected, tamponade of is present.
the nasal cavity is necessary. The tampon-
ades must be weighed before insertion into
the nose and after removal. After 24 h the 14.3.3 Valence
tamponade is removed or changed, here the
side indication is very important. The tam- Christel Vockelmann
ponades are measured in the borehole. In
addition, a blood sample must be taken in . Table 14.7 shows the use of the respec-
each case, as some of the tracer enters the tive therapeutic options depending on the
tamponades even without a fistula. Now the problem

.       Table 14.7 Value of the therapeutic procedures

Sonogra- Conven- Fluoroscopy/ CT MRI Nuk PET

phy tional Angiography

Acute stroke N N W P W N N
Dementia N N N P W W N
assessment
Brain death N N W N* W P N
diagnostics

N Not indicated, P Primary diagnosis, W Further diagnosis

N* Of course, every patient who is diagnosed with brain death will receive a computer tomography of the
skull. However, this cannot be used to diagnose brain death

14
Neurology
157 14
14.4 Therapy

14.4.1 Interventional Radiology

Christel Vockelmann

Angiographic Interventions
In acute occlusions of the proximal middle
cerebral artery with corresponding stroke
symptoms, the thrombus that led to the ves-
sel occlusion is removed with special suction
catheters and stent retrievers. For this pur-
pose, the internal carotid artery of the
affected side is probed via a femoral access
route. Via a long sluice, i.e. a working chan-
nel, the occluded vessel is visited and probed
with a microcatheter. The thrombus is then
removed by aspiration. Alternatively or
complementarily, the vessel is first released
by stent implantation. In this case, the
thrombus is initially only pushed to the side.
After a few minutes, the inserted stent, in
which the thrombus has then lodged, is
removed together with the thrombus.
Symptomatic stenoses of the internal
carotid artery, which are typically located
close to the origin, should be treated within
14 days after the initial event such as a TIA,
since the risk of a further event such as a
large infarction in the area supplied by the
middle cerebral artery is significantly
increased. The primary procedure is surgery
of the stenosis, indications for interven-
tional therapy by means of stent angioplasty
are restenosis after surgery, postradiogenic
stenosis or unfavorable anatomical condi-
tions such as a very short neck or a high
division of the carotid artery. For stent ..      Fig. 14.13 Carotid stent
angioplasty, a transfemoral approach with
insertion of a long sheath into the common a bifurcation-­bridging stent from the ACI to
carotid artery is also performed. Often, a the ACC, with the external carotid artery
wire-guided filter system is then first inserted being stented over (. Fig. 14.13). After
into the internal carotid artery above the ste- postdilation, the filter is then recaptured via
nosis to prevent possible intracranial emboli a retrieval system and the procedure can be
caused by detached plaque materials during terminated. To avoid a vasovagal reaction
the course of the intervention. The filter due to the dilatations—comparable to an
wire is then usually used for pre-dilatation external carotid pressure—0.5 mg atropine
before a stent is inserted. This is inserted as is applied i. v. before each dilatation.
 158 C. Vockelmann et al.

14.4.2 Radiotherapy Skull Base Meningiomas

55 Definitive radiotherapy of the meningi-
If a tumor can be treated surgically, it is usu- oma in case of inoperability or postop-
ally removed by neurosurgery and, if there erative radiotherapy of the residual
are residual findings, irradiated with or finding in case of incomplete tumor
without chemotherapy. removal. The 5-year progression-free
The following are used survival is 40–61% after subtotal sur-
55 Stereotaxy (e.g. for 1–3 brain metasta- gery and 68–95% with subsequent
ses) or the radiotherapy.
55 Proton therapy (e.g. for chordomas,
chondrosarcomas)  coustic Neuromas (Vestibular
A
Schwannomas)
z Side Effects 55 Radiotherapy of the tumor: The total
Appetite or sleep disturbances, optic nerve dose in conventional technique is around
in a stereotaxy >15 Gy → visual impairment 54 Gy (1.8–2 Gy/week). In the case of a
in about 1/3 d. F., acoustic neuroma (vestib- small tumor, 12–15 Gy are given stereo-
ular schwannoma) → hearing ability↓. tactically.

z Complications Pituitary Adenoma

Radionecrosis (therefore compliance with the 55 Definitive radiotherapy of the adenoma
absolute doses for the single dose of a maxi- in case of inoperability or postoperative
mum of 10 Gy per 10 mL of brain tissue). radiotherapy of the residual findings in
case of incomplete tumor removal
Gliomas 55 Conventional radiotherapy: 45–50 Gy
Glioblastoma (5 × 1.8–2.0 Gy/week)
z Therapy 55 Particle therapy for hormone-active
55 Definitive radiotherapy of the tumor in pituitary adenoma
case of inoperability and always postop- 55 Stereotaxy with 1 × or 3–5 × 5 Gy for
erative radiotherapy of the tumor bed. prolactinoma and ACTH-producing
Dose in each case 60 Gy (5 × 2 Gy/week) adenomas
or 40.05 Gy (5 × 2.67 Gy/week).
55 Chemotherapy, e.g. with temozolomide,
14 especially patients with an altered DNA Chordomas, Chondrosarcomas
repair enzyme MGMT benefit from this. of the Skull Base
55 Conventional RT: 48–66.6 Gy
Astrocytoma 55 Stereotaxy: 1 × 14-16 Gy
Definitive radiotherapy of the tumor in case 55 Protons, heavy ions (helium, carbon): 60
of inoperability or postoperative RT of the CGE–83 CGE
tumor remnant from WHO grade II. Dose
54–60 Gy each (5 × 1.8–2.0 Gy/week).
Craniopharyngeomas
Oligodendroglioma 55 Definitive radiotherapy of the tumor in
Definitive radiotherapy of the tumor in case case of inoperability or in case of resid-
of inoperability or postoperative RT of the ual tumor postoperative RT of the resid-
tumor remnant in WHO III, dose 54–60 Gy ual tumor, 54 Gy (5 × 1.8 Gy)
each (5 × 1.8–2.0 Gy/week). 55 Stereotaxy and particle therapy
Neurology
159 14
Childhood
Cerebrospinal Fluid Space hanging down. She immediately calls the
Investigations into medulloblastoma have emergency doctor. He suspects an acute
shown that at the time of diagnosis, 25–40% stroke. Since Mr. Asmacher woke up with
of tumor cells are floating in the CSF, and the symptoms, the time window, i.e. the
there is also a higher risk with germ cell exact onset of the symptoms, is unclear.
tumors. In these cases, the entire CSF space There is a so-called wake-up stroke.
is therefore irradiated. Nevertheless, the emergency physician
takes the patient to the nearest stroke unit
Whole Brain as quickly as possible and also announces
In leukemias, the entire brain is irradiated the patient there as an acute stroke. Here
due to the diffuse cell distribution. the patient is received by the neurologist
on duty, Dr. Hammer. After a quick
Brain Metastases anamnesis, Mr. Asmacher is first taken to
Therapy for Multiple Brain Metastases the CT. The native cranial CT suggests a
hyperdense media sign on the left as an
55 Multiple brain metastases: Whole brain
indication of a thrombotic occlusion of
irradiation
the cerebral artery, otherwise it is incon-
Therapy for 1–3 Brain Metastases spicuous. As the patient is otherwise in a
very good general condition, a CT perfu-
55 Surgery, whole brain radiation (increas-
sion and a CT angiography are performed
ingly with hippocampal excision and ste-
in addition. Perfusion imaging shows an
reotactic therapy of the individual
area at risk (called tissue at risk or penum-
metastases are used individually either
bra) in the middle mediastinal flow area,
solo or in combination).
but no demarcated area yet. CT angiogra-
55 Stereotaxy for deeper metastases up to
phy confirms occlusion of the left proxi-
3 cm in size, irradiated with high single
mal middle cerebral artery in the M1
dose, e.g. 1 × 15–24 Gy.
segment. Based on the good condition
and CT perfusion result, Dr. Hammer
Glioblastoma discusses with the wife and patient the
option of intravenous lysis with rtPA
In the case of glioblastoma, definitive radio-
despite the unclear time window.
therapy is given to the tumor if it is inoper-
Additionally, Dr. Hammer advises a
able, and always postoperative radiotherapy
thrombectomy to quickly reopen the ves-
to the tumor bed. The dose in each case is
sel. Both measures are initiated after a few
60 Gy (5 × 2 Gy/week) or 40.05 Gy
minutes of consideration. In the angiog-
(5 × 2.67 Gy/week).
raphy to which Mr. Asmacher is taken,
Brain Metastases the occlusion of the left cerebral artery is
still present. The thrombus is removed by
55 Whole Brain Irradiation.
means of a stent retriever. The symptoms
improved rapidly after the operation.
Case Study Subjectively, Mr. Asmacher is symptom-
free again after a few days. The MRI three
Volker Asmacher, 59, is woken up in the
days later shows only a few small puncti-
morning by the alarm clock. However, he
form diffusion disturbances in the supply
does not manage to switch off the alarm
area of the left cerebral artery. Bleeding
clock with his right hand. His wife notices
due to the lysis therapy did not occur.
that the right corner of his mouth is also
 160 C. Vockelmann et al.

Practice Questions 4. What differential diagnoses should

1. How to distinguish an epidural from a you be aware of for space-occupying
subdural hemorrhage? lesions in the cerebellopontine angle?
2. Which localizations of intracerebral
hemorrhage are called typical local- Solutions 7 Chap. 27
izations and what is the general cause
of these hemorrhages?
3. How can tumor-related edema be dis-
tinguished from ischemic edema on
native CT?

14
 161 15

Head/Neck
Martina Kahl-Scholz, Christel Vockelmann, Ursula Blum
and Guido Heilsberg

Contents

15.1 Anatomical Structures – 162

15.2 Disease Patterns – 163

15.2.1  ead – 163
H
15.2.2 Neck – 166

15.3 Diagnostics – 167

15.3.1  iagnostic Radiology – 167
D
15.3.2 Nuclear Medicine – 168
15.3.3 Valence – 168

15.4 Therapy – 169

15.4.1 Radiotherapy – 169

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 162 M. Kahl-Scholz et al.

This chapter deals with the essential possibili- gualis). The most prominent of these are the
ties of radiological diagnostics, nuclear medi- palatine tonsils, which are visible in the ton-
cine and radiotherapy for diagnostics and sillar fossa between the two palatine arches.
therapy in the area of the head and neck. An
introductory section provides a brief over- z Larynx (Larynx)
view of anatomy and function, and a con- The larynx consists of cartilage, ligaments
cluding section includes some practice and muscles. Important forming cartilages
questions on this topic. are the thyroid cartilage (Cartilago thyroi-
dea), the cricoid cartilage (Cartilago cri-
coidea) and the articular cartilage
15.1 Anatomical Structures (Cartilago arytenoidea). The epiglottis
closes the access to the trachea during swal-
Martina Kahl-Scholz lowing.
The skull (cranium) is formed by many
Important anatomical structures from the individual bones that have grown together in
“head/neck” area are above all the paranasal the course of development.
sinuses, the thyroid gland, lymph nodes and
salivary glands. z Skullcap (Calvaria)
The paranasal sinuses are the air-filled The skullcap is formed by
spaces in the bones close to the nasal cavity. 55 Parietal bone (Os parietale)
They correspond to the lightweight princi- 55 Occipital bone (Os occipitale)
ple. The sinuses include the maxillary sinus 55 Frontal bone (Os frontale)
(Sinus maxillaris), frontal sinus (Sinus fron-
talis), ethmoidal cells (Cellulae ethmoidales) These parts are joined together by sutures
and sphenoidal sinus (Sinus sphenoidales). (sutturae):
The major salivary glands include the 55 Sutura coronalis between frontal and
parotid gland (glandula parotidea), which is parietal bones
located in front of and behind the ear on the 55 Sutura sagitalis between the two parietal
mandible and mastoid process. The excre- bones
tory duct (ductus parotideus) opens into the 55 Sutura lambdoidea between parietal
oral cavity opposite the upper second molar. bones and occipital bone
Other large salivary glands are the subman- 55 Frontal sutura
dibular gland and sublingual gland. 55 Sutura squamosa between parietal bone
The minor salivary glands include the lip and temporal bone
15 glands (glandula labialis), palatal glands
(glandula palatinae), cheek glands (glandula z Facial Skull
buccales) and tongue glands (glandula lin- The facial skull is composed of the follow-
guales). ing bony parts:
Important components of the pharynx, 55 Frontal bone (Os frontale)
which consists mainly of muscles important 55 Nasal bone (Os nasale)
for the act of swallowing, are the tonsils, the 55 Sphenoid bone (Os spheniodale)
thyroid gland and the larynx. 55 Zygomatic bone (Os zygomaticum)
The lymphatic pharyngeal ring consists 55 Ethmoid bone (Os ethmoidale)
of several “defense stations”, which also 55 Temporal bone (Os temporale)
include the pharyngeal, palatine and lingual 55 Parietal bone (Os parietale)
tonsils (tonsilla palatina, pharyngea et lin- 55 Lacrimal bone (Os lacrimale)
Head/Neck
163 15
55 Upper jaw bone (maxilla) and pressure pain depending on the localiza-
55 Lower jaw bone (mandible) tion of the inflammation.

The orbit is formed by the Os sphenoidale, z Diagnostics

Os ethmoidale, Os lacrimale, Os frontale, Os Conventional X-ray (. Fig. 15.1)
zygomaticum and Maxilla. CT of the NNH (in case of complica-
tions or chronic inflammation)
55 Acute sinusitis: mucosal wall thickening
in the NNH, mirror/shadow formation
15.2 Disease Patterns of mucous effusions within the NNH
55 Chronic sinusitis: similar, possibly with
Martina Kahl-Scholz
polypous changes of the mucosa

Mucocele
15.2.1 Head In the case of a mucocele (. Fig. 15.2),
cysts form within the paranasal sinuses
Sinusitis which cannot empty because the openings in
This is an acute, sometimes chronic inflam- the sinuses are narrowed. If an infection
mation of the paranasal sinuses (NNH). occurs, this is called a pyocele.

z Clinic z Clinic
(Persistent) facial and headache, purulent Feeling of pressure, protrosio bulbi, possi-
secretion, difficult nasal breathing, tapping bly visual disturbances

a b

..      Fig. 15.1 a Sinusitis and b Pansinusitis in X-ray image

 164 M. Kahl-Scholz et al.

pharyngeal area and destruction of the bony

structures as well as a contrast image in the
MRI.

>>In case of unclear shadowing and bony

destruction, think of the possibility of a
nasopharyngeal tumor!

Orbit
These include benign (meningioma) or
..      Fig. 15.2 Mucocele of the NNH
malignant (retinoblastoma) space-­
occupying lesions in the orbital region.
z Diagnostics
z Clinic
Conventional X-ray
Frequent symptoms are the protrusion of
The paranasal sinus is dilated and
the eyeball (exophthalmos), mobility disor-
shaded, the walls thinned but not inter-
ders and possibly pain.
rupted.
z Diagnostics
>>DD mucocele shadowing vs. tumor
Both sonography (first diagnostic step) and
shadowing of the NNH: thinning of the
CT and MRI are used. There are the follow-
wall without destruction in mucocele!
ing characteristics:
55 Retinoblastoma: calcifications
CT Similarly, also extension of the NNH
55 Optic glioma: dilatation of the optic
and thinning of the wall visible.
canal
55 Optic meningioma: calcifications around
MRI Accumulation of mucous fluid without
the optic nerve
enhancement.

Tumors Salivary Glands

Nasopharyngeal Area The most common tumor is pleomorphic
These include benign (e.g. nasopharyngeal adenoma.
fibroma, polyp) and malignant (such as
nasal pharyngeal carcinoma) space-­z Clinic
Often the tumors remain silent for a long
15 occupying lesions of the nasopharynx.
time and do not cause any symptoms. In
z Clinic some cases, only a mass is initially notice-
Depending on the size and location of the able, sometimes with pressure pain. In the
tumor, various symptoms may occur, such later course, pain, fascial paresis, possibly
as obstruction of nasal breathing, ear pain, dry mouth and swelling of the lymph nodes
nasal dribbling, etc. may occur.

z Diagnostics z Diagnostics
CT/MRI Diagnostically, sonography, CT and MRI
For the diagnostic procedure mainly CT are used. Most conspicuous are inhomoge-
and MRI are used for correct differentia- neous parenchymal patterns and an enlarged
tion. Noticeable are shadowing in the naso- gland.
Head/Neck
165 15
Sialography In sialography, which can also taken in order to be able to assess the
be used to visualize salivary stones, the orifice zygomatic arch. However, CT should be
­
of the respective gland is probed with a fine given generous priority, especially if more
cannula and filled with KM to enable better complex fractures are suspected.
visualization in conventional X-rays, CT or
MRI. Middle Face
Midface fractures are classified according to
Fractures LeFort into:
Skull Base 55 LeFort I = basal detachment of the max-
Fractures of the skull base are divided into illa
frontobasal (frontal sinus posterior wall, 55 LeFort II = pyramidal detachment of
ethmoid roof, sphenoid sinus) and petrous the maxilla including the bony nose
fractures. 55 LeFort III = high avulsion of the entire
midfacial skeleton including the bony
z Clinic nose
The clinic varies depending on the location.
Cerebrospinal fluid (CSF) hemorrhages and z Clinic
cranial nerve deficits may occur, while frac- Occlusion disorders of the dentition may
tures of the temporal bone may lead to inju- occur. If the orbit is involved (LeFort II and
ries of the middle ear with the associated III), eye mobility may also be restricted and
clinical symptoms. bleeding may occur in the form of a mon-
ocular or spectacle hematoma.
z Diagnostics
CT/MRI z Diagnostics
CT and MRI are the best way to assess Conventional Radiography
the extent and course of the fracture. Co-­ Imaging of the NNH allows assessment
injuries to other structures and the entry of of the nasal skeleton, orbital walls, and
air (pneoencephalon) can also be detected in shadowing/mirroring (hematosinus). A lat-
this way. eral image allows co-assessment of the max-
X-ray illa, ethmoid cells and sphenoid sinus.
If a skull base fracture is suspected, a CT CT
is primarily indicated today; conventional In the case of a LeFort III injury, it is
X-rays are no longer performed in the con- useful to perform a CT scan to assess any
text of these questions. structures that may be involved.

Zygomatic Bone Orbital Floor

z Clinic In the case of an orbital fracture, if the force
Decreased sensation in the supply area of is applied directly to the eye, a so-called
the infraorbital nerve, motility disorders of blow-out fracture can occur, in which the
the bulb and difficulties in opening the orbital floor fractures and orbital contents
mouth may accompany a zygomatic fracture can enter the maxillary sinus.
clinically.
z Clinic
z Diagnostics The mobility of the eyeball, especially the
Conventional X-ray elevation of gaze, may be impeded by entrap-
Often, images of the paranasal sinuses ment of the muscles. Furthermore, enoph-
(NNH) or so-called bicipital images are thalmos and eyelid emphysema may occur.
 166 M. Kahl-Scholz et al.

z Clinic
Respiratory distress, expiratory/inspiratory
stridor.

z Diagnostics
Transillumination
This shows a lumen variation.
CT
A stenosis of the trachea can be detected
more precisely by means of CT, especially
since it is possible to assess directly what is
..      Fig. 15.3 Hanging drop in blow-out fracture
probably causing the narrowing (enlarged
thyroid gland, tumorous changes, etc.).
z Diagnostics
Conventional X-ray/CT/MRI Cervical Cyst
In all three imaging variants, the so-­ A distinction is made between the lateral (at
called “hanging drop” is the specific detec- the anterior border of the sternocleidomas-
tion (. Fig. 15.3). This refers to the contents toid muscle) and the median cervical cyst
of the orbit, which become visible on the (mainly in the region of the base of the
maxillary sinus roof. tongue).
Attention should be paid to whether a
foreign body (depending on the mechanism z Clinic
of the accident) may also be found. In addi- Mostly asymptomatic.
tion, mirror formation in the maxillary
sinus, orbital emphysema and shadowing of z Diagnostics
the ethmoid cells may occur, depending on Sonography
the localization of the fracture. This shows an anechoic lumen, a
smooth wall structure and a distal sound
amplification.
15.2.2 Neck CT
This is only used if sonographic imaging
Laryngocele is not possible.
These congenital dilations of the sacculus
laryngis may be air-filled or mucus-filled. Thyroid Gland
15 7 Chapter 21, Endocrinology
z Clinic
As a rule, there are no symptoms. In most Parathyroid Gland
cases, resistance can already be felt from the 7 Chapter 21, Endocrinology
outside.
Tumors
z Diagnostics Laryngeal Carcinoma
CT/MRI In ENT, laryngeal carcinoma is the most
CT/MRI allows good visualization of a common malignant tumor and is most likely
laryngocele as a hypodense structure. localized to the glottis itself.

Trachelastenosis z Clinic
This is understood to be the narrowing of This may be silent at first and then, depend-
the tracheal lumen. ing on the location, manifest as hoarseness,
Head/Neck
167 15
foreign body sensation, difficulty swallowing Conventional radiography plays a
and irritable cough. minor role in imaging of the neck. One of
the few possible indications is lateral imag-
z Diagnostics ing of the soft tissues of the neck to assess
CT calcifications and spondylophytes of the
A change in density in the tumorous tissue cervical spine leading to narrowing of the
and, depending on the extent, obliteration esophagus.
(i.e. spreading) of the anatomical fatty tissue
layers can be seen. Furthermore, the depth of Fluoroscopy/Angiography
infiltration and metastases can be detected. Fluoroscopic examinations of the neck can
MRI be performed to assess the pharynx and
This can also be used to assess depth and esophagus, and in particular the swallowing
metastasis. act. Rare indications are visualizations of
Sonography the lacrimal duct, here if necessary also with
Sonography is useful to investigate meta- the possibility of interventional therapy of
static spread to the cervical lymph nodes. stenoses.
Thyroid Carcinoma Computer Tomography (CT)
(7 Chapter 21) Conventional X-ray diagnostics often can-
not reliably differentiate between reduced
Salivary Gland Carcinoma pneumatization and inflammatory shadow-
(Section tumors) ing of the paranasal sinuses. Prior to surgi-
cal treatment of sinusitis, the ENT physician
would often also like to be able to assess the
15.3 Diagnostics bony anatomy of the paranasal sinuses, as
this is highly variable. For example, there are
15.3.1 Diagnostic Radiology patients in whom the carotid artery runs
elongated in the skull base and extends far
Christel Vockelmann into the sphenoid sinus with or even without
bony cover. The rhinobase, i.e. the bony
Sonography lamella between the frontal brain and the
Primary imaging for the examination of the nose, may also be of varying depth. This is
soft tissues of the neck with thyroid gland, elementarily important information for the
salivary glands and lymph nodes is sonogra- surgeon. For this reason, CT scanning of
phy. Color Doppler sonography is also used the paranasal sinuses is performed relatively
to assess blood flow. frequently. Since this involves bony struc-
tures and soft tissue swelling, i.e. findings
Conventional X-ray Diagnostics that have a high contrast, a low-dose CT of
A typical indication for X-ray diagnostics in the paranasal sinuses is sufficient for the
the head region is still the X-ray of the para- diagnosis of sinusitis or prior to surgery.
nasal sinuses. As a rule, this is only performed Computed tomography plays a particu-
in the occipito-mental beam path. The exam- larly important role in staging examina-
ination should be performed with the patient tions for tumor diseases or in acute
in a sitting position, since acute sinusitis leads diagnostics. All soft parts of the neck can
to fluid levels that cannot be detected in the be assessed, as well as the neck vessels and
X-ray image when the patient is lying down. bony structures.
 168 M. Kahl-Scholz et al.

Magnetic Resonance Imaging (MRI) Most cases are squamous cell carcino-
MRI is particularly suitable for diagnosing mas (95%). In larger tumors (T3 and 4) with
the soft tissues of the neck due to its high soft lymph node involvement, secondary tumors
tissue contrast. MRI can also be used to are not uncommon.
assess all soft tissues of the neck, as well as Normally squamous cell carcinoma
the neck vessels and bony structures. However, show good FDG storage. In primary diag-
in contrast to computed tomography, it is nostics, PET/CT increases the diagnostic
even more necessary to adapt the sequence sensitivity and specificity with regard to the
parameters as well as the slice direction and lymph node status. PET/CT is more impor-
the examination section to the questions. tant in the diagnosis of recurrence, and
PET/CT can also be helpful in determining
the extent of surgery or the radiation fields.
15.3.2 Nuclear Medicine Sentinel lymph node (SLN) imaging is
possible. The safety of SLN removal alone
Ursula Blum for early detected tumors has not yet been
sufficiently researched in comparison to
Tear duct scintigraphy and salivary gland standardized elective removal of the cervical
scintigraphy have been superseded in clinical lymph nodes and is currently only permissi-
diagnostics by radiological diagnostics, ble in the context of studies.
especially MRI. With PET-CT, however, a Skeletal scintigraphy is indicated only in
newer procedure is becoming increasingly individual cases.
important in tumor diagnostics.
The main risk factors for the develop-
ment of malignant diseases in the ENT area 15.3.3 Valence
are smoking or regular consumption of high-­
proof alcohol. In the combination of smok- Christel Vockelmann
ing and drinking, the risk increases up to 30
times that of the normal population (LL . Table 15.1 shows the use of the respective
Oncology 5/14/25). Other risk factors can be therapeutic options depending on the prob-
the HP virus, as well as poor oral hygiene. lem.

.       Table 15.1 Value of the therapeutic procedures

15 Sonography Conventional Fluoroscopy/ CT MRI Nuk PET

Angiography

Head and N N N P W N W
Neck Tumor
Sinusitis W P N W W N N
Dysphagia N N P* N W N N

N Not indicated, P Primary diagnosis, W Further diagnosis

P* High-frequency kinematography is the primary imaging method for dedicated swallowing disorders.
Of course, endoscopic diagnostics should always be performed first
Head/Neck
169 15
15.4 Therapy Oral Cavity Carcinoma (Carcinoma
of the Floor of the Mouth, Carcinoma
15.4.1 Radiotherapy of the Tongue)
Adjuvant radiotherapy or platinum-based
Guido Heilsberg radiochemotherapy is applied to the former
tumor bed 60–66 Gy and the lymphatic
Head/Neck Tumors drainage 54–60 Gy with 5 × 2.0 Gy per week
The irradiation of ENT tumors is nowadays as IMRT.
almost exclusively carried out with the aid of
IMRT (intensity-modulated radiotherapy). Hypopharyngeal Carcinoma
Usually both sides of the neck are irradiated. (Carcinoma of the Lower Pharynx)
It is important to undergo dental rehabilita- Oropharyngeal carcinoma section
tion in advance, because the teeth and gums are
affected by the radiation. The impact of the Laryngeal Carcinoma (Carcinoma
radiation on the implants/metal fillings causes of the Larynx)
additional scattered radiation, which stresses In advanced stages, primary radiotherapy or
the oral mucosa. The dental splint made must radiochemotherapy may be considered with
be worn during the daily radiation therapy ses- 56.25/63 Gy in stage T1 with 5 × 2.25 Gy per
sion and also serves to harden the tooth enamel week, 70 Gy from stage T2.
with the help of fluoride-containing gels and
thus make it more resistant to the radiation.
Case Study
In the case of aggressive therapy con-
cepts, a PEG system should be considered if
A 60-year-old truck driver who has been a
necessary.
heavy smoker since his youth has been com-
Acute side effects from radiotherapy
plaining of persistent hoarseness for about
include xerostomia, erythema, ageusia, and
two months, suffers from stridor (whistling
mucositis.
when breathing) and has lost 8 kg. His wife
Chronic side effects include: Xerostomia,
sends him to an ENT specialist, who finds a
permanent dark discoloration of the skin,
clearly visible tumor on laryngoscopy and
fibrosis, and lymphedema.
takes a biopsy. He also palpates a large swol-
len lymph node on the neck. The biopsy
Nasopharyngeal Carcinoma
reveals a PLECA of the larynx, and the
(Carcinoma of the Nasopharynx) patient is referred to radiation oncology. The
Nasopharyngeal carcinoma occurs predom- radiation oncologist presents the patient to
inantly in the form of PLECA (squamous an interdisciplinary tumor board to deter-
cell carcinoma) or lymphoepithelial carci- mine appropriate therapy depending on the
noma (Schmincke’s tumor). findings and in consultation with ENT spe-
Primary radiotherapy is combined with cialists. Due to the extensive findings, the
platinum-based concurrent chemotherapy and patient is recommended primary combined
a dose of 68–72 Gy at 5 × 2.0 Gy per week. radiochemotherapy to enable organ preser-
vation, including the vocal cords and larynx.
Oropharyngeal Carcinoma (Carcinoma The patient receives a PEG device in advance
of the Oral Cavity) in order to ensure nutrition during radio-
Simultaneous radiochemotherapy with cis- therapy, as the side effects, such as xerosto-
platin, 5-FU or MMC (mitomycin) as ther- mia and mucositis, are expected to worsen
apy of choice with 70–72 Gy with 5 × 2.0 Gy the nutritional situation.
per week as IMRT with chemotherapy.
 170 M. Kahl-Scholz et al.

Practice Questions 4. In what pathology is the “hanging

1. On imaging, what is a possible distin- drop” seen?
guishing feature between mucocele 5. For which problem is sialography
shadowing vs. carcinoma shadowing? used?
2. What are the key features that sono-
graphically indicate a neck cyst? Solutions 7 Chap. 27
3. How are midface fractures classified?

15
 171 16

Gynecology
Carla M. Kremers, Guido Heilsberg, Ursula Blum,
Christel Vockelmann and Martina Kahl-Scholz

Contents

16.1 Anatomical Structures – 172

16.2 Disease Patterns – 172

16.2.1  hest – 172
C
16.2.2 Small Basin – 177
16.2.3 Tumors of the Uterus – 178
16.2.4 External Female Genitalia – 183

16.3 Diagnostics – 183

16.3.1  iagnostic Radiology – 183
D
16.3.2 Nuclear Medicine – 185
16.3.3 Valence – 186

16.4 Therapy – 186

16.4.1 I nterventional Radiology – 186
16.4.2 Radiotherapy – 187

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 172 C. M. Kremers et al.

This chapter presents various options for the Breast Carcinoma

treatment and therapy of gynecological dis- Breast carcinoma is the most common malig-
eases. Diseases of the mammae are discussed nancy in women (a rare one, but possible in
as well as diseases of the pelvis. The diagnos- men) and continues to be a common cause of
tic and therapeutic options for the treatment death. In order to detect these tumors as early
of benign as well as malignant masses are as possible, there is (as the only preventive pro-
discussed. Diseases in young adulthood, gram working with X-rays) in Germany the
such as extrauterine pregnancy and adnexal mammography screening program. Women
torsion, are also discussed in this chapter. In between 50–69 years of age receive invitations
addition to the diagnostic and therapeutic by mail. If a woman decides to take part in the
procedures of radiology, nuclear medicine program, she will be examined at specialized
and radiation therapy procedures are also centers.
presented.
z Clinic
Breast carcinoma hardly causes any symp-
16.1 Anatomical Structures toms; only in very late stages can painful
retractions of the breast tissue or exulcerat-
Martina Kahl-Scholz ing masses occur.

In addition to the mammary gland, the z Diagnostics

female reproductive organs include the ova- Sonography (. Fig. 16.1)
ries, uterus, vagina and labia. If a mass is detected in the breast, sonog-
The mammary gland consists mainly of raphy is usually performed first. A breast
fatty and connective tissue, the skin with the carcinoma can then be delineated as an
areola mammae and the nipple (papilla echo-poor, blurred round focus, possibly
mammaria). From puberty onwards, the tis- with dorsal sound extinction and above all
sue increases in size in women. with interruption of the longitudinal connec-
The ovary is about the size of a plum tive tissue structures (Cooper’s ligaments).
and is located in the side wall of the pelvis Mammography
in the ovary fossa. From it originates the Mammograms of both breasts are taken in
fallopian tube (tuba uterina), which is about two planes and examined independently by
10–15 cm long and ends in the uterus two specialist radiologists. In case of any
(womb). The uterus is pear-shaped and is abnormality, the woman is asked to present
divided into the body (corpus uteri) and the herself again for a supplementary examination.
cervix uteri. The latter passes into the Mammographic signs of breast carci-
vagina (vagina), which is about 10 cm long noma are (. Fig. 16.2)
16 and leads to the labia majora et minora 55 Grouped or segmentally arranged micro-
pudendi and the vaginal vestibule (vestibu- calcifications
lum vaginae). 55 A blurred, possibly spiculated focal find-
ing in two planes
55 Architectural abnormalities such as a
tent sign (zipfelf-shaped gathering of
16.2 Disease Patterns mammary gland tissue)
55 A thickening of the cutis or nipple and a
16.2.1 Chest nipple retraction
55 An asymmetry compared to the opposite
Carla M. Kremers side
Gynecology
173 16

a b

..      Fig. 16.1 a,b Breast carcinoma on sonography. sponding to Cooper’s ligaments – are not displaced
The echo-poor focus with dorsal sound extinction is but interrupted. (With kind permission of Dr. Göb)
not sharply delineated. The reflex-rich stripes – corre-

a b

..      Fig. 16.2 Multicentric breast carcinoma. At least three foci are visible, some of which show microcalcifica-
tions. Adjacent to the cranially located focus in mlo projection, a cutaneous retraction and can also be seen

Unfortunately, however, even in the case of clarification of circumscribed compressions,

a round, smoothly circumscribed round supplementary magnification target images
focus, a carcinoma cannot be excluded and of the conspicuous area can equalize over-
further clarification is necessary. For further lays.
 174 C. M. Kremers et al.

In order to indicate the density and thus In addition to native T1 and T2

the assessability of the breast, a grading sequences, dynamic contrast medium series
based on the American College of Radiology are also prepared, i.e. after a native T1
criteria is given (. Table 16.1). sequence, contrast medium is applied i.v.
The higher the classification, the more and the sequence is repeated several times at
difficult the examination is to assess and the different times in order to subsequently
easier it is to overlook a focal finding. assess the contrast medium dynamics at spe-
Suspected malignancy is also graded cific locations. The contrast-enhancing focal
using such a scheme, the Breast Imaging findings can then be detected with the aid of
Reporting And Data System (. Table 16.2). subtraction. For this purpose, the native
series is subtracted from a series with con-
MRI Further unclear findings (e.g. due to trast medium enhancement. What remains
dense mammary gland tissue) or malignan- is an almost black image in which only the
cies, the extent of which cannot be assessed structures that absorb contrast agent are
beyond doubt, require an additional MRI illuminated. Fuzzy, spiculated foci with
mammogram. To avoid motion artifacts, rapid, inhomogeneous, possibly ring-shaped
the patients lie prone on a coil that leaves contrast uptake and rapid contrast washout
one chamber free for each breast. The are suspicious. The Göttingen score has
mammae are additionally compressed in been established for assessing the dignity of
these chambers. contrast-­absorbing lesions in MR mam-
mography (. Tables 16.3 and 16.4).

Biopsy Suspicious focal findings are clari-

..      Table 16.1 American college of radiology
criteria fied with a histological examination. Biopsies
can be performed sonographically, mammo-
ACR1 Predominantly fatty, easily assessable graphically or by MRI. To ensure that the
tissue location of the biopsy can be found again
ACR2 Predominantly fibroglandular tissue after the biopsy or after neoadjuvant therapy,
small metal clips are often inserted during the
ACR3 Inhomogeneous dense tissue
biopsy to mark the location.
ACR4 Extremely dense fabric If breast-conserving therapy (BET) is
planned, the malignant or suspicious lesion

.       Table 16.2 Breast imaging reporting and data system

BI-­RADS 0 No classification possible, further imaging necessary

16 BI-­RADS 1 No conspicuousness
BI-­RADS 2 Descriptive but not malignant findings
BI-­RADS 3 Unclear, probably benign findings Follow-up in six months
BI-­RADS 4 Findings requiring clarification, biopsy recommended
BI-­RADS 5 Highly suspicious findings, biopsy recommended
BI-RADS 6 histologically confirmed carcinoma
Gynecology
175 16

.       Table 16.3 Göttingen score scheme

Zero Points One Point Two Points

Initial contrast agent enrichment <50% 50–100% >100%

Postinitial contrast agent behavior Further KM recording Plateau Wash out
(>+10%) (+/−10%) (<−10%)
Contrast agent distribution Homogeneous Inhomogeneous Annular
Form Round, oval Irregular, dendritic
Limitation Sharp Fuzzy

z Clinic
.       Table 16.4 Score evaluation Mostly asymptomatic.
0–1 Point MRM Certainly benign
z Diagnostics
BIRADS 1
Sonography
2 Points MRM Probably On sonography (which should be the
BIRADS 2 benign
method of first choice in young women),
3 Points MRM Unclear they are smooth-bordered, low-echo, and
BIRADS 3 respect the connective tissue layers of the
4−5 Points MRM Probably breast, i.e., they displace but do not break
BIRADS 4 malignant through Cooper’s ligaments. Due to hor-
6–8 Points MRM Certainly mone sensitivity, their size may fluctuate
BIRADS 5 malignant under hormonal influence. If the findings
remain unclear or the lesion shows a ten-
dency to grow, a biopsy is indicated.
Mammography
can be marked using a thin wire In mammography, fibroadenomas are
(. Fig. 16.3) to allow the surgeon to locate also round and smoothly limited in all
and safely remove it. planes. They often contain coarse calcifica-
tions, which facilitates their diagnosis. The
Galactography A possible symptom of displacement of surrounding tissue by com-
breast carcinoma is a (bloody) secretion from pression during mammography can cause a
the nipple. If the focus cannot be detected halo effect, i.e. a ring-shaped lightening
using the above methods, galactography is around the lesion.
used. For this purpose, a thin button cannula
is inserted into the secretory milk duct and Cysts
iodine-­containing contrast medium is injected These are also possible in the breast. More
above it. An intraductal mass can be detected often they occur in the context of fibrocystic
on the basis of the contrast medium recesses mastopathy.
within the milk duct.
z Clinic
Fibroadenoma Mostly asymptomatic.
Fibroadenomas are common benign masses
of the mamma and occur mainly in women z Diagnostics
of reproductive age. Sonography
 176 C. M. Kremers et al.

a b

..      Fig. 16.3 Checking the position of a wire marker the clip or the microcalcifications have been removed
before surgery. After partial resection of the breast, in their entirety – if parts are missing, resection is nec-
the removed tissue is examined again to check whether essary

A definite sonographic diagnosis is possi- of multiple cysts, which makes the breast
ble if the lesion is round, smooth bordered, unclear in all imaging. Due to hormone sen-
anechoic with dorsal sound enhancement. Also sitivity, size variations of the existing lesions
a cyst does not break through Cooper’s liga- are possible.
ments. Further clarification is not n ­ ecessary.
Mammography z Clinic
On mammography, cysts can be delin- Depending on the cycle, feelings of tension
eated as homogeneously compacted, round, and pain can occur.
smoothly circumscribed masses that may
exhibit a halo effect similar to a fibroadenoma z Diagnostics
16 due to displacement of the surrounding tissue. Sonography
Sonographically, the cystic lesions can be
Fibrocystic Mastopathy easily recognized and distinguished from
Fibrocystic mastopathy makes breast diag- solid structures. Again, care must be taken
nosis difficult. It is a remodeling of the that the cysts do not contain any solid por-
mammary gland tissue with fibrotic altera- tions, which may correspond to precancer-
tion of the connective tissue and formation ous lesions.
Gynecology
177 16
Mammography (plasma cell-rich infiltrate, often asymp-
In mammography, a juxtaposition of tomatic) are linear, lancet-shaped calcifica-
patchy shadows is found, which makes it dif- tions.
ficult to differentiate between individual
foci. In addition, microcalcifications may
occur, which, however, are not grouped, but 16.2.2 Small Basin
are diffusely distributed. If grouped micro-
calcifications can be demarcated, they are Tumors of the Ovary
suspicious and require clarification. Ovarian tumors can take very different
MRI forms from solid to cystic due to different
In MRI, multiple diffusely distributed, histological entities (different ovarian
partly planar contrast images can be delin- tumors as well as metastases are possible).
eated, which show a rather slow enhance-
ment. z Clinic
Due to the lack of early symptoms, they are
Mastitis (Plasma Cell Mastitis) often noticed late.
Mastitis is a bacterial inflammation of the
breast (mastitis puerpalis) that usually z Diagnostics (. Figs. 16.4 and 16.5)
occurs during lactation. If such an inflam- Ovarian cysts are so named only from a
mation occurs independently of the breast- diameter of 3 cm. Smaller lesions are usually
feeding period, it is referred to as non-puerpal functional cysts (or follicular cysts). Larger
mastitis. cystic findings may be benign cystadenoma.
Although this is primarily benign, it can
z Clinic degenerate into malignancy and is then
Pain, redness, swelling, possibly fever, chills, called cystdenocarcinoma. Ovarian cysts
malaise. should therefore be further clarified.
In all imaging, septations are usually
z Diagnostics seen in cystadenomas. In addition, the con-
Sonography/Mammography tent is not always water-equivalent, i.e. sono-
Radiological imaging is not necessary for graphically echo-poor but not echo-free or
puerpal mastitis. Sonographic controls, possibly T1w hyperintense or in CT around
which are mostly carried out by the col- 15–25 HU. Solid, contrast-enriched areas
leagues of the gynecology, clarify whether indicate the presence of cystadenocarci-
an abscess is present. noma.
Mastitis non-puerpalis must be differen- In contrast to cystadenocarcinomas,
tiated from the special form of breast carci- masses of the ovary can also be solid. In
noma, the inflammatory breast carcinoma. principle, any solid mass of the ovary is con-
Clinically and mammographically, mastitis sidered suspicious. It is usually detected by
and inflammatory breast carcinoma look (endovaginal) sonography. MRI is the
very similar: in addition to a thickened cutis, method of choice for further assessment of
a diffusely condensed breast parenchyma a lesion that cannot be classified with cer-
can also be seen. If the clinical course and tainty by sonography. If a carcinoma is sus-
imaging are not conclusive, a biopsy may be pected, a primary CT is indicated for staging.
necessary. Depending on the definition, an extra-
Typical mammographic findings of an uterine pregnancy is also a mass in the
expired so-called plasma cell mastitis ovary – it should not normally stray into
 178 C. M. Kremers et al.

a b

..      Fig. 16.4 CT images of a cystadenoma originating from the right ovary. From the image alone, no distinc-
tion can be made between a cystadenocarcinoma and a cystadenoma

a b

..      Fig. 16.5 Largely solid mass of the left ovary. The finding was surgically removed. It was a dermoid

radiology. In women and girls of childbear- amniotic sac including embryo in the area of
16 ing age with lower abdominal pain and pos- the adnexa may also be visible.
sibly pressure pain resistance, a β-HCG test
should shed light on the situation.
Complementary sonography may show an 16.2.3 Tumors of the Uterus
empty uterine cavity or a pseudo-gestational
sac (a circumscribed accumulation of fluid Fibroids
in the cavity) if β-HCG is positive. Myomas are extremely common and fortu-
Depending on the size and position of the nately benign masses in the female genita-
embryo, a dilated tube and possibly an lia – they are most frequently found in the
Gynecology
179 16
uterus, but vaginal localization is also pos- lack of oxygen and hopefully no longer
sible, for example. They are hormone-­ stands in the way of the patient.
sensitive tumors that occur at childbearing
age. Polyps
Within the uterus, they are further classi- Polyps can occur in the uterus and cervix.
fied based on their location: submucosal They are usually noticed during the gyneco-
fibroids grow into the cavum uteri. logical examination. Sonographically, they
Intramural fibroids, as the name suggests, can be delimited by an echo and are usually
are located within the uterine wall and sub- an incidental finding without relevance.
serosal fibroids grow on the outside of the
uterus. Myomas may be pedunculated and Carcinoma of the Corpus
cause similar discomfort to tubal torsion Corpus carcinomas (= endometrial carcino-
during pedicle rotation. mas) are conspicuous by postmenopausal
bleeding and sometimes lower abdominal
z Diagnostics discomfort and are diagnosed during gyne-
Sonography cological examination (colposcopy/abrasio).
In all imaging, fibroids are round and
have smooth borders. Due to frequent calci- z Diagnostics
fication and sometimes fat deposits the Sonography may reveal a focal widening of
internal structure may appear inhomoge- the endometrium with an echo. If further
neous. Sonographically they are predomi- diagnosis of the local findings is necessary
nantly hypodense (if necessary with acoustic for therapy planning, MRI is the method of
effacements) and usually the sonographic choice in which the extension and possibly
imaging is already sufficient. infiltration into or even into surrounding
MRI structures can be assessed (. Fig. 16.6).
On MRI, fibroids are primarily hypoin- Important lymph node stations here are
tense to the uterine musculature in both T1w
and T2w. The pattern may become very
inhomogeneous in case of calcification, fatty
deposits or hemorrhage.
CT
On CT, fibroids stand out as secondary
findings; they are then smoothly circum-
scribed, usually calcified masses in or on the
uterus.
In contrast medium-supported examina-
tions they show a strong (arterial) contrast
medium accumulation. This effect can be
used in the treatment of symptomatic
fibroids (those that cause pain or abnormal
bleeding): One possible form of therapy is
embolization of fibroids. In this procedure,
the artery supplying the fibroid is probed
with a catheter and then sealed with the help ..      Fig. 16.6 CT of an endometroid growing uterine
of small particles. The myoma dies from the carcinoma
 180 C. M. Kremers et al.

above all locoregional, parailiac and sacral attention should be paid to lymph node
lymph nodes. However, direct exposure to enlargements (predominantly parametranal,
retroperitoneal and para-aortic lymph nodes sacral and inguinal, possibly para-aortic). If
is also possible. malignancy is detected, CT can be used to
search for distant metastases.
Cervical Carcinoma
Cervical carcinoma is ideally detected dur- Endometriosis
ing the annual gynecological check-up. Endometriomas are to be understood as
uterine mucosa scattered in unusual places,
z Diagnostics (. Fig. 16.7) which, depending on the cycle, undergoes
Endosonography is often sufficient for imag- the same cycle of formation and degrada-
ing, in which the mass can be recognized as tion as the normal endometrium. They are
an echo-poor area. Larger findings can lead also called chocolate cysts because of their
to an obstruction of the cervix and thus to thick old-blooded brown content.
hydrometra. If hydrometra is detected as an
incidental finding on a CT scan in a post- z Clinic
menopausal woman, a supplementary gyne- The patients often complain of menstrual
cological examination should therefore be pain and are accordingly examined by a
performed. If further pre-therapeutic imag- gynecologist.
ing is required after sonography, MRI is
indicated to assess the local finding and its z Diagnostics
spread. In T2w, a hypointense area is then Sonography
noticed in contrast to the rest of the cervix. In sonography, a very inhomogeneous
It is important to assess the extension: does mass can be delineated, which shows no sig-
it grow into adjacent structures? Is the sur- nal (i.e. no blood flow) in the Doppler flow
rounding fatty tissue inconspicuous (i.e. measurement.
bright in T2w)? Is there a fat lamella between MRI
the rectum and the bladder? In addition, In the case of atypical location of endo-
metriomas (i.e. not in or on the female geni-
tals, but for example in the abdominal wall),
the search continues with MRI. In
T2-weighting, a mirror image can be indica-
tive in the case of larger findings: in the case
of overall fluid filling, the blood degradation
products (T2w hypointense) collect at the
bottom of the mass and the upper portion is
16 T2w hyperintense, as is appropriate for fluid.
For smaller nodules, T1 weighting is helpful:
due to the bloody content, the signal in T1
weighting is hyperintense. In order to be able
to distinguish it from any surrounding fatty
tissue, a fat-saturated, T1-weighted sequence
should be performed (fat is then shown
hypointense, i.e. dark). In addition, endome-
..      Fig. 16.7 T2-weighted image of a cervical carci- triosis lesions also absorb contrast medium
noma at the left dorsal circumference of the cervix and can thus be detected.
Gynecology
181 16
Cysts z Clinic
Cysts exist in the female genital tract in var- It leads to bleeding disorders and is usually
ious locations. Physiologically, follicular diagnosed on the basis of the gynecological
cysts of different sizes are found in the ova- examination. Pain and fever.
ries of childbearing women. One speaks of
an ovarian cyst only when the lesion is larger z Diagnostics
than 3 cm. Cysts in the cervix are called Sonography
ovula nabothi. They can grow up to 1 cm in Sonographically, the endometrium is
size. In the vagina, there are cysts that origi- shown to be odematous (echo-poor) thick-
nate from the Garnter ducts. They are called ened. Frequently there is involvement of the
Gartner cysts. myometrium.
In myometritis, the myometrium is cor-
z Clinic respondingly widened oedematously. If fluid
Depending on size, mostly unspecific. is deposited – e.g. due to a swollen cervix—
this is referred to as hydro-, hemato- or pyo-
z Diagnostics (. Fig. 16.8) metra, depending on the type of fluid
As in all other organs, cysts in the lesser pel- (. Fig. 16.9). While hydrometra is sono-
vis should be fluid filled, round, smooth bor- graphically imaged as anechoic fluid reten-
dered and delineated with a filmy wall. In tion, blood and pus collections are anechoic.
sonography they are anechoic. In MRI water Further imaging is rarely necessary.
T1w hypointense and T2w hyperintense. In MRI
CT the density values should be around 0 In MRI, the inflamed uterine parts will
HU. show a signal increase in T2w and a signal
It is sufficient to know that they are phys- decrease in T1w due to their edema in addi-
iologically present and have little pathologi- tion to a widening. After administration of
cal relevance. contrast medium there is a strong enhance-
ment. The content of a hydrometra is fluid
Inflammatory Changes isointense in MRI, thus hyperintense in T2w
Endometritis and hypointense in T1w. A hematometra is
Endometritis refers to inflammation of the conspicuous by high signal intensity in T1
inner layer of the uterus. weighting with otherwise liquid content

a b

..      Fig. 16.8 CT of a young patient with several large ovarian cysts in coronary and axial sectioning.
a Coronary, b Axial
 182 C. M. Kremers et al.

filled with fluid. In this case, depending on

the fluid, one speaks of a hydro-, hemato- or
pyosalpinx.
The imaging of these fluids is analogous
to the accumulation of fluid in the cavum
uteri (see above).
MRI
In MRI, inflammatory edema leads to a
signal increase in T2w and a signal decrease
in T1w, just as in the uterus. In order to
make such edematous changes particularly
well visible, “fat-saturated” T2-weighted
..      Fig. 16.9 CT in sagittal slice guidance showing a
sequences can be used, in which the fat is
uterus filled with fluid in hematometra. The fluid has a then imaged hypointense and only fluids (i.e.
density of approx. 50 HU also an edema) remain bright (hyperin-
tense). The increased blood flow due to
(T2w hyperintense). The signal of a pyome- inflammation is correspondingly noticeable
tra varies depending on the protein content. by a strong accumulation of contrast
Often air inclusions are detectable and an medium.
edge accentuated contrast uptake. CT
CT Usually, cross-sectional imaging also
CT reveals a thickened uterus with strong reveals edema in the surrounding adipose
contrast uptake. The contents of the uterus tissue; on CT, this may be the only evidence
can be further evaluated by its density values of inflammation of the adnexa
if sufficiently filled (water approx. 0 HU, pus (. Fig. 16.10).
>10 HU and blood >30 HU).

Adnexitis
Adnexitis is an inflammation of the ovary
and the tube. If only the tube is inflamed, it
is called salpingitis, and if the ovary is
inflamed in isolation, it is called oophoritis.

z Clinic
Primarily, there is an edematous swelling of
the respective organ accompanied by local
16 pain.

z Diagnostics
Sonography
In ultrasound, the respective structure is ..      Fig. 16.10 CT of a patient with lower abdominal
then inhomogeneous due to the edema and pain and significantly elevated inflammatory parame-
ters. Several fluid formations can be seen, some with
predominantly echo-poor. Due to drainage vigorous contrast uptake in the marginal area and
obstacles, e.g. due to inflammation or in the some with air inclusions. Several tuboovarian
case of scarred structures, the tube may be abscesses were involved
Gynecology
183 16
Torsions 16.3 Diagnostics
z Clinic
A torsion of the tube or ovary is followed by 16.3.1 Diagnostic Radiology
a strong, sudden (usually with a jerky move-
ment) onset and unilateral lower abdominal Christel Vockelmann
pain (accompanying nausea or vomiting are
also possible) with otherwise unremarkable Sonography
laboratory parameters. Ideally, the history Besides the internal genitals, the female (and
alone is sufficient to seek contact with the also male) mammary gland belongs to the
gynecologist – especially since this is a gyne- field of gynecology. In the examination of
cological emergency that requires immediate the mamma, sonography is part of the basic
surgical repair to prevent infarction of the diagnostics in addition to the clinical exami-
organ. Pedunculated cysts or fibroids can nation including palpation of the breast.
also cause similar complaints. Sonography of the breast requires a high-­
resolution transducer (7.5 MHz). Both
z Diagnostics breasts are examined in detail, usually once
Sonography completely transversally and in the second
Sonographically, the respective organ is direction sagittally. As an additional plane,
edematously swollen and in duplex sonogra- especially in the case of existing findings, an
phy the blood flow (in contrast to inflamma- alignment of the transducer to the nipple is
tion) is reduced or absent. Accompanying suitable. In this orientation, milk ducts in
ascites (fluid in the Douglas space) is often the breast can be delineated in the course.
seen. In case of complaints, especially in
CT younger patients (<30 years), sonography is
In the cross-sectional image (in this the most important examination modality.
case, a CT is more likely to be requested On the basis of the findings then available, a
due to the acute onset of symptoms and decision is made about possible further
clinical impairment), the lack of contrast diagnostics.
medium accumulation can be groundbreak-
ing due to the vessels occluded by the stran- Conventional X-ray Diagnostics
gulation. Mammography is the standard in breast
diagnostics with the exception of younger
patients. As the only X-ray examination to
16.2.4 External Female Genitalia date, mammography is also used as a screen-
ing method in Germany. All women between
The external genitals can be adequately 50 and 69 years of age are invited for screen-
imaged on the basis of the gynecological ing. In this population group, it has been
examination, if necessary with the aid of proven that screening with mammography
sonography. In the case of tumors of the can save lives through early diagnosis.
vulva and vagina, radiology is rarely Mammography screening may only be per-
required for the diagnosis of spread or infil- formed by certified screening units. The
tration. Then it is important to identify the mammograms must meet strict quality
tumor spread and the involved structures as requirements. The MTRA working in a
precisely as possible. MRI is then the imag- screening unit must have undergone special
ing of choice. further training and a certification course
 184 C. M. Kremers et al.

“Specialist for Mammography Diagnostics”. from different angles. From these images,
A double diagnosis is carried out by two simple back projection (remember: back pro-
specialized and certified radiologists. jection also existed in CT image calculation)
Discrepant findings are discussed by a third is used to calculate layered images of the
radiologist and a consensus conference. In breast that are free of superimposition. At
addition to screening, typical indications for present, the procedure is only used by a few,
the performance of a so-called curative mainly large clinics. Tomosynthesis is not yet
mammography are suspicious palpation used in routine diagnostics. Advantages are
findings or complaints. offered above all in the case of breasts with
very dense glandular parenchyma, where the
>>Screening mammograms in asymptom- assessability is considerably limited due to
atic women may only be performed by the numerous superimpositions in conven-
certified screening units. tional mammograms.

Another special feature of mammography is Magnetic Resonance Imaging

the use of the very soft X-rays between Magnetic resonance imaging has been an
25–30 kV. Compression is also a special fea- established procedure in the diagnosis of
ture of mammography. This achieves, on the certain breast changes for several years. Not
one hand, a reduction in scattered radiation. every conspicuous finding is examined in
The second effect is a homogenization of the conventional mammography. The indication
thickness of the breast, which of course is for an MRI examination of the breast is on
normally much thicker near the chest wall the one hand the young patient with very
than in the area of the nipple. dense breasts and a high risk of disease. The
Galactography is available as a further confirmed lobular carcinoma is often exam-
diagnostic option. With the advent of MR ined in MRI in order to exclude secondary
mammography, this procedure has moved findings. A classic indication for MRI is the
into the background. However, in the case differentiation between a scar after breast
of bloody galactorrhoea and otherwise surgery and a recurrence of a breast carci-
inconspicuous imaging, there are still indi- noma.
cations for this procedure. The image itself The examination is performed in a spe-
corresponds to that of the “normal” mam- cial mammography coil. The patient lies on
mogram. Beforehand, however, the radiolo- her chest during the examination, and there
gist probes the milk duct with a thin cannula, are two recesses in the coil for the two
e.g. the plastic cannula of a blue Viggo, and breasts. The breasts are fixed in these to min-
injects contrast medium into it. The goal is imize breathing artefacts. The administra-
to find contrast gaps in the milk ducts that tion of contrast medium is obligatory during
indicate a papilloma. Papillomas are basi-
16 cally benign tumors, but they have a certain
the examination in order to achieve a
dynamic examination of the breast. The
potential for degeneration and are therefore background to this is that breast carcinomas
operated on in most cases. show an early contrast medium enhance-
ment 1–3 min after contrast medium admin-
Computed Tomography istration, and in the later sequences generally
Computer tomography plays no role in show a washout or even a plateau phase of
breast diagnostics. Digital tomosynthesis is a the contrast medium. Benign tumors, on the
new procedure that is ultimately also based other hand, tend to accumulate contrast
on images acquired with the aid of X-rays. medium less strongly, but increasingly in the
To generate the image, images are first taken course of the examination.
Gynecology
185 16
>>An MRI examination of the breast In the case of extensive tumor stages,
always requires the administration of a preoperative chemotherapy is administered
contrast medium. first. If necessary, the sentinel lymph node is
marked and removed before chemotherapy.
After chemotherapy, the sentinel lymph
16.3.2 Nuclear Medicine node may be pathologically false negative.
Skeletal scintigraphy is usually per-
Ursula Blum formed postoperatively as a staging exami-
nation.
In gynecology, nuclear medicine examina- If disseminated skeletal metastases are
tions are mainly required after the diagnosis found, palliative pain therapy, e.g. with
of a malignant disease. samarium, can be performed.
Rarely, questions about renal outflow in A PET/CT examination is currently not
the case of anatomical malformations or recommended in primary diagnostics.
after surgical interventions (extensive oper- However, there is a benefit in the diagnosis
ations of the lower abdomen, e.g. removal of local recurrence and mediastinal or para-
of the uterus with removal of the ovaries sternal lymph node metastases. In the detec-
and lymph nodes). The determination of tion of distant metastases, PET/CT appears
the side-separated kidney function can also superior to other methods in some cases;
be useful in the context of chemotherapy exceptions are small lung metastases
or a planned radiation of the abdominal (<10 mm) or brain metastases. PET/CT
cavity. also plays an important role in therapy
monitoring.
Breast Carcinoma
As part of preoperative diagnostics, sentinel Vulvar Carcinoma
lymph node scintigraphy (SLS, 7 Chap. 22) If vulvar carcinoma is confirmed (biopti-
is a standard examination in breast centers. cally), SLN diagnostics can be performed
A distinction is made here between a proto- preoperatively if the lymph node status is
col on the day before surgery and a protocol clinically inconspicuous. In this case, 4 (-6)
on the day of surgery. In accordance with activity depots are injected intracutaneously
the Directive on Protection against Damage around the primary tumor. The images were
by Ionizing Radiation (StrSchV), it must be taken dynamically as well as statically up to
ensured that the activity in the patient at the one hour after the injection. The first pre-
time of surgery does not exceed the exemp- senting lymph nodes should be marked on
tion limit of 10 MBq. In addition, there are the skin. Matching is performed during sur-
different injection techniques (intradermal, gery with the gamma probe.
subdermal, peritumoral, subaureolar, peri- Further imaging diagnostics is only nec-
areolar). So far, no injection technique essary for special questions from stage
seems to be superior with regard to the visu- FIGO III.
alization of axillary lymph nodes. In the
context of purely dermal and aureolar  LN Diagnostics in Other
S
injections, sentinel lymph nodes outside the Gynecological Tumors
axilla (e.g. parasternal) may not be detected. Recent studies show that SLN imaging
However, these lymph nodes are usually not could also be helpful for other gynecological
surgically removed. The highest correct tumors (cervical carcinoma, uterine carci-
visualization of the SLN is achieved with noma). Further studies still have to prove
T1 and T2 tumors. the benefit.
 186 C. M. Kremers et al.

.       Table 16.5 Value of the therapeutic procedures

Sonography Conventional Fluoroscopy/ CT MRI Nuk PET

Angiography

Primary diagnostics P P N N W N N
breast carcinoma
Vulvar cancer P* N N W W W W
Ovarian cancer P N N P N W W

N Not indicated, P Primary diagnosis, W Further diagnosis

P* Transvaginal endosonography

Ovarian Carcinomas
Here, too, FDG-PET/CT can be used in pri-
mary diagnostics, recurrence diagnostics
and therapy monitoring.

16.3.3 Valence

Christel Vockelmann

. Table 16.5 shows the use of the respective

therapeutic options depending on the prob- ..      Fig. 16.11 Prepared device for vacuum aspiration
lem. biopsy with 11G biopsy needle

table which has a hole for the breast to be

16.4 Therapy examined. The corresponding breast hangs
through this hole. A mammography device
16.4.1 Interventional Radiology is set up under the table. This is used to
take two oblique images of the lesion to be
Christel Vockelmann biopsied, usually malignant microcalcifi-
cations, in order to localize the pathologi-
cal findings. In these two images, the
16 Stereotactic Vacuum Suction radiologist marks the calcification. The
Biopsy of the Breast stored computer program can then deter-
Stereotaxy is a diagnostic rather than a mine the depth of the lesion in the breast
therapeutic procedure. Today, it generally and the access route from the two mark-
replaces the open surgical mammary ings. After local anesthesia and a stab inci-
biopsy in the case of focal findings that sion, the radiologist inserts the biopsy
could not already be punched sonographi- needle, most commonly an 11-G needle,
cally (usually by the gynecologist). The with a trocar to just in front of the lesion.
biopsy is mammographically guided. The . Figure 16.11 shows prepared vacuum
patient usually lies on an examination suction device.
Gynecology
187 16

..      Fig. 16.12 Stereotactic control images with biopsy

needle in front of the microcalcification group to be
biopsied

After another X-ray to check the posi-

tion, the biopsy needle is released
(. Fig. 16.12). ..      Fig. 16.13 Punch biopsies taken with microcalcifi-
Then at least 12 samples are taken. The cations in several samples
breast tissue is sucked through the vacuum
into the biopsy channel and then cut out
with the needle and taken. For the next sam-
ple, the needle is rotated a little so that ulti-
mately samples are taken all around the
needle.
Then the needle in the trocar is with-
drawn slightly and a control image is taken.
Often, no more microcalcifications can be
detected at this point. In this case, a clip
should be inserted through the trocar into
the sampling area. If the biopsy reveals a
malignancy, a follow-up operation must be
performed. The clip is then used to operate
on the correct area. ..      Fig. 16.14 Preparation after surgery with wire and
The samples obtained with the vacuum clip in preparation
suction biopsy are first x-rayed using the
mammography technique. This serves to
send the specimens with microcalcifications 16.4.2 Radiotherapy
(. Fig. 16.13) to the pathologist separately,
since a particularly complex processing must Guido Heilsberg
be carried out here.
If a stereotactically biopsied area has to Cervical Carcinoma
be reoperated, the clip left behind is Indications for radiation are: positive lymph
marked with a wire (. Fig. 16.14). The node involvement, tumor size over 4 cm,
localization for the wire insertion is done from FIGO III primary radiochemotherapy
in the same way as for stereotaxy. The wire is usually performed as combined tele- and
then serves the surgeon as a guide to the brachytherapy, adenocarcinoma, R1/2, or
surgical area. narrow tumor-free resection margin.
 188 C. M. Kremers et al.

55 Percutaneous radiotherapy total dose radiotherapy in combination with brachy-

45–50.4 Gy, single dose 1.8–2 Gy/5× therapy (afterloading).
weekly. Primary percutaneous radiotherapy of
55 HDR brachytherapy with Ir-192 with the lesser pelvis 40 Gy with 5 × 1.8 Gy per
GD 30–42.5 Gy/5–9 Gy per fraction week as pelvic box, or 4 × per week if as
combination therapy with afterloading
Side effects: vaginal and anal mucosal reac- started after a dose of 20 Gy by percutane-
tions, diarrhea, rectitis, frequent emptying ous irradiation. Blocking out of the central
of the bladder. structures during percutaneous irradiation
at the start of afterloading in order to avoid
Breast Carcinoma exceeding the tolerance doses.
Breast-Conserving Therapy 50 Gy, 5 × 1.8– The patient is placed in the supine posi-
2.0 Gy/week, the target volume includes the tion, her legs are padded with a standard
entire mammary gland tissue and the adja- pad, and her arms are placed on her chest.
cent thoracic wall. Boost can reduce the
recurrence rate in the breast for invasive carci- Vulvar Carcinoma
nomas, i.e. no boost is given for DCIS. The Primary radiotherapy of the vulva and both
boost dose is (10)-16 Gy 5 × 1.8–2.0 Gy/week. groins up to 50 Gy (for N0) with 5 × 2.0 Gy
The local saturation can be applied as elec- per week, boost of the primary up to 60 Gy.
tron standing field, photon standing field or In case of lymph node involvement: in addi-
tangent, in mixed-­beam technique (electrons tion to the groin, irradiation of the lymph
and photons) or as integrated boost (SIB, nodes in the pelvic region with 45–50 Gy, if
simultaneous integrated boost). necessary boost with 10–20 Gy to the
affected lymph nodes. Postoperatively as
Mastectomy 50 Gy, 5 × 1.8–2.0 Gy/week, adjuvant radiotherapy to the primaries and
the target volume encloses the thoracic wall, if necessary the inguinal lymph nodes
including the surgical scar with safety margin. 50–60 Gy with 5 × 1.8 Gy per week.
The patient is placed in the supine posi-
Irradiation of the Regional Lymph Drainage tion, her legs are padded with a knee roll
System Only in case of residual tumor in the and spread apart in the frog position, her
axilla or >3 affected lymph nodes. Total dose arms are placed on her chest.
approx. 50 Gy, 5 × 1.8–2.0 Gy/week.
Positioning is in the supine position, e.g.
Case Study
on a special “mammaboard” and with knee
padding for the legs. The arms are taken Mrs. Zucker had a breast carcinoma two
above the head, comfortably and reproduc- years ago. The regular follow-ups were
16 ibly positioned. In the planning CT the scar
should be marked with a wire marker.
always fine. Now, however, the radiolo-
gist has discovered a new compression in
Side effects: Redness of the skin and the area of the old surgical scar. What
swelling of the irradiated breast, moist epi- procedures or interventions should be
theliolysis, esophagitis, pneumonitis, cardiac used to clarify the findings? MR mam-
arrhythmias. mography is a suitable imaging proce-
dure for differentiating between a scar
Vaginal Carcinoma
and a recurrence. If the findings are also
Primary radiotherapy depends on the size conspicuous in MR mammography, a
and location of the tumor and can help to vacuum suction biopsy or punch biopsy
preserve the vagina and its function. The is performed.
primary therapy concept is percutaneous
Gynecology
189 16

Practice Questions T2-weighted sequences, the fat

1. What imaging signs would make you appears hypointense and the fluids
think of breast carcinoma on sonog- that are seen are bright (hyperin-
raphy? tense). Furthermore, a strong con-
2. What do you need to think about dif- trast enhancement is seen. What does
ferential diagnosis of mastitis? this finding indicate and what is your
3. What are the treatment options for tentative diagnosis?
fibroids? 5. What are the indications for radio-
4. You will see a signal increase in T2w therapy in breast cancer?
and a signal decrease in T1w in the
adnexa on MRI. In the “fat-­saturated” Solutions 7 Chap. 27
 191 17

Respiratory System
Martina Kahl-Scholz, Christel Vockelmann and Ursula Blum

Contents

17.1 Anatomical Structures – 192

17.1.1 Trachea and Lungs (Pulmo) – 192

17.2 Disease Patterns – 192

17.2.1  leura – 192
P
17.2.2 Emphysema – 195
17.2.3 Bronchiectasis – 195
17.2.4 Pulmonary Oedema – 196
17.2.5 Pulmonary Fibrosis – 197
17.2.6 Infectious Diseases – 197
17.2.7 Interstitial Lung Disease – 201
17.2.8 Pneumonitis Radiation – 202
17.2.9 Lymphangiosis Carcinomatosa – 203
17.2.10 ARDS – 203
17.2.11 Sarcoidosis – 203
17.2.12 Tumors – 204
17.2.13 Pulmonary Embolism – 207
17.2.14 Childhood – 208

17.3 Diagnostics – 209

17.3.1  iagnostic Radiology – 209
D
17.3.2 Nuclear Medicine – 210
17.3.3 Valence – 212

17.4 Therapy – 213

17.4.1 I nterventional Radiology – 213
17.4.2 Radiotherapy – 213

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 192 M. Kahl-Scholz et al.

This chapter deals with the main possibili- three lobes and, in contrast to the left lung,
ties of radiological diagnostics, nuclear is limited caudally by the liver pushing the
medicine and radiotherapy for the diagnosis diaphragm further upwards.
and therapy of the respiratory system. An The bronchus principalis dexter and sin-
introductory section provides a brief over- ister divide into 2–3 lobe bronchi as they
view of anatomy and function, and a con- pass through the lung, and these in turn
cluding section contains some case studies divide into 2–5 segmental bronchi.
from practice.
>>Right lung: three lobes, ten segments.
Left lung: two lobes, 8–10 segments.
17.1 Anatomical Structures
A special structure of both lungs is the area
Martina Kahl-Scholz in which the vessels and main bronchi move
in and out, the so-called lung clearing
(hilus).
17.1.1 Trachea and Lungs (Pulmo) In the right lung the bronchus principalis
dexter, the Vv. pulmonalis, A. pulmonalis
The trachea extends about 12 cm from the pass through the hilus, in the left lung the
larynx to the bronchi of the lungs. It is made bronchus principalis sinister as well as like-
up of alternating cartilaginous clasps (carti- wise the A. pulmonalis and the Vv. pulmo-
lagines tracheales) and annular ligaments nalis correspond.
(ligg. anularia) that open backwards and
can thus move along when the lung expands
downwards during inhalation or when the 17.2 Disease Patterns
larynx moves upwards during swallowing or
when the head is tilted backwards. The pos- 17.2.1 Pleura
terior part of the cartilaginous braces is
completed by muscles (Mm. trachealis). Pleural Effusion
The trachea divides into a left and right In a pleural effusion, fluid is found in the
main bronchus (bronchus principalis dexter pleural cavity (>20 mL).
et sinistra). The site of division is called the
bifurcatio trachea and the spur-like protru- z Clinic
sion that arises there is called the carina tra- Pleural effusion is usually a concomitant of
chea. The right main bronchus has a much another disease, such as pneumonia, heart
steeper course than the left, so that when the failure or carcinoma. The clinical manifesta-
airway is obstructed by foreign bodies (aspi- tions are dyspnoea and an attenuated breath
ration), the right main bronchus is more fre- sound.
quently affected. Within the lung, the
17 bronchial tree divides further and further,
see below.
z Diagnostics
Conventional X-ray
The lungs are divided into the right and 55 Standing: Fluid collects on the dorsal
left lungs. The left lung, in turn, is divided aspect of the phrenicocostal recess. With
into two lobes (lobus) and is slightly smaller small amounts <150 mL it may be diffi-
than the right lung because much of the cult to detect the effusion at all. Basal
heart lies against it from the medial side and homogeneous shadowing occurs
takes up space. The right lung is divided into (. Fig. 17.1).
Respiratory System
193 17

a b

..      Fig. 17.1 Pleural effusion. a posterior-anterior. b lateral

55 Lying down: Here the effusion is distrib- z Clinic

uted and pleural space widening occurs. Depending on the underlying disease.
However, if the patient is lying on his
back, an effusion can only be detected z Diagnostics
above 500 mL. Possible signs then are a Conventional X-ray
widening of the pleural border, a blurred Calluses can be seen as shadowing in two
diaphragmatic contour and a shadowing planes in the X-ray thorax. Extent, localiza-
of the lateral sinus. tion and degree of calcification of a pleural
callus often indicate the cause: api-
Sonography cal = probably due to expired pneumonia or
Transthoracic sonography can also be tuberculosis; basal = most likely pleural
used to try to diagnose pleural effusion in effusion.
patients (especially those who are bedrid-
den). In this case, anechoic parts of the >>A distinction callus vs. effusion is possible
pleura are visible. by taking the picture in lateral position:
CT the effusion runs out laterally at the tho-
CT allows detection of even small racic wall, the callus remains unchanged.
amounts of fluid. It is also possible to deter-
mine whether the fluid is transudate or exu- Pneumothorax
date, which in turn allows conclusions to be If air enters the pleural space, it is called a
drawn about the underlying disease. pneumothorax. A distinction is made
between:
>><10 U=transudate, >10 U=exudate. 55 closed pneumothorax (no external
injuries are responsible for the pneu-
Pleural Callosity mothorax, the air leakage is from the
This is a scar-like change of the pleura, lungs),
which can be of different genesis (traumatic, 55 open pneumothorax (air enters due to
inflammatory, vascular, degenerative). external trauma),
 194 M. Kahl-Scholz et al.

55 partial pneumothorax (there is a partial

collapse of the lung tissue),
55 total pneumothorax (complete collapse
of the lungs),
55 seropneumothorax (with additional fluid
accumulation),
–– hematopneumothorax (there is addi-
tional bleeding),
–– pyopneumothorax (with purulent
effusion),
55 spontaneous pneumothorax (occurs for
no apparent reason),
55 bilateral pneumothorax (both lungs are
affected).

The cause may be trauma, chronic lung

changes such as asthma or emphysema, or
an iatrogenic cause.

z Clinic ..      Fig. 17.2 Mantle pneumothrax

Depending on the severity of the pneumo-
thorax, there is shortness of breath and stab-
bing pain as well as a dry cough.

z Diagnostics
Conventional X-ray
A pneumothorax appears on X-ray as a
transparent structure free of pulmonary ves-
sels. In a mantle pneumothorax (. Fig. 17.2,
pneumothorax in the form of a flat air man-
tle; is often silent percutorily and ausculta-
torily) only a narrow air line (so-called
hairline) parallel to the thoracic wall is seen.

>>The air often collects in the top of the

lungs, even in small amounts, so a stand-
ing and expiratory intake is useful.

We speak of a tip pneumothorax when only

17 a small amount of air enters the pleural
space, which is then found mainly (see
..      Fig. 17.3 Tip pneumothorax
above) in the tip of the lung (. Fig. 17.3).
In seropneumothorax there is also a fluid
level. of a tension pneumothorax, immediate
In tension pneumothorax, the lung is relief by means of a drainage is necessary.
completely collapsed and the mediastinum In an emergency, an indwelling venous
is displaced to the opposite side. In the case cannula in the 2nd or 3rd ICR in the
Respiratory System
195 17
medioclavicular line is also sufficient if the 2. Panlobular emphysema = mostly genetic
patient goes into shock in your radiology (congenital deficiency of alpha-­ 1-­
department. antitrypsin), localized in the lower part
of the lung
Mesothelioma 3. Old-age emphysema = lungs lose elastic-
Mesothelioma is a malignant tumor origi- ity with increasing age
nating from the mesothelium of the pleura,
which is frequently associated with exposure z Clinic
to asbestos. It is then a notifiable occupa- Cough, dyspnoea (especially on exertion)
tional disease. and fassthorax.

z Clinic z Diagnostics
At the beginning of the disease there are no Conventional X-ray (. Fig. 17.4)
or only nonspecific symptoms. In the further In order to be able to detect emphysema
course there is increasing thoracic pain. on a normal X-ray, it must already be in an
advanced stage, otherwise it is difficult to
z Diagnostics distinguish between emphysema and “nor-
Conventional X-ray mal lung”.
There may be an accompanying pleural Important signs of emphysema are:
effusion (section pleural effusion). 55 increased lung transparency or rarified
Furthermore, in the further course of the vascular bed
disease, elongated or garland-like pleural 55 flattened diaphragmatic domes
thickening and extensive growth may be seen 55 enlarged retrosternal space and sterno-
on the X-ray. vertebral diameter (also called deep
CT diameter)
CT can be used primarily to examine the
extent and course of the disease. Here, a CT
pleural thickening encompassing the entire CT may be able to detect bullous changes
inner thoracic wall, nodular contours and earlier than conventional X-ray.
possibly the involvement of the septa can
also be seen. Furthermore, pleural calcifica-
tions and effusions may be manifested. 17.2.3 Bronchiectasis

This leads to irreversible dilatation of the

17.2.2 Emphysema bronchial tubes.

Lung emphysema is the irreversible over-­ z Clinic

expansion of the smallest air-filled struc- Cough, sputum (“mouthful expectoration”
tures. It represents the endpoint of a number with three-layer sputum: foamy, mucous,
of chronic lung diseases (COPD, bronchial purulent), recurrent infections, possibly
asthma). A distinction is made between the drumstick finger.
following forms:
1. Centrilobular emphysema = most com- z Diagnostics
mon type, COPD-­associated, localized in Conventional X-ray
the upper part of the lung with the for- There are streaky condensations follow-
mation of larger emphysema bubbles and ing the course of the bronchovascular struc-
dilatation of the bronchiolii respiratorii. tures, so-called tram lines (rail track
 196 M. Kahl-Scholz et al.

a b

..      Fig. 17.4 Lung emphysema. a pa. b Lateral

a b

..      Fig. 17.5 a,b Bronchiectasis on CT

phenomenon) due to thickened bronchial method is almost completely replaced by

walls, ring shadows due to saccularly dilated CT.
bronchi.
CT (. Fig. 17.5)
17 Dilated bronchi, possibly punctate/ 17.2.4 Pulmonary Oedema
finger-­shaped/micronodular condensations
(due to mucus-filled dilated bronchi) can be There is an accumulation of fluid in the
detected. lungs, which can be interstitial or interalveo-
Bronchiography lar. Often an underlying cardiac disease is
KM is applied via the bronchoscope to the cause, but also drugs, infections or carci-
visualize the bronchial tree. However, this nomas can cause pulmonary edema.
Respiratory System
197 17
z Clinic
Dyspnoea, cough (cardiac asthma), rales,
possibly tachycardia, cyanosis, pallor.

z Diagnostics
Conventional X-ray
The x-ray shows the following character-
istics:
55 Kerley B/C line = interstitial edema in
the interlobular septa in the form of a
reticular pattern.
55 “Frosted glass phenomenon” due to
intralobular edema.
55 Peribronchial cuffing = edema formation
in the peribronchial interstitium.
55 “washed-out” hilus. ..      Fig. 17.6 Pulmonary fibrosis with bronchiectasis
55 Subpleural edema.
position in order to avoid reduced ventila-
tion due to positioning.
17.2.5 Pulmonary Fibrosis

Pulmonary fibrosis, which can be caused by

various pathologies (e.g. ARDS, sarcoid-
17.2.6 Infectious Diseases
osis), leads to irreversible fibrotic remodel-
Pneumonia
ing of the lung.
Pneumonia describes an inflammation of
z Clinic the lung tissue. Pneumonias are divided into
Initially, exertional dyspnea, tachypnea, and the following forms:
a dry, irritable cough may be present. Later, 1. Alveolar pneumonia: the inflammation
cyanosis, drumstick fingers, clock glass nails is located within the alveoli of the lungs
and cor pulmonale as well as terminal respi- –– Bronchopneumonia = multifocal
ratory insufficiency may develop. focal pneumonia, usually in several
lobes of the lung
z Diagnostics –– Lobar pneumonia = affection of an
Conventional X-ray/CT (. Fig. 17.6) entire lobe of the lung (further subdi-
The x-ray usually shows a proliferation vision into lower lobe, middle lobe
of drawings in the lung structure. Due to and upper lobe pneumonia)
connective tissue remodeling of the paren- 2. Interstitial pneumonia: the inflammation
chyma, the lung borders shift cranially. This is localized in the interstitium, often
can also be seen in the X-ray thorax in the called atypical pneumonia
form of fixed and raised diaphragmatic –– Acute interstitial
legs. In late stages a honeycomb lung is –– Chronic interstitial
present. The structure of the lung can be 3. Community-acquired pneumonia
determined even more precisely than with 4. Nosocomial acquired pneumonia
an X-ray examination by means of a high- 5. Primary pneumonia
resolution computer tomography. In spe- 6. Secondary pneumonia (due to an exist-
cial cases, this is performed in the prone ing underlying disease)
 198 M. Kahl-Scholz et al.

z Clinic z Diagnostics (. Fig. 17.7)

Increased respiratory rate, possibly dyspnea, Conventional X-ray
fever, cough (dry or productive depending The radiographic signs of pneumonia depend
on etiology). on the type of pneumonia (. Table 17.1).

a b
Cu - Fil ter

17

..      Fig. 17.7 Types of pneumonia. a Lobar pneumonia. b, c Lower lobe pneumonia

Respiratory System
199 17

.       Table 17.1 Types of pneumonia

Interstitial Pneumonia Alveolar Pneumonia Fungal Pneumonia

Broncho Pneumonia Lobar
Pneumonia
– 
Interstitial Confluent shading Segmental – 
Aspergilloma: homogeneous
shadowing pattern shading round shadow with ring-/
due to thickening of sickle-­shaped air accumulation
the interlobular – 
Candidiasis: infiltrates in the
septa bronchiopulmonary region
– 
Predominantly – 
Hematogenous seeding: even
strip-shaped distribution throughout the lungs
condensations – 
Pneumocystis carinii: interstitial
– 
Finely-spotted foci drawing proliferation, initially
– 
Diffuse milky glassy mainly perihilar, then rapid
haze spread to mid/lower field
– 
Extensive shadowing in the area of
the lung lobes
– 
Shading sharply defined by the lobe
borders, blurred to the rest of the
parenchyma

CT also called Ghon’s focus. Possibly a primary

Similar to conventional X-ray. cavern develops, which can spread broncho-
genically or hematogenically, with “minimal
Tuberculosis lesions” in the lung, which often appear as
Tuberculosis (short: Tbc or Tb) is an infec- spotted shadows in the lung apex (=Simon
tious disease that is most often caused by apex) and possibly other organs. Assmann’s
Mycobacterium tuberculosis. The bacteria are early infiltrates (=flat, infraclavicular Felck’s
mainly transmitted by air, so that the lungs shadows) are, in addition to the reactivation
are often affected first. However, organ man- of Simon’s lace foci, a sign of post-primary
ifestation and involvement of the nervous TB.
system can also occur in the further course of An expired TB is often indicated by a
the disease. The following stages of the dis- calcified primary complex on x-ray.
ease can be distinguished (. Table 17.2). CT
If primary tuberculosis is suspected, a
z Clinic chest CT may be performed for a more spe-
B-symptomatics, in case of formation of a cific diagnosis.
pulmonary primary complex: cough,
hemoptysis, local lymph node swelling, dys- Ascaridosis
pnoea. Roundworm infestation with Ascaris lum-
bricoides is widespread worldwide (it is esti-
z Diagnostics mated that about ¼ of the population is
Conventional X-ray (. Fig. 17.8) infected). Transmission is oral (and then via
The X-ray shows the so-called primary the small intestine and bloodstream, includ-
complex (usually intrapulmonary), which is ing to the lungs).
 200 M. Kahl-Scholz et al.

.       Table 17.2 Stages of tuberculosis

Stage Designation Clinic Radiological Signs

I Latent Positive tuberculin Primary complex (=Ghon hearth)

tuberculous reaction without
infection evidence of organ
findings
II Primary Symptomatology due When spreading, it can come to the scattering in the
tuberculosis to a first organ bronchial system possibly also in other organs. In the
manifestation lungs: shadowing and ring shadows (caverns), possibly
atelectasis, pleurisy, Simon foci
III Postprimary Organ tuberculosis Most often, first reactivation of Simon spikes foci,
TB due to endogenous which melt down and break into the bronchial system.
reactivation Then there is expansion to the lungs and other organs

a b

..      Fig. 17.8 a,b Tbc in the posttuberculous state with (b) scar

z Clinic some drugs such as penicillin). It is present

Bronchitis, shortness of breath, intestinal when the infiltrate is no longer detectable
colic and diarrhoea, loss of appetite, possi- after a maximum of ten days, eosinophilia is
17 bly allergic skin reactions. present, and relatively mild (pulmonary)
symptoms are present.
z Diagnostics (. Fig. 17.9)
Conventional X-ray Echinococcal Infection
Confluent spot shadows that “migrate Echinococcosis can be caused by different
across the lung” are seen on the X-ray. This echinococci, but Echinococcus cysticus (dog
migration is also called Löffler infiltrate tapeworm) and Echinococcus multilocularis
(. Fig. 17.9) (which can also occur with (fox tapeworm) are the most likely.
Respiratory System
201 17
a b

..      Fig. 17.9 Löffler infiltrate in ascaridosis. (a) Middle lobe, (b) Lower lobe

z Clinic Silicosis
Especially the liver and lungs are affected. Silicosis refers to pathological changes in
There can be years of symptomlessness. The the lungs caused by long-term inhalation of
larvae (hyatids) can form a cyst, which can quartz dust particles (silica crystals).
cause pain when ruptured. Furthermore, Silicosis is an occupational disease for which
coughing and dyspnoea may occur and, compensation is payable.
depending on the size of the hyatids, tissue
may be displaced. z Clinic
The disease can be asymptomatic for years/
z Diagnostics decades. Acute symptoms are dyspnoea,
Conventional X-ray cyanosis, chest pain and cough. Signs of a
Individual, smooth-edged round foci chronic course are lung rigidity (due to scar-
appear, which are homogeneous. After cyst ring), shortness of breath, dry cough, possi-
rupture, a water level may also be visible on bly dark sputum.
which the echinococcus wall floats (so-called
water lily sign). Sometimes there is also the z Diagnostics
formation of a so-called meniscus sign, if Conventional X-ray
the membrane does not lie tightly against Initially, the lung pattern is enhanced.
the capsule wall, but some air exists in Later, especially in the middle and upper
between. lung field, dense spotted shadows develop,
the so-called silicosis nodules.
The following breakdown by size is made
17.2.7 Interstitial Lung Disease (. Table 17.3):
As the disease progresses, the spotted
Interstitial lung disease (ILD) affects the shadows may become more pronounced and
interstitial tissue of the lungs and the alve- calcifications may be added (so-called shot
oli. Pneumoconiosis (also known as “pneu- lung).
moconiosis”) is the term used to describe Scarring leads to emphysema areas and
lung diseases caused by the inhalation of larger calluses. A so-called eggshell silicosis
dust and its deposition in the lungs. develops due to shell-like calcifications
 202 M. Kahl-Scholz et al.

Organic Dusts
..      Table 17.3 Size classification of stain
shadows in silicosis Exogenous allergic alveolitis is an allergic
inflammation of the alveoli triggered by
Abbreviation Meaning Size in mm inhalation of fine dust (e.g. organic dusts
such as molds, chemical substances).
P Pinhead 1.5
Q Micronodular 1.5–3 z Clinic
R Nodular 3–10
A few hours after exposure there is fever,
cough, dyspnea.

z Diagnostics
Conventional X-ray
under the capsule of the lymph nodes, espe- An X-ray is rather unspecific, especially
cially at the pulmonary hilus. in the early stages, and can be difficult to dis-
CT tinguish from pneumonia of a different ori-
CT allows earlier and more accurate gin. There may be streaky or nodular
detection of the changes caused by silicosis confluent changes in the lower and middle
(see above). fields of the lung.
CT
Asbestosis For a precise diagnosis (which should
Asbestosis is caused by inhalation of dust always be made in the context of the other
containing asbestos (fiber length >5 μm, anamnestic parameters such as lung
fiber thickness <3 μm), which may also have function test, laboratory values, etc.), a
­
carcinogenic effects. high-­resolution CT (HR-CT) should be per-
formed. This also makes it possible to dif-
z Clinic ferentiate between inflammatory and already
In most cases, dyspnoea, dyspnoea, sputum scarred areas.
and cyanosis may occur years to decades
after exposure. Later, a general lung insuffi-
ciency with disability may result. 17.2.8 Pneumonitis Radiation
z Diagnostics Irradiation of tumors in the thoracic region
Conventional X-ray can lead to co-irradiation of the lungs and,
The X-ray shows fibrosis of the middle as a result, to reactive-toxic inflammation.
and lower fields with a reticulated, striated
spread. In contrast, emphysema (7 Sect. z Clinic
17.2.2) is often seen in the upper lung field. The symptoms are divided into an early and
Pleural plaques and calcifications may also a late phase. The early phase may be asymp-
be seen. tomatic, possibly accompanied by irritable
17 CT cough, dyspnoea and pain. Either healing
CT allows earlier and more accurate or, with repeated exposure, remodeling of
detection of the changes caused by silicosis the lung tissue and permanent pulmonary
(see above). fibrosis then occur.
Respiratory System
203 17
z Diagnostics 17.2.10 ARDS
Conventional X-ray
In the early phase, a homogeneous shad- Acute respiratory distress syndrome
owing of the affected area is seen. In the (ARDS) is an acute and life-threatening
later, fibrotic state, striated scars with shrink- lung dysfunction that can be caused by
age of the lung tissue are formed. The extent shock, aspiration, sepsis, etc. The ARDS is
of the change corresponds very exactly to classified into four stages (. Table 17.4).
the (mostly angular) radiation field. ARDS is divided into four stages
(. Table 17.4).

17.2.9 Lymphangiosis z Clinic

Carcinomatosa Depending on the underlying cause, dys-
pnea, cyanosis…
Lymphangiosis carcinomatosa manifests
itself in the lungs as malignant interstitial z Diagnostics
lung disease, but can also affect other areas Conventional X-ray (. Fig. 17.11)
such as the skin (e.g. the mamma). The can- . Table 17.4, there is initially patchy
cer cells spread along the lymphatic vessels. indistinct compression (without cardiac
enlargement or pleural effusion) in the sense
z Clinic of edema, which then changes to a reticular
B-symptomatics, possibly dyspnea. pattern in the final stage.

z Diagnostics
Conventional X-ray/CT (. Fig. 17.10) 17.2.11 Sarcoidosis
A reticular pattern with fine nodular con-
densations is seen, possibly accompanied by Sarcoidosis (also known as Boeck’s disease)
a pleural effusion (section Pleural effusion). is an inflammation, the cause of which is not

a b

..      Fig. 17.10 a Lymphangiosis carcinomatosa on the right in BC; b Basally accentuated lymphangiosis
carcinomatosa on both sides
 204 M. Kahl-Scholz et al.

.       Table 17.4 Stages of ARDS

Phase Time Description Radiological Signs

Course

Initial Phase Until 1 h Formation of interstitial Blotchy fuzzy condensations

pulmonary edema
Early Stage 1–24 h Alveolar pulmonary edema, Rapid fusion to homogeneous compactions
microthrombi…
Intermediate 1–7 days Microatelectasis, fibroblast Regression to spotty shading
Phase proliferation
Late Stage >7 days Pulmonary fibrosis Regression of the spotted shadows, reticular
pattern (=irreversible fibrosis)

a b

..      Fig. 17.11 ARDS. a Stage II, b Stage III

yet fully understood, in which epithelioid Depending on the stage, the following
cell granulomas are formed. characteristics may be seen in the radio-
graph or cross-sectional diagnosis
z Clinic (. Table 17.5).
Acute (=Löfgren’s syndrome): erythema
nodosum, arthritis, adenopathy, possibly
17 infection, fever. 17.2.12 Tumors
Chronic: Irritable cough, dyspnea, irido-
cyclitis, uveitis, and many others. Benign tumors of the lung (which are quite
rare) include hamartoma, carcinoid, and
z Diagnostics benign mesothelioma. Malignant tumors,
Conventional Radiology/CT (. Fig. 17.12) which are discussed in the following sec-
Respiratory System
205 17

a b

..      Fig. 17.12 a–c Sarcoidosis with b bihilary lymphadenopathy and c bipulmonary round foci

Bronchial Carcinoma
.       Table 17.5 Stages of sarcoidosis A bronchial carcinoma is a malignant neo-
plasm of cells in the lower airways (bron-
Stage Radiological Features
chi). With 25% of all carcinomas, bonchial
I Symmetrical bihilar adenopathy carcinoma is a relatively frequent diagnosis,
(. Fig. 17.12b) and men are more frequently affected than
women.
II Involvement of the parenchyma with
interstitial reticular drawing prolifera- A distinction is made between different
tion forms of bronchial carcinoma
(. Table 17.6).
III Pulmonary fibrosis (7 Sect. 17.2.5)
Most bronchial carcinomas are found
centrally (75%), but peripheral or diffuse
localization is also possible.
tions, are primarily bronchial carcinoma, Metastasis often occurs to the liver,
malignant lymphoma, and metastases to the brain, adrenal glands and skeletal system,
lung from other tumors. especially the spine.
 206 M. Kahl-Scholz et al.

.       Table 17.6 Bronchial carcinoma variants

Form Frequency in % Localization Metastasis

Small cell lung carcinoma 15 Mostly central Early

Non-small cell lung cancer 85
Of this: Squamous cell carcinoma 40 Mostly central Late
Adenocarcinoma 35 Mostly peripheral Relatively fast
Large cell carcinoma 10 Central and peripheral Early

z Clinic 55 Unilateral hilar enlargement

In the early stages usually initially asymp- 55 Upper congestion
tomatic, then possibly cough, chest pain, 55 Diaphragmatic herniation (phrenic nerve
whistling breathing, shortness of breath paresis)
(shortness of breath), hemoptysis (bloody 55 Pleural effusion of unknown origin (pos-
tinted sputum), hoarseness and swelling of sibly pleuritis carcinomatosa)
the face/throat.
Pancoast tumor is a special variant of Other chest x-ray findings suspicious for
bronchial carcinoma. It is initially located at carcinoma may include:
the apex of the lung, but rapidly affects the 55 Central tumor with hilifugal endobron-
thoracic wall, border cord and brachial chial spread
plexus, which may lead to Horner’s syndrome 55 Tumor with melting (tumor cavern)
with miosis, ptosis and enophthalmos. 55 Hilar tumor shadow
The term bronchioalveolar carcinoma, 55 Chest wall infiltration
which belongs to the adenocarcinomas, is 55 Segmental bronchus closure
no longer found in the current classifica- 55 General tissue displacements
tions. Radiologically, this form, which is
currently pathologically designated with a
lepidic growth pattern, impresses as a >>Since adenocarcinoma is usually found
pneumonia-­typical infiltrate, which, in the periphery (. Table 17.6), it may
­however, shows no response to appropriate also initially appear like a pneumonic
antibiotic therapy. infiltrate.

z Diagnostics CT For precise diagnosis and tumor staging,

Conventional X-ray a CT should be performed if there is a justi-
17 There are initially non-specific clues that fied suspicion. The administration of CT can
may raise suspicion of carcinoma on x-ray. also improve the assessment of possible vas-
These include: cular occlusions. If histological confirmation
55 Atelectasis due to bronchial stenosis is not possible by bronchoscopy, a CT-guided
55 Persistent infiltrate puncture can be performed. The risk of pneu-
55 Lung tip shadowing mothorax can be reduced by positioning the
55 Mediastinal widening patient on the side to be punctured.
Respiratory System
207 17
>>A puncture is contraindicated if it is a
potentially primary operable finding!

Malignant Lymphoma
Malignant lymphoma is a neoplastic disease
of the lymphatic system, which usually man-
ifests itself in the lymph nodes, but can also
affect other organs, such as the spleen, liver,
lungs.

z Clinic
General B-symptomatology and swelling of
the lymph nodes, cough, dyspnoea and pain
if the lungs are affected. ..      Fig. 17.13 Lung metastases (in the lung window
CT) in NCC as primarius
z Diagnostics
Conventional X-ray
Mediastinal and hilar lymph node ules (of different sizes) with sharp margins
enlargement may present. Both hilus and and symmetrical involvement (often the sub-
mediastinum may appear widened. If the fields are affected). If necessary, there may
involvement is pronounced, the mediasti- be fusion or calcification.
num appears widened like a chimney. CT (. Fig. 17.13)
CT See above.
CT is used for the precise assessment of
the lymph node involvement and a possible
pulmonary manifestation with mostly some- 17.2.13 Pulmonary Embolism
what blurred circumscribed condensations.
However, pulmonary lymphoma involve- Pulmonary embolism is the occlusion of a
ment can cause very different patterns and pulmonary artery branch by a displaced
should therefore always be considered if the thrombus (usually from the venous pelvic/
underlying disease is present. leg circulation).

Metastases z Clinic
Lung metastases occur in about 75% of Symptoms may be absent or nonspecific.
cases of renal carcinoma, in about 60% of Depending on the size of the affected area,
cases of thyroid carcinoma, breast carci- there may be shortness of breath and/or
noma and malignant melanoma and in accelerated breathing, palpitations, chest
about 40% of cases of prostate carcinoma. pain, anxiety, coughing and/or hemoptysis.
Laboratory chemistry shows elevated
z Clinic D-dimers, a breakdown product of fibrin. In
In most cases, it is the primary tumor that addition, ECG and cardiac echo show right
first causes symptoms. heart strain.

z Diagnostics z Diagnostics (. Fig. 17.14)

Conventional X-ray Conventional X-ray
Foci with a size of >10 mm can be Conventional X-rays show a regional
detected. Characteristics are multiple nod- reduction in blood flow, which reduces the
 208 M. Kahl-Scholz et al.

a b

..      Fig. 17.14 Pulmonary embolism. a Axial, b Coronary

diameter of the vessel and results in a sec- Hemorrhage

ondary increase in transparency (so-called Pulmonary hemorrhage in infancy describes
Westermark sign). Furthermore, there is pulmonary hemorrhage due to a coagula-
the so-called knuckle sign, an enlargement tion disorder and left heart failure, which
with a jump in caliber, which results from can occur especially in premature infants or
the ballooning of the central artery and a as a complication of respiratory distress
resulting clear difference in size to the con- syndrome.
tinuing vessels. Another characteristic is
the shadowing district (Hampton’s hump), z Clinic
in which a hemispherical shadowing (=alve- Acute dyspnea, possibly bloody secretion.
olar hemorrhage) sitting on the pleura can
be seen (but only after about 1–4 days post z Diagnostics
embolism). Further findings may be a dia- Conventional X-ray
phragmatic herniation and squamous atel- Depending on the location, a patchy con-
ectasis. fluent lung shadowing is seen, but it is usu-
CT ally difficult to differentiate from pneumonia
Since in most cases an X-ray can be unre- or respiratory distress syndrome.
markable, CT angiography (CTA) in pulmo-
nary arterial phase is the means of choice. Pulmonary Emphysema
Among other things, it allows direct detec- Congenital lobar emphysema describes
tion of the embolus via a filling defect or hyperinflation of one or more lobes of the
termination of the CM column. lung in the newborn/infant.
Scintigraphy
7 Section 17.3.2. z Clinic
17 Dyspnea, tachypnea.

17.2.14 Childhood z Diagnostics

Conventional X-ray
See also 7 Chap. 24. As in adult emphysema there is a mostly
unilateral increase of transparency, possibly
Surfactant Deficiency Syndrome with displacement of the mediastinum to the
7 Section 24.1.1. opposite side.
Respiratory System
209 17
Lung Cyst lung parenchyma, which cause an edema-
This is a congenital cystic malformation of tous peribronchial density increase. Due to
the lung. the peribronchial compressions, the lumen
of the bronchi becomes radiologically more
z Clinic transparent to the surrounding tissue, which
Dyspnea. is called a positive bronchopneumogram.

z Diagnostics Meconium Aspiration

Conventional X-ray 7 Section 24.1.2.
A sharply bordered, round lightening
area is visible, depending on the size of the
cyst with mediastinal displacement. 17.3 Diagnostics
Transient Neonatal Tachypnea 17.3.1 Diagnostic Radiology
(See also 7 Chap. 24). This is an intraalveo-
lar fluid retention (synonym also “wet lung Christel Vockelmann
disease”) and a respiratory distress syn-
drome caused by it, which can affect prema- Sonography
ture infants in particular. Sonography is very well suited for detecting
pleural effusions, i.e. fluid in the pleural cav-
z Clinic ity. In the case of larger amounts of effu-
Retractions at sternum and intercostal spaces, sion, sonographically guided puncture of
tachypnea >60/min, attenuation of breath the effusion is also an excellent option. As a
sounds, pale gray skin coloration, cyanosis. rule, this is performed by internists, since
they often primarily treat patients with rele-
z Diagnostics vant pleural effusions.
Conventional X-ray
The characteristics depend on the stage Conventional X-ray Diagnostics
(. Table 17.7): The basic diagnosis of the lungs and bron-
A bronchopneumogram results from chi is the chest X-ray. In individual cases, a
inflammatory or other infiltrations in the tracheal image is taken to detect tracheoma-
lacia caused by an enlargement of the
­thyroid gland.
..      Table 17.7 Stages of respiratory distress
syndrome
>>Often the radiographic thorax is x-rayed
Stage Radiological Signs with the question of a pneumothorax in
expiration. However, recent studies show
I Fine granular transparency reduction that there is no significant difference in
II Additional positive aerobronchogram the detection of pneumothorax between
extending beyond the cardiac contour images taken in inspiration and expira-
III Additionally further reduction of
tion.
transparency with blurring of the
diaphragm and heart contours Fluoroscopy/Angiography
IV White lung, the heart contours cannot
Fluoroscopic examinations of the thorax
be differentiated from the lung have become relatively rare. Fluoroscopy
parenchyma can be used, for example, to assess the
mobility of the diaphragm or to further
 210 M. Kahl-Scholz et al.

clarify a questionable compression in the informed about the examination procedure.

X-ray thorax. Often, however, a computer Practice with the still inactive system with
tomography of the thorax is performed as a the mouth tightly closed and the nose
much more sensitive procedure. closed is useful. This procedure ensures
that the inhaled radioactive air remains
Computed Tomography trapped in the filter system provided for
In the meantime, computed tomography is this purpose and does not contaminate the
not only a complementary diagnostic staff or the immediate environment. If nec-
method to X-ray thorax for the clarifica- essary, the bronchial system can be dilated
tion of diseases of the thorax. In many with a metered-dose aerosol (e.g. Berodual)
cases, CT of the lung is performed as the before inhalation. The patient should be
primary diagnostic method. In the case of instructed to cough and take deep breaths
certain diseases, e.g. rectal carcinoma, in and out to loosen mucus plugs, the lungs
many oncological centers primarily per- expand. The target activity usually does
form a CT of the lung to exclude metasta- not exceed 10–20 MBq, so that the ventila-
sis. The advantage of CT compared to tion study must precede the perfusion
conventional radiography is the possibility study.
of detecting even small round foci corre- In order to prevent the release of thrombi,
sponding to metastases. the patient is carefully positioned. He lies on
his back. The arms are positioned comfort-
Magnetic Resonance Imaging ably and stably above the head using appro-
Magnetic resonance imaging has not yet priate positioning aids. Planar scintigrams
proved its worth in the assessment of the are obtained from eight views: ventral
lung parenchyma. On the one hand, this is (RVL); dorsal (LDR); left lateral; right lat-
due to the detection of minute changes in an eral; and right anterior oblique and left ante-
organ that is dependent on breathing and rior oblique (RAO/LAO) and right posterior
thus difficult to immobilize. Then, small cal- oblique and left posterior oblique (RPO/
cifications are very important for the assess- LPO). For the evaluation of complex find-
ment of changes. Like air, these are ings, the acquisition of SPECT images (64
signal-free in MRI, so these findings escape views à 24 s/matrix 128 × 128) has proven to
MRI. For these reasons, MRI of the lung is be useful. A SPECT/CT offers the possibil-
not a common diagnostic technique today. ity to combine functional and m ­ orphological
Nevertheless, in many examinations, such as imaging in a low-dose technique.
a cardio-MRI or an examination of the Ventilation can also be carried out with
upper abdomen, the lungs are at least par- other gases, but this is associated with exten-
tially included in the examination area and sive logistical requirements. 133Xenon
should always be examined as well in order requires special structural radiation protec-
not to miss any relevant findings. tion measures, while 81mkrypton, daughter
nuclide of 81rubidium, requires the daily
17 procurement of a new generator system due
17.3.2 Nuclear Medicine to its extremely short HWZ.

Ursula Blum Lung Perfusion Scintigraphy

Immediately following and in the same posi-
Pulmonary Ventilation Scintigraphy tion, 150–200 MBq 99mTc labeled human

Ventilation scintigraphy is acquired after albumin aggregates (MAA) are injected,

inhalation of gases, aerosols or vaporized which are larger than the lung capillaries
carbon particles. The patient should be well and block approximately every 10,000th
Respiratory System
211 17
capillary. The regional distribution of the tern indicates pulmonary space occupying
particles corresponds to the relative perfu- lesions, infections, pleural effusions, conse-
sion of the lung. If there is constriction or quences of obstructive or restrictive lung
occlusion of a pulmonary artery, the subse- diseases or old pulmonary embolisms and is
quent flow area is only partially or not at all caused by the Euler-Liljestrand reflex.
reached, and there is an under-occupation Mismatch findings are characterized by
of the corresponding section of the lung in a markedly reduced or abolished perfusion
typical wedge shape. A commercially sup- with intact ventilation. A mismatch finding
plied kit containing the inactive particles is manifests the pathology of recent pulmo-
connected to the generator eluate according nary embolism. In rare cases, other patholo-
to the manufacturer’s instructions and under gies of the lung also show mismatch findings.
exclusion of air. Before taking the required To increase the specificity of the result, a
amount of activity of approx. 200 MBq recent radiograph should be available at
99mTc MAA, the kit vial must be shaken, as baseline. Alternatively, SPECT in combina-
the particles settle in the bottom of the glass tion with low dose CT can be used in the
and cannot otherwise be taken out in the diagnosis of acute pulmonary embolism.
correct dosage (approx. 100,000 to 200,000
particles). Determination of Postoperative
The activity is shaken again before appli- Pulmonary Function
cation and then injected i. v. slowly and lying To predict postoperative lung function, per-
down over several deep breaths. The venous fusion scintigraphy is obtained before a
access must not contain a filter. Aspiration planned pneumectomy or lobectomy. The
of blood to control the position of the access radiopharmaceutical is injected in a sitting
must also be avoided, as otherwise thrombi position to account for gravity-induced per-
will form which carry relatively high activi- fusion changes. First, static images are
ties and lead to an inhomogeneous distribu- acquired ventrally and dorsally using a pla-
tion of the nuclide with focal hot spots. nar technique. Then, regional distribution in
Regional perfusion is position-dependent. If upper, middle, and lower lobes of both sides
the patient is sitting, the caudal lung sec- is quantified via the placement of ROIs. The
tions are more perfused, which may be use- percentage uptake of the lung area to be
ful for examination in other indications. The removed is subtracted from the total func-
MAA particles are degraded intrapulmo- tion and the result is multiplied by the pre-
nary via proteolysis with a HWZ of 2–3 h. operative forced expiratory volume (FEV).
The count rate of perfusion uptake must be If this results in a postoperative FEV of less
a factor of five higher than that of ventila- than 0.8 L, the upcoming operation must be
tion in order to achieve a reliable superposi- critically questioned.
tion of the ventilation study. The study
protocol is the same as that of ventilation Right-Left-Shunt
for comparability of both studies. Even in healthy individuals, about 2% of the
blood circulating in the pulmonary circula-
Evaluation tion is removed from the oxygenation pro-
Normal findings show a homogeneous cess. Various pathological changes or
activity distribution in ventilation and per- malformations can increase the proportion
fusion in all lung segments. of blood flowing past the pulmonary circu-
In the so-called match findings, there is a lation, resulting in a global oxygen defi-
reduction in activity or a loss of activity at ciency. After application of 99mTc MAA
the same site in both ventilation and perfu- particles, in case of pathologically increased
sion. Such a scintigraphic distribution pat- right-left shunt, accumulation occurs in
 212 M. Kahl-Scholz et al.

organs where the particle size exceeds the and kidneys in anterior and posterior views,
capillary diameter (e.g. brain, liver and the percentage shunt can be calculated. A
kidneys). After planar imaging of the lungs renal cardiac output of 25% is assumed.


Nierenzahlrate ´4
Shunt ( % ) =

Nierenzahlrate  rate
´ 4 + Lungenzahl

Pulmonary Hypertension tion. Tumors of different histology show

In patients with chronic recurrent pulmo- different memory behavior. While squamous
nary embolisms, the pathological pressure cell carcinoma of the lung shows a high 18F-­
increase in the pulmonary circulation can be FDG uptake, the tracer of adenocarcino-
detected via pulmonary ventilation perfu- mas of the lung is acquired very inconstantly.
sion scintigraphy. If 99mTc MAA is applied In small cell bronchial carcinoma, the proce-
in a sitting position, the lung base of the dure is used when the location of the pri-
healthy person must show a higher activity marius and lung function permit surgical
accumulation than the upper lung sections intervention and distant metastases have not
due to gravitation. been detected on any imaging modality. If
In pulmonary hypertension there is no PET and CT findings are negative, mediasti-
difference in the distribution, sometimes even noscopy can be omitted. If a mediastinal
the upper lung sections are more perfused. lymph node is found in one of the two diag-
nostic procedures, it requires histological
clarification.
Lung PET
In the diagnosis of unclear solitary lung
findings, the 18F-FDG PET/(CT) provides a 17.3.3 Valence
diagnostically valuable gain, especially if the
patient’s general condition does not permit a Christel Vockelmann
biopsy. Round tumors smaller than 1 cm
may escape imaging due to the inadequate . Table 17.8 shows the use of the respective
spatial resolution of the device and the therapeutic options depending on the prob-
patient’s respiratory motion during acquisi- lem.

.       Table 17.8 Value of the therapeutic procedures

Sonography Conventional Fluoroscopy/ CT MRI Nuk PET

Angiography

17 Pneumonia W P N W N N N
Bronchial N P N P N N W
carcinoma
Pulmonary N N N P N W N
embolism
Pulmonary fibrosis N P N P N N N

N Not indicated, P Primary diagnosis, W Further diagnosis

Respiratory System
213 17
17.4 Therapy and also to achieve a sufficient safety dis-
tance, the puncture is CT-guided. As the
17.4.1 Interventional Radiology coking is very painful—the tissue is heated
to at least 75 °C, so imagine you are touch-
Angiography ing a hot hotplate—the procedure is often
performed under intubation anesthesia, or
Angiography is used as a therapeutic proce-
at least under analgesia. Indications for such
dure, e.g. for removing a torn port catheter
a procedure include patients who are inoper-
or a CVC. For this purpose, a venous punc-
able for general reasons or single metastases
ture is made in the femoral vein. The pulmo-
of certain tumors such as colorectal carci-
nary artery is then probed with a catheter, in
noma. Local recurrence of bronchial carci-
which the catheter is advanced to the right
noma, e.g. after radiotherapy, can often be
heart via the inferior vena cava. From the
treated by thermoablation.
right ventricle, the pulmonary artery is
The coking of the tumor tissue leads to
probed. Then a snare loop, a lasso-like loop,
the death of the cells. In the course of the
is used to capture the lost catheter and
thermoablation, a scarring shrinkage of the
remove it via the sheath in the femoral vein.
area occurs.
Another field of application of angiogra-
phy is the treatment of hemoptysis. This
term describes a coughing up of blood
caused, for example, by pulmonary bleeding 17.4.2 Radiotherapy
from the bronchial arteries. If such a condi-
tion cannot otherwise be treated by bron- Bronchial Carcinoma
choscopy, the bronchial artery of the Positioning is supine with the arms above
corresponding side is probed. A microcath- the head.
eter is then advanced into the bronchial
artery and the artery is occluded with small z Therapy of Non-Small Cell Lung Cancer
particles. The procedure is feasible without (NSCLC)
leading to necrosis of the lung, since the The total dose for definitive radiochemo-
lung tissue is not only supplied via the bron- therapy is 60–70 Gy, and that for adjuvant
chial arteries, but also still via the pulmo- therapy is 50–60 Gy.
nary arteries.
z Therapy of Small Cell Lung Cancer (SCLC)
Computed Tomography Four to six cycles of chemotherapy followed
For the treatment of primary bronchial car- by radio-chemotherapy of the primary
cinoma or pulmonary metastasis, thermoab- tumor and adjacent lymphatic drainage area.
lation can be considered in certain cases. After completion of chemotherapy and
This is performed in particular in the lungs exclusion of metastases, prophylactic whole-­
under computer tomography control. brain irradiation (PCI: Prophylactic Cranial
Thermoablation ultimately means the cok- Irradiation) with a total dose of 30 Gy is
ing of tissue. For this purpose, a probe is performed.
inserted into the tumor and heat is then Side effects: Skin irritation, esophagitis,
applied. In order to hit the tumor exactly pneumonitis, pericarditis.
 214 M. Kahl-Scholz et al.

Case Study

Mr. Tuschka, a 76-year-old man, has noticed nounced emphysema, but this can be treated
hemoptysis lately. His wife has been telling well with a drainage. After the diagnosis has
him to quit smoking for 30 years. However, been confirmed, the patient is presented to
he never got off it. Now, he has also lost the tumor conference of the clinic. The con-
weight in the last month. Due to the many ference, which is attended by the oncologist,
years of nicotine abuse and weight loss, the radiotherapist, the radiologist, the pul-
bronchial carcinoma is suspected. After a monologist, the thoracic surgeon and the
chest X-ray, which revealed a round focus in pathologist, decides that the patient should
the right lower lobe of the lung, a computer undergo radio-chemotherapy. Mr. Tuschka
tomography was performed. The suspicion agrees to the procedure. He comes through
of bronchial carcinoma is confirmed. CT-­ the therapy well. A few side effects occur
morphologically no mediastinal lymph node (such as tingling in the extremities and also
metastases are found. The left adrenal gland hair loss). The blood values were also
is slightly thickened. The radiologist gives changed in the meantime due to anemia.
the tumor stage as cT1bN0Mx. Incidental However, he did not develop any complica-
findings include marked bullous emphy- tions of the radiation such as dermatitis.
sema. The radiologist recommends a com- However, he feels quite weak during the
pletion of the staging. He is especially treatment and the first time afterwards.
concerned about the left adrenal gland. After two years the CT thorax shows an
First, a bronchoscopy is performed, but the increase of the scar in the area of the tumor.
tumor is too far peripherally in the lung to The radiologist suspects a recurrence. To
be punctured bronchoscopically. In addi- confirm the diagnosis, Mr. Tuschka is again
tion, an FDG-PET-CT scan and an MRI of sent for a PET-CT. Here the radiologist’s
the neurocranium are performed. The MRI suspicion is confirmed. In the tumor area
is necessary because cerebral metastases can there is an increased glucose utilization as a
only be inadequately detected in the FDG-­ sign of a vital tumor. The PET-CT is exam-
PET due to the high sugar metabolism of ined jointly by the nuclear medicine special-
the brain. For the definite exclusion of cere- ist Dr. Blümchen and the radiologist Dr.
bral metastases, the MRI examination is Vau. Based on the size of the recurrence of
performed with contrast medium, although 2.5 cm, the radiologist recommends discuss-
the native images show no abnormalities. ing a thermoablation in the tumor confer-
Mr. Tuschka was lucky. Apart from the ence. Another irradiation of the area is out
tumor in the lung, no other malignant find- of the question. Chemotherapy alone has
ings are found. Actually, due to the favor- only very limited chances of success in Mr.
able tumor stage without metastasis, surgery Tuschka. Therefore, the conference agrees to
would now be the primary option. However, thermoablation, which is performed in the
the lung function test showed that an opera- clinic under CT guidance. Mr. Tuschka sur-
17 tion is not possible due to the pronounced vives the procedure well, even though he has
emphysema. To confirm the diagnosis and a pleural drainage for a few days due to a
histologically determine the exact tumor pneumothorax. The further CT checks and
entity, a CT-guided puncture is performed. follow-up examinations with the oncologist
In this case, there is a significantly higher show no recurrence in the next months and
risk of pneumothorax due to the pro- years.
Respiratory System
215 17

Practice Questions 4. What are the stages of ARDS and

1. In a pleural effusion on CT, what what are the radiological findings
characterizes a transudate and what depending on the stage?
characterizes an exudate? 5. When do Westermark signs and
2. What are signs of pulmonary edema Knuckle signs show up?
on x-ray?
3. What do the abbreviations “p”, “q”, Solutions 7 Chap. 27
and “r” stand for in the size classifica-
tion of spot shadows in silicosis?
 217 18

Gastrointestinal Tract
Christel Vockelmann, Ursula Blum, and Guido Heilsberg

Contents

18.1 Anatomical Structures – 218

18.2 Disease Patterns – 218

18.2.1  harynx, Oesophagus – 218
P
18.2.2 Stomach and Duodenum – 222
18.2.3 Duodenal Diverticulum – 223
18.2.4 Jejunum and Ileum – 225
18.2.5 Colon and Rectum – 226
18.2.6 Mesentery, Peritoneum and Abdominal Wall – 230
18.2.7 Liver and Biliary System – 233
18.2.8 Gall Bladder and Bile Ducts – 240
18.2.9 Pancreas – 241

18.3 Diagnostics – 243

18.3.1  iagnostic Radiology – 243
D
18.3.2 Nuclear Medicine – 245
18.3.3 Valence – 249

18.4 Therapy – 249

18.4.1 I nterventional Radiology – 249
18.4.2 Radiotherapy – 251

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 218 C. Vockelmann et al.

The gastrointestinal tract includes all organs liver into the right and left hepatic lobes.
that serve to absorb and process food, i.e. The individual segments are formed by the
the esophagus, gaster, duodenum, jejunum, branches of the portal vein with the accom-
ileum, colon and rectum, as well as the liver, panying bile ducts and the venous drainage
pancreas and biliary system. In addition to areas.
inflammatory changes, tumorous changes The gallbladder is located at the lower
play a major role in medicine and thus also border of the liver at the surgical border
in imaging techniques, which are indispens- between the right and left liver lobes. It is the
able in the diagnosis and therapy of these reservoir for bile. The outflow of bile takes
diseases. place via the dexter and sinister hepatic
ducts into the common hepatic duct. After
union with the ductus cysticus, bile flows via
18.1 Anatomical Structures the ductus choledochus (clinically DHC)
into the duodenum via the papilla vateri.
Christel Vockelmann The pancreas lies secondarily retroperi-
toneal. It fulfils exocrine and endocrine
The digestive tract begins with the mouth functions. Sonographically, the lienal vein
and pharynx (7 Chap. 15) and then contin- (V. splenica) serves as a guide structure,
ues through the thorax with the approx. which runs along the upper edge of the pan-
25 cm long oesophagus into the abdomen. creas. The arterial supply of the liver, gall-
Here the stomach lies subdiaphragmally on bladder and pancreas is via the truncus
the left. The duodenum lies retroperitone- coeliacus.
ally in the middle section up to the flexura
duodenojejunalis (Treitz’s ligament).
Jejunum and ileum lie intraperitoneally, via 18.2 Disease Patterns
Bauhin’s valve the digested food pulp
reaches the colon, which is fixed retroperito- Christel Vockelmann
neally in the ascending and descending part.
The arterial supply of the small and large
intestine up to the right flexure is via the supe- 18.2.1 Pharynx, Oesophagus
rior mesenteric vein, the descending colon
and rectosigmoid are supplied via the inferior Oesophagitis
mesenteric artery. Venous outflow is via the These are inflammatory changes of the
mesenteric vein to the portal vein (V. porta). mucosa. Nowadays, the diagnosis is made
The liver lies intraperitoneally in the endoscopically. The reason for this, in addi-
right upper abdomen and is protected in tion to reflux, which leads to irritation espe-
large parts by the thorax. The liver is fused cially in the distal esophagus, is a restricted
to the diaphragm only via the pars affixa, in immune system with then infection of the
the remaining area there is a covering with esophagus by mainly fungi (Candida).
the peritoneum. This runs out into the liga- Thermal or chemical damage can also lead
ments falciforme, hepatograstricum and to esophagitis.
18 hepatoduodenale as well as teres hepatis. The complications of rupture of the
The surgical anatomy and segmentation, esophagus due to vomiting is called
which is therefore also relevant in clinical Boerhaave syndrome. Other reasons for rup-
practice, is based, among other things, on ture are iatrogenic perforation in about
the falciform ligament, which divides the 55–60% of cases.
Gastrointestinal Tract
219 18
z Clinic CT
Burning thoracic, pain on ingestion of fluids Computed tomography is used to assess
and food. the complications of inflammatory diseases
of the esophagus. Possible abscesses in long-
z Diagnostics standing changes can be reliably detected.
Radiological diagnostics are mainly used in The extent of pneumomediastinum can also
the evaluation of complications. Sometimes be reliably assessed.
the esophageal swallow is still used as a diag-
nostic procedure to assess the extent of Diverticula of the Oesophagus
reflux and the contractility of the esopha- Diverticula are divided into the following
gus. variants:
Conventional X-ray (. Fig. 18.1) 55 Zenker’s diverticulum: 70% of all diver-
Air in the mediastinum can be detected ticula, cervical pulsatile diverticulum.
by demonstrating lines of lightening along Preferred in men of older age. Large
the mediastinal pleura or even the pericar- pseudodiverticulum localized dorsally at
dium. If pneumomediastinum is suspected, a the upper esophageal jugular predomi-
CT scan should always be followed up to nantly on the left side.
better assess the extent of the injury and the 55 Bifurcation diverticulum: True diverticu-
possible cause. lum due to scarring, e.g. after TBC.
Transillumination 55 Epiphrenic pulsatile diverticulum: Pseu-
Fluoroscopy allows assessment of con- dodiverticulum above the hiatus, often
trast passage and contractile waves of the combined with a hiatal hernia or achala-
esophagus as well as the location of the car- sia (sec. Achalasia)
dia below the diaphragm, observation of
possible reflux of contrast. z Clinic
Mostly only Zenker diverticula become
symptomatic by food retention with regurgi-
tation or bad breath. Complication can be
aspiration pneumonia.

z Diagnostics
Fluoroscopy (. Fig. 18.2)
The esophageal swallow is used to assess
the location and size in addition to endos-
copy.

>>A Zenker diverticulum may sonographi-

cally mimic a left retrothyroidal mass.

Swallowing Disorders
Swallowing disorders are distinguished
between:
55 Dysphagia: A feeling of tightness or pain
when swallowing. This can be caused by
a wide variety of diseases, e.g. divertic-
..      Fig. 18.1 Pneumomediastinum ula, tumors, inflammations or even cere-
 220 C. Vockelmann et al.

a b

..      Fig. 18.2 a, b Zenker diverticulum

bral ventricle diseases such as infarctions z Diagnostics

resulting in cranial nerve failures. In addition to the unspecific diagnosis of
55 Aspiration: transfer of food, liquids or esophageal swallowing, kinematography can
saliva into the trachea with the risk of be performed in cases of dysphagia, espe-
pneumonia. cially with aspiration.
55 Tertiary contractions: Non-propulsive Fluoroscopy (. Fig. 18.3)
contractions especially of the distal It allows the observation of the onward
esophagus as a disturbance of the swal- transport of contrast medium or contrast
lowing act. Frequent incidental finding medium-soaked food pulp from the mouth
in older patients, may be combined e.g. into the upper esophagus and makes it pos-
with a hiatal hernia or reflux. Possible sible to exclude a transfer into the trachea
cause is also a diabetic neuropathy of the (aspiration).
gastointestinal tract.
Achalasia
Clinic
18 z
Irritable cough on aspiration, pain on swal-
Achalasia is a narrowing of the lower
esophageal sphincter with sectular dilata-
lowing, globus sensation (often localized tion of the esophagus. It is a rare condi-
higher than the actual pathology, e.g. in the tion with an incidence of 1:100,000
mid-thorax in case of bolus occlusion of the population/year. Peak incidence 3rd–5th
distal esophagus). decade of life.
Gastrointestinal Tract
221 18

..      Fig. 18.4 Achalasia

constriction, at the level of the aortic arch

and in the diaphragmatic fossa. Risk factors
..      Fig. 18.3 Aspiration include concentrated alcohol, hot drinks,
smoking, nitrosamines, reflux disease, acha-
z Clinic lasia, papillomavirus.
Dysphagia with frequent after-drinking, Metastasis occurs to the upper esopha-
bad breath, retrosternal feeling of fullness. gus with early infiltration to adjacent organs
due to lack of serosal coating and early lym-
z Diagnostics phogenic metastasis. Hematogenous metas-
Fluoroscopy (. Fig. 18.4) tasis to liver, lung and bone is rather late.
The oesophageal swallow with water-­
soluble contrast medium shows a pathogno- z Clinic
monic chalice-like dilatation of the distal Dysphagia, possibly weight loss. Often late
oesophagus. In contrast to carcinoma this symptoms with characteristic complaints.
has a smooth border of the esophagus.
z Diagnostics
Oesophageal Carcinoma CT (. Fig. 18.5)
This is a malignant epithelial tumor of the CT is used for the diagnosis of spread.
esophagus – frequently squamous cell carci- PET-CT, as the most sensitive method,
noma (approx. 40% age peak 55 years), ade- enables the detection of distant metastases,
nocarcinoma (approx. 60%, age peak but is currently not primarily used. Usual
65 years) (=Barrett’s carcinoma) in the dis- staging: endoscopy and CT, if operability is
tal esophagus, rarely undifferentiated. The given → diagnostic laparoscopy to exclude
tumor is frequently localized at the three peritoneal carcinomatosis (also not reliably
physiological strictures at the esophageal detectable on PET-CT).
 222 C. Vockelmann et al.

Postoperative/Posttherapeutic
Changes
Significantly relevant changes in radiology
here include:
55 Gastric elevation: stomach displaced
into the thorax after resection of the dis-
tal esophagus.
55 Colonic interposition: Replacement of
the esophagus by the colon, then usually
with cervical and abdominal anastomo-
sis, elevation mostly retrosternal or intra-
thoracic, occasionally subcutaneous.

z Clinic
With insufficiency fever, septic picture.

z Diagnostics (. Fig. 18.6)

In the case of complications, a CT should be
performed for clarification, and in the case
of suspected insufficiencies, positive oral
contrast medium (as a diluted, approxi-
mately 3% solution) should be used if
­necessary.

18.2.2 Stomach and Duodenum

Gastritis, Ulcers and Complications
These are inflammatory changes of the gas-
tric mucosa. The cause is often exogenous
..      Fig. 18.5 Esophageal carcinoma noxae such as alcohol excess or drugs (corti-

Bed recording

a b

18

..      Fig. 18.6 a, b Stomach elevation

Gastrointestinal Tract
223 18
costeroids, ASA, non-steroidal anti-­ Duodenal ulcers may also perforate ret-
inflammatory drugs, chemotherapeutic roperitoneally. Here one has to look for a
drugs). lightening fringe along the psoas shadow as
Complication: Ventricular or duodenal a sign of retroperitoneal perforation.
ulcer (ratio about 1:3) with bleeding or per- In acute upper GI bleeding, diagnosis
foration. After healing, scarring with steno- and treatment are usually performed endo-
sis occurs. scopically. If a bleed in a duodenal ulcer
Atypically localized ulcers must be sug- cannot be stopped endoscopically, endovas-
gestive of malignancy. cular therapy can be attempted (7 Sect.
18.4.1).
z Clinic
Nausea, loss of appetite, upper abdominal
pain, feeling of pressure. With complica- 18.2.3 Duodenal Diverticulum
tions “acute abdomen”, upper GI bleeding.
This is an outpouching of the duodenal
z Diagnostics wall, mostly para- or juxtapapillary, fre-
The primary diagnosis is usually made quency increasing with age (about 3% of the
endoscopically. population).
Conventional X-ray
Furthermore, an X-ray abdomen, usu- z Clinic
ally in a lying position and on the left side, is Mostly symtpomeless, may possibly cause
taken to detect free air. outflow obstruction of DHC or D. wirsung-
CT ianus.
Frequently, CT is also primarily used as
a much more sensitive method for detecting z Diagnostics
free air and hollow organ perforations. It is a frequent incidental finding with an
air- or contrast-filled cavity directly related
>>To detect free air, patients should lie on to the duodenum on CT or fluoroscopy
their left side for at least 5 min before the examinations (. Fig. 18.7), usually without
radiograph is taken in the left lateral pathological significance.
position.

Free air is recognizable in the left lateral

position as a lightening between the abdom-
inal wall and the liver under the diaphragm.
If the patient cannot be positioned in the
left lateral position for a sufficiently long
time, a standing X-ray of the thorax and
abdomen may be helpful, where the free air
can be detected as a lightening in the form
of a black crescent between the liver and dia-
phragm. In the supine x-ray, the air usually
collects centrally in the upper abdomen and
may then be demarcated as a roundish
increase in transparency (“football sign”). ..      Fig. 18.7 Duodenal diverticulum
 224 C. Vockelmann et al.

Benign Tumors z Diagnostics

These include polyps or mesenchymal The primary diagnosis is made endoscopi-
tumors (lipomas or neurofibromas). They cally.
are rare overall. CT
The staging is determined by means of
z Clinic CT diagnostics. The primary tumor is often
Mostly asymptomatic. not assessable. Lymph node metastases are
detectable by lymph node enlargement.
z Diagnostics Liver metastases appear as flat hypodense
Primarily an endoscopic diagnosis is per- lesions in the portal venous phase. Ascites
formed. may be interpreted as a sign of peritoneal
CT carcinomatosis.
A CT is used in the clarification of mes-
enchymal tumors. Here, a smoothly bounded >>In the hepatoduodenal ligament, lymph
mass is seen in the stomach wall. In the case nodes up to 2 cm in size may be normal.
of lipoma, there is evidence of fat isodense
density values. Gastrointestinal Stromal Tumors
(GIST)
 astric Carcinoma, Duodenal
G Gastrointestinal stromal tumors, GIST for
Carcinoma short, are rare sarcomas of the gastrointesti-
This is a malignant mass of the stomach, nal tract. The most frequent localization is
mostly adenocarcinoma. Duodenal carcino- the stomach. Characteristic is a submucosal
mas are very rare. location of the tumors in contrast to gastric
The Siewert classification of adenocarci- carcinoma. Risk factors for the develop-
nomas of the esophagogastric junction ment of GIST are not known. Affected are
(AEG) is important for treatment. mainly older patients in the 6th and 7th
55 AEG I (actually Barrett’s carcinoma): decade of life. Staging is performed accord-
1–5 cm orally down the cardia. ing to the TNM classification, whereby the
55 AEG II (actually cardiac carcinoma): Oral tumor size is decisive for the T-stage and
<1 cm and aboral <2 cm from the cardia. not, as is usually the case, the infiltration
55 AEG III (subcardiac gastric carcinoma): into the surrounding area and neighboring
>2 to 5 cm from the cardia. organs.

Metastasis occurs relatively early lympho- z Clinic

genically; hematogenically first to the liver, No specific symptomatology, with progres-
then also to the lungs, bones and brain. Per sive disease B-symptomatology.
contingent breath, peritoneal carcinomato-
sis with ascites may occur (this must usually z Diagnostics (. Fig. 18.8)
be excluded laparoscopically in the case of CT/MRI
surgically apparent carcinomas from the Primary diagnosis by endoscopy and
preliminary diagnosis). CT-diagnostics. Because of the good vascu-
18 Krukenberg tumor is a drip metastasis in larization in the arterial phase enhanced
the ovaries or in the Douglas space. contrast enhancement in CT and MRI. The
tumor is T1w isointense and T2w hypo- to
z Clinic isointense, so that contrast medium admin-
Upper abdominal discomfort, B symptoms, istration significantly improves the detection
aversion to meat, acute bleeding. of the tumor.
Gastrointestinal Tract
225 18
a b

..      Fig. 18.8 a, b GIST

In particular, PET-CT with 18F-FDG is know the previous operations and anasto-
increasingly used for follow-up examina- moses. It is helpful, if possible, to talk to the
tions and for the primary diagnosis of surgeon or to have a look at the surgical
spread, since GIST tumors show a strong report. An anastomosis insufficiency is indi-
enhancement. cated by a contrast medium leakage with
oral positive contrast in CT (diluted CM!)
Postoperative Changes and fluoroscopy. Often more sensitive are
These include: air pockets and fluid collections at the anas-
55 Gastrectomy: Complete gastric resec- tomosis. Dumping syndromes are character-
tion, oesophagojejunostomy with jejunal ized by accelerated passage time of contrast
pouch or radiopaque tracers, with the diagnosis
55 Gastric resection: made primarily clinically and imaging
–– Formerly Billroth I: Resection of the obtained to rule out other causes.
distal 2/3 of the stomach, gastroduo-
denostomy.
–– Billroth II: Resection of the distal 2/3 18.2.4 Jejunum and Ileum
of the stomach. Blind closure of the
duodenal stump, gastrojejunostomy Inflammatory Diseases
by means of Braun footpoint anasto- These include:
mosis or Y-Roux anastomosis. 55 Diverticulitis of the jejunum or ileum:
inflammation of one or more small intes-
z Clinic tinal diverticula. Very rare overall.
55 Early dumping: abdominal pain, vomit- 55 Morbus Whipple: Systemic infection
ing within the first 30 min after eating. with Tropheryma whipplei.
55 Late dumping: symptoms of hypoglyce-
mia about 2–3 h after eating. z Clinic
Nonspecific, abdominal pain up to acute
z Diagnostics abdomen.
The altered anatomy is problematic postop-
eratively. End-to-side anastomoses may z Diagnostics
become bulging. It is therefore important to Sonography/CT
 226 C. Vockelmann et al.

Sonography, supplemented by CT diag- Malignant tumors are malignant lympho-

nostics in the case of pronounced symp- mas or neuroendrocrine tumors (NET).
toms. Whipple’s disease may be associated These are localized mainly in the ileum and
with enlarged mesenteric lymph nodes. appendix.
Diverticulitis of the small intestine shows a
comparable picture to diverticulitis of the z Clinic
large intestine with surrounding reaction of Often incidental finding. Depending on the
the small intestine when a diverticulum is size, passage problems. Carcinoid syndrome
detected. with flushing symptoms in hepatic metasta-
sis of a NET.
Coeliac Disease
This is an intolerance to gliadin, a compo- z Diagnostics
nent of gluten. The prevalence in Germany MR Sellink
is 1:500. Oral contrast with sorbitol leads to dis-
tension of the small intestinal loops.
z Clinic Butylscopolamine is administered to
Including diarrhea, malabsorption syn- decrease intestinal peristalsis. Detection of
drome, iron deficiency anemia, chronic hep- contrast-enhancing space-occupying lesions
atitis. may occur.

z Diagnostics Postoperative Imaging/

In a gastrointestinal passage shows acceler- Complications
ated passage time and mucosal swelling.
Short bowel syndrome: malabsorption and
Meckel’s Diverticulum bile acidosis syndrome. It can occur from a
resection length of 40 cm of the ileum.
Meckel’s diverticulum is a remnant of the
omphaloenteric duct and is present in about Clinic
z
2% of the population. The localization in
Diarrhoea, megaloblastic anemia due to
adults is about 100 cm proximal to the ileo-
vitamin B deficiency12.
cecal valve, the length is up to 8 cm.
z Diagnostics
z Clinic
Imaging is only performed as a supplemen-
Mostly asymptomatic, due to ectopic gastric
tary procedure, e.g. MR-Sellink or gastroin-
mucosa possibly ulceration with clinical pic-
testinal passage.
ture similar to appendicitis or occult bleed-
ing. Possible cause also of a volvulus (section
hernias).
18.2.5 Colon and Rectum
z Diagnostics
In case of complication with clinical picture
Acute Inflammatory Diseases
of hemorrhage or acute abdomen CT is rec- Inflammatory diseases include:
18 ommended. 55 Colitis: Inflammation of the colon, e.g.
due to ischemia, toxins (pseudomembra-
Small Intestinal Tumors nous).
Spatial lesions of the small intestine are very 55 Diverticulitis: Inflammation of one or
rare overall. Benign variants are e.g. leiomy- more diverticula with an inflammatory
omas, lipomas, angiomas, familial polyposis environmental reaction. In the sigmoid
syndromes, small bowel endometriosis. colon (90% of cases) pseudodiverticula
Gastrointestinal Tract
227 18
due to constipation, increasing with age. 55 Appendicitis: Acute inflammatory
In the coecum true diverticula. A classifi- change of the appendix vermiformis.
cation is shown in . Table 18.1. 55 Appendicitis epiploicae: Spontaneous
necrosis of an appendix epiploicae.

According to S2K guideline on diverticular

disease (AWMF, May 2014)
.       Table 18.1 Classification of diverticulitis

Designation Clinic/Imaging z Clinic

Diarrhea, pain, fever, blood in the stool.
Type Asymptomatic Diverticula Appendicitis: Periumbilical pain moving
0 diverticulosis detection to the right lower abdomen. Release pain,
Type Acute fever.
1 uncomplicated Appendicitis epiploicae: Picture of diver-
diverticulitis ticulitis.
Type Without Clinical symptoms,
1a ambient at most wall z Diagnostics
response thickening visible Sonography
on imaging
In acute symptomatology, sonography is
Type With phleg- Streaky compac- performed with evidence of a cocard in cir-
1b monous tion of the cumscribed wall thickening.
environmental surrounding area
reaction with thickening of
CT
the wall with In the case of diverticulitis: CT of the
evidence of abdomen with rectal application of contrast
diverticula medium (H2O) to assess the extent of inflam-
Type Uncomplicated mation and clarify complications (perfora-
2 diverticulitis as tion, bleeding, abscess).
1b, plus: Pseudomembranous colitis shows a long-­
Type Microabscess Fluid content distance (pancreatic) hypodense wall thick-
2a or minimal ≤1 cm, tiny ening of the colon. Ischemic colitis is often a
perforation paracolic air consequence of microangiopathic vascular
pockets changes. Indication of an ischemic genesis is
Type Macroabscess Liquid content a correlation to the arterial flow areas.
2b >1 cm, also >1 cm with rim To look for bleeding, an arterial and a
paracolic or enhancement, air venous phase of the abdomen should be
mesocolic, pockets locally
covered
obtained on CT to find a contrast leak. If
perforation these two phases are not clear, a late phase
after 2–3 h may be helpful.
Type Free perfora- Air under the
2c tion, free fluid, abdominal wall at a
Appendicitis presents as a cocard >7 mm.
generalized distance from the The wall is thickened to >3 mm. Often a cal-
peritonitis… local findings, cified appendicolith is detectable. The sur-
ascites rounding area is infiltrated with
Type Chronic inflammation. Air in the appendix or a ret-
3 diverticular rograde CM filling speaks against appendi-
disease citis. The mucocele of the appendix must be
Type Diverticular Detection of the differentiated, which can be distinguished as
4 bleeding source of bleeding a fluid-filled, distended appendix.
Intraoperative rupture of this benign change
 228 C. Vockelmann et al.

..      Table 18.2 Differential diagnosis of IBD

according to Herold: Internal Medicine 2015

Ulcerative Crohn’s Disease

Colitis

Localiza- Colon Entire digestive

tion tract
Rectal Always 20%
Involve-
ment
Ileum Rarely Up to 80%
Involve-
..      Fig. 18.9 Appendicitis epiploicae ment
Spreading Continuous Discontinuous

is followed by pseudomyxoma peritonei Typical Toxic mega- Fistulas, fissures,

Complica- colon, abscesses,
(7 Sect. 18.2.5). tions bleeding stenoses

>>A mucocele of the appendix must not Typical Petren loss Cobblestone relief,
X-ray → Bicycle short segmental
rupture intraoperatively to avoid a pseu- Signs inner tube stenoses, fissures
domyxoma peritonei.

Appendicitis epiploicae presents pathogno- z Diagnostics

monic as an oval fatty isodense lesion on the The diagnosis is based on clinical findings,
colon with central hypodensity and annular endoscopy, sonography with thickening of
adipose tissue inhibition (. Fig. 18.9). the intestinal wall if necessary. A differential
diagnosis is shown in . Table 18.2.
 hronic Inflammatory Bowel
C
MR-sellink after oral contrasting with
Disease (IBD) mannitol or sorbitol. Axial and coronary
These include Crohn’s disease (MC) and T2w sequences as well as T1w sequences are
ulcerative colitis (CU). The incidence in obtained natively and after contrast medium.
Germany is about 6/100,000/year. The peak The inflammatory altered bowel sections are
incidence for CU is 25–35 years of age, for detectable wall thickened with enhanced
MC 15–35 years of age. enhancement. In particular, fistulas and
abscesses can be detected in the contrast-­
z Clinic enhanced sequences. MR-Sellink has com-
Pain, diarrhoea, bloody-mucous in CU. pletely replaced conventional Sellink
Complications of IBD: Extraintestinal fluoroscopy.
symptoms (erythema nodosum, eyes, joints,
liver with primary sclerosing cholangitis – Voiding Disorders/Dysfunction
18 5% in MC, more common in CU). of the Pelvic Floor
In MC: fistulas (40%), anorectal These include constipation or incontinence.
abscesses (25%).
In CU: colorectal carcinomas (correlat- z Clinic
ing with extent of colonic involvement and Constipation, incontinence. Most often in
duration of disease). women with childbirth, obesity.
Gastrointestinal Tract
229 18
z Diagnostics Colorectal Carcinoma
Defecography These are malignant tumors of the colon or
In the case of a functional disorder, con- rectum. The borderline between colon and
ventional defecography or MR defecography rectum is a distance of 16 cm between the
can provide information. The advantage of aboral edge of the tumor and the anocuta-
conventional defecography is the natural sit- neous line, measured in rigid rectoscopy.
ting posture during defecation, compared to Colorectal carcinoma is the second leading
MR defecography. The disadvantage is the cause of death in men (after bronchial car-
inability to assess the soft tissues such as the cinoma) and women (after breast carci-
vagina and bladder and the radiation expo- noma).
sure, which should not be underestimated. Localization: Rectum (50%) > Sigma
Pathological findings: (30%) > Ascending colon (10%) > Remaining
55 Enterocele: Displacement of the small colon.
intestine, omentum, or sigmoid into the Metastasis: lymphogenic, hematogenic
Douglas space. liver (in distal rectal carcinoma also primary
55 Rectocele: The most frequent finding is lung), lung.
an anterior rectocele with a ventral pro-
trusion of the anterior rectal wall. z Clinic
55 Intussusception: folding of the rectal Peranal bleeding, constipation, changing
mucosa during defecation. This is often the bowel habits, B-symptomatics.
cause of defecation-obstruction syndrome.
55 Cystocele: Descensus of the urinary z Diagnostics
bladder with subsidence of the anterior CT
compartment of the pelvic floor. First endoscopy, a virtual CT colonos-
55 Uterovaginal prolapse: descensus of the copy is performed if colonoscopy is incom-
vagina and uterus or often of the vaginal plete. Furthermore, also a CT abdomen, CT
stump after hysterectomy. thoracic abdomen for staging in rectal can-
55 Anismus: absent or paradoxical contrac- cer.
tion of the puborectal loop. In the imag- MR (. Fig. 18.10)
ing impression of the posterior wall of An MR rectum is used to assess local
the rectum, narrow anal canal, reduction findings and distance from the mesorectal
of the anorectal angle during pressing. fascia in lower and middle third rectal can-
cer.
Polyps of the Colon
This is a mucosal protrusion, by definition
no statement about the dignity of the mass
is possible. Polyps can be detected in about
10% of adults, increasing with age.

z Clinic
None, possibly blood in the stool.
Degeneration possible, endoscopy with
polyp removal is “real” cancer screening.

z Diagnostics
Endoscopy, only in case of incomplete and
not possible colonoscopy a virtual colonos- ..      Fig. 18.10 Mesorectal fascia (red arrow) with car-
copy by CT is performed. cinoma
 230 C. Vockelmann et al.

Postoperative/Posttherapeutic 55 Hiatal hernia with passage through the

Changes and Complications esophageal hiatus; axial hiatal sliding
These include: hernia (>90%): Cardia intrathoracic;
55 Anastomosis insufficiency, knowledge of paresophageal hiatal hernia: cardia
the anastomosis technique (e.g. end-to-­ abdominal; mixed hernia; special form:
side or end-to-end) is helpful here, thoracic stomach (upside-down stom-
55 Anastomosis Stenosis, ach) with herniation of more than 2/3 of
55 Postradiogenic changes after irradiation, the stomach to intrathoracic, risk of gas-
e.g. of a rectal carcinoma, are the almost tric volvulus
regularly detectable transformation of 55 Bochdale hernia in the dorsal part of the
the covered bone marrow into fatty mar- diaphragm bds. with prolapsing fat
row. In case of irradiation of bladder 55 Morgagni hernia in the ventral part near
and intestine, inflammatory changes of the sternum
the mucous membranes with cystitis or
colitis develop. Furthermore, there are different abdominal
wall hernias:
z Clinic 55 Paraumbilical hernia at the level of the
Anastomosis insufficiency with postopera- navel
tively increased infection parameters up to 55 Epigastric (above the umbilicus) or hypo-
sepsis. gastric (below the umbilicus) hernia:
Anastomotic stenosis leads to constipa- passing through the midline
tion. 55 Spieghel hernia between internal and
external transverse abdominal muscles
z Diagnostics paramedian infraumbilical
CT/Fluoroscopy
Scar hernias are classified according to the
In this case, contrast medium leakage
previous operations:
occurs in case of insufficiency.
55 Internal hernias: Passage through the
Inflammatory changes of involved
mesenteric root
organs in the irradiation field lead to wall
55 Inguinal hernias: directly through the
thickening with hypodense imaging on CT.
Hesselbach triangle or indirectly along
MR
the inguinal canal
MR shows a postradiogrenous fat mar-
55 Femoral hernias: medial along the femo-
row with corresponding hyperintense imag-
ral vessels; predominantly in women
ing in T1w sequences as well as a very sharp
55 Obturator hernias: Passage between
border to the non-irradiated bone marrow.
obturator muscle and ridge muscle

z Clinic
18.2.6 Mesentery, Peritoneum Protrusion, passage problems up to ileus
and Abdominal Wall with a picture of acute abdomen, in case of
entrapment also danger of vascular strangu-
Hernias
18 lation; in case of hiatus hernia thoracic
Hernias are caused by the contents of the tightness, reflux.
abdominal cavity passing through fascia of
the abdominal wall or mesentery. z Diagnostics
A distinction is made between the fol- Sonography
lowing diaphragmatic hernias: The first diagnostic test is sonography.
Gastrointestinal Tract
231 18
CT 55 Situs inversus totalis: thoracic and
A CT is used to evaluate the hernial ori- abdominal mirror-image arrangement of
fices and contents. organs
Conventional X-ray (. Fig. 18.11) 55 Malrotation: arises in the 5th–6th embry-
A hiatal hernia is a frequent incidental onic week
finding on chest x-ray with retrocardiac –– Nonrotation: large intestine on the
space with mirror formation. left, small intestine on the right in the
abdomen
 ositional Changes of Organs
P –– Malrotation I: Coecum and ascending
of the Abdominal Cavity colon lie in front of the small intesti-
These include: nal loops

a b

..      Fig. 18.11 Hiatal hernia. a In CT, b In X-ray p. a. and c Laterally

 232 C. Vockelmann et al.

–– Malrotation II: the colon lies behind, ated with retroperitoneal fibrosis and
the distal duodenum in front of the Whipple’s disease and lead to wall thick-
mesenteric root ening of small bowel loops
55 Sigmavolvulus: rotation of the sigmoid 55 Lipoma: Fatty tissue tumor
colon around its mesenteric axis 55 Endometriosis: Functional endometrial
tissue outside the cavum uteri
z Clinic
Sigmavolvulus: acute abdomen with ileus, z Clinic
common in patients >70 years of age. Endometriosis: typical triad with dysmenor-
rhea, dyspareunia and infertility.
z Diagnostics
Situs inversus and malrotations are often z Diagnostics
incidental findings on radiographs, sonogra- Endometriosis cysts are up to 15 cm in
phy, and CT imaging of the abdomen. size; if they are hemorrhagic, they appear
In sigmoid volvulus (. Fig. 18.12) the as chocolate cysts. Endometriosis lesions
coffee bean sign is pathognomonic, in CT are often only a few mm in size and are
rotation of the mesenteric root as whirl- hardly visible on imaging. Laparoscopy
pool-sign (. Fig. 18.13). remains the gold standard; transvaginal
ultrasound and MRI can be used to
 enign Changes of the Mesentery
B attempt detection.
and Abdomen MRI
Benign changes include: MRI shows T2w hypointense lesions
55 Panniculitis mesenterialis: Chronic with single hyperintense spots. Hemorrhages
fibrosing change of the mesenteric root. can be hyperintensely delineated in a fat-­
Often incidental finding, may be associ- saturated T1w sequence.

a b

18

..      Fig. 18.12 a, b Volvulus

Gastrointestinal Tract
233 18

..      Fig. 18.14 Omental cake

..      Fig. 18.13 Whirl-pool-sign

exclusion of peritoneal carcinomatosis.

Malignant Changes Peritoneal tumor nodules as CM enhance-
of the Peritoneum and Abdomen ment can rarely be detected.
Peritoneal carcinomatosis is the most com- A typical manifestation of peritoneal
mon malignant disease of the peritoneum carcinomatosis in ovarian carcinoma is the
and occurs mainly in tumors of the ovary, so-called “omental cake”, which can be
stomach, colon, mamma, pancreas and delineated on CT as a pronounced nodular-­
lung. surfaced compression of the omentum majus.
A rare special form is pseudomyxoma Calcifications in the peritoneum are also
peritonei with gelatinous implants in pri- indicative of ovarian carcinoma as the pri-
mary tumors of appendix and ovary.
mary tumor (. Fig. 18.14).
Sarcomas, liposarcomas, or primary
peritoneal carcinomas are rare forms of pri-
mary malignancy of the peritoneum or
18.2.7 Liver and Biliary System
abdomen.
Fatty Liver (Steatosis Hepatis)
z Clinic
B-symptomatics due to tumor disease, asci- 35–40% of the adult population in industri-
tes with abdominal circumferential prolifer- alized nations show increased fat storage in
ation. the hepatocytes. The fatty liver shows dif-
ferent degrees of severity up to micronodu-
z Diagnostics lar cirrhosis. Non-alcoholic fatty liver
Sonography/CT disease is mainly caused by the metabolic
Sonographically and CT-­morphologically syndrome. Approximately 5–10% of the
ascites can be easily detected. However, the population in Western Europe has alcoholic
exclusion of ascites does not mean a definite fatty liver.
 234 C. Vockelmann et al.

z Clinic
Early stages asymptomatic, in late stages
clinic of liver cirrhosis.

z Diagnostics
Sonography
In the ultrasound image the liver is rich
in echoes, well demarcated in comparison to
the kidney.
CT
On CT the liver is more hypodense (nor-
mal value 55–65 HU), the hepatic vessels
can be demarcated hyperdense to the liver
tissue in the native image.
..      Fig. 18.15 Liver cirrhosis with collaterals and
Storage Disorders splenomegaly
This includes:
55 Iron: Primary hemochromatosis, hemo- z Diagnostics
siderosis (transfusion- or nutrition-­ CT (. Fig. 18.15)
related); deposition also in myocardium Imaging shows a small- or coarse-­
55 Copper: Wilson’s disease with pathogno- nodular remodeling of the liver with an
monic Kayser-Fleischer corneal ring, undulating surface of the liver. The paren-
deposits also in the basal ganglia chyma is inhomogeneous, the liver margin
rounded. In portal hypertension, portal
venous bypasses via the splenic vein, esoph-
z Clinic ageal varices, or recanalization of the umbil-
Hepatomegaly, liver enzyme elevation. ical vein can be demonstrated.
Regenerative nodules can often not be
z Diagnostics distinguished from hepatocellular carci-
CT/MRI noma (section liver cirrhosis) with ultra-
Storage diseases usually lead to increased sound and CT. Here, MRI of the liver with
density of the liver on CT (>70 HU) or to a liver-specific contrast agent helps. In con-
signal drop of the liver on MRI in T2w trast to HCC, regenerated nodules retain the
sequences. contrast medium and are isointense to the
liver tissue in late T1w images.
Liver Cirrhosis
This leads to the destruction of the liver Benign Tumors of the Liver
parenchyma and the formation of fibrosis and Biliary Tract
and regenerative nodules. The incidence in These include:
Europe is approx. 250/100,000/year. The 55 Hemangioma: The most common benign
etiological cause is alcohol abuse in up to liver tumor with about 10% in autopsy
18 40% of cases and viral hepatitis in about specimens.
55%. 55 Hepatocellular adenoma: Relatively rare,
frequent in women of childbearing age,
z Clinic hamartoma of the hepatocytes, some-
Hepatic insufficiency, portal hypertension. times very large (>10 cm); surgical indi-
Gastrointestinal Tract
235 18
cation especially for large and Cystic Lesions of the Hepatic Cavity
superficially located adenomas; risk of Cystic hepatic space claims are subdivided
degeneration in adenomatosis with >10 into:
adenomas. 55 Dysontogenetic multiple or solitary liver
55 Focal nodular hyperplasia (FNH): Pre- cysts: Frequent incidental finding
dominantly women, frequent with oral 55 Echinococcosis: Caused by larvae of the
contraceptives, hamartoma of normal fox tapeworm, incubation period
liver tissue. 10–20 years, usually asymptomatic
55 Abscess: Consequence of bacteremia
z Clinic through the portal vein, e.g. in diverticu-
Asymptomatic, incidental finding, rarely litis or appendicitis; multiple small
bleeding complication in hemangioma or peripheral abscesses in cholangitis
large adenomas. 55 Liver hematoma: Hemorrhage into the
liver; caveat: free perforation with bloody
z Diagnostics ascites, concomitant splenic injury
Step-by-Step Diagnostics
A stepwise imaging diagnosis with color z Clinic
duplex sonography, CE-ultrasound, multi- Abscess with typical clinic (fever, laboratory
phase CT, MRI; PET-CT for differentiation constellation); liver hematoma after trauma
from malignant tumors is recommended: with upper abdominal pain.
55 Hemangioma: Sonographically echo-­
rich, typical garland-shaped arterial z Diagnostics
enhancement, “closing” in portal venous CT
and later phase with hyperdense imaging A fluid isoechogenic or -isodensic picture
in CT compared to surrounding liver is seen centrally. The cysts are sharply delin-
parenchyma. eated without rim enhancement and with
55 Hepatocellular adenoma: Small tumors sonographic dorsal sound enhancement. An
isoechogenic, arterial enhancement, abscess is seen with thickened capsule and
venous iso- to hypodense. rim enhancement, bleeding is hyperdense to
55 FNH: Arterial enhancement, rapidly the liver on CT depending on the stage
parenchymisodens; central scar with late (. Fig. 18.17).
enhancement in MR (. Fig. 18.16).

a b c

..      Fig. 18.16 Liver hemangioma H and metastasis M, a arterial, b late, c venous

 236 C. Vockelmann et al.

a b

c d

..      Fig. 18.17 Liver cysts a arterial and b venous. c Liver abscess. d Liver hematoma with sarcoma metastases

Pseudotumours localization is at the falciform ligament; a

This is a focal textural disturbance of the lesser degree of fatty degeneration is more
liver that may mimic a mass. Especially often echoic on sonography.
it is a focal excess or deficiency of fat.
Budd-Chiari-Syndrome
z Clinic It is the occlusion of the venous outflow
Asymptomatic. from the liver, in the typical picture with
occlusion of the large hepatic veins and the
18 z Diagnostics hepatic venous sternum.
A focal multiple fatty lesion is seen on
sonography to be anechoic, sharply demar- z Clinic
cated, more map-like than round; CT and Hepatomegaly due to the outflow obstruc-
MRI show evidence of fat, hypodense to the tion, lack of flow signal in the hepatic
surrounding parenchyma. The most frequent veins.
Gastrointestinal Tract
237 18
z Diagnostics primary tumors often gastrointestinal or
MRI mammary
There is hepatomegaly with detectable
increased T2 signal and occlusion of the z Clinic
hepatic veins. In HCC usually associated with liver cirrho-
sis; liver metastases with B-symptomatics;
Malignant Tumors of the Liver with large tumor burden capsular pain.
and Biliary Tract
These include: z Diagnostics
55 Hepatocellular carcinoma, usually as a 55 HCC: Arterial early enhancement with
result of liver cirrhosis (>90%), at the wash-out. A typical finding on two imag-
time of diagnosis in 50% of patients mul- ing modalities is considered conclusive in
tilocular growth, metastasis mainly in the presence of liver cirrhosis
lymph nodes and also bones (. Fig. 18.18).
55 Liver metastases: Most common form of 55 Liver metastases: Different appearance
malignant liver disease, often multiple; depending on the primary tumor, often

a b

c d

..      Fig. 18.18 HCC. a–c Arterial, venous, late, d In MR T2fs

 238 C. Vockelmann et al.

echo-poor halo, rim enhancement on CT, avoid implantation metastases (about in

predominantly hypodense but not liquid 2%).
isodense (. Fig. 18.19).
. Table 18.3 once again provides an over-
>>Tumor puncture of HCC should be view of differential diagnostic factors.
avoided at potentially curative stage to

b c

d e

18

..      Fig. 18.19 Liver metastases. a Sono, b Arterial, c Venous, d T1, e T2

.       Table 18.3 Differential diagnosis of liver diseases
Gastrointestinal Tract

Tumor Ultrasound CT Density MRI Signal Morphology CM Behavior

Entity

Cyst Echo-free, dorsal Liquid T2w strongly hyperintense, T1w Sharply defined, round No enhancement
sound amplification isodens hypointense
Heman- Echo rich, variable Blood T2w hyperintense, “light bulb Sharp, larger hemangiomas Garland-like early enhancement in
gioma with increasing size isodens phenomenon” with increasing often lobulated and the marginal area, “closing” in portal
signal intensity with increasing somewhat inhomogeneous venous and especially in the helpful
T2 weighting late phase
Adenoma Isoechogenic, Iso/hypoden Non-specific; T1w iso/hypoin- Often in larger findings Short-term enhancement, late
variable with tense, T2w iso/hyperintense inhomogeneous with approximation to the parenchyma or
hemorrhages hemorrhages and necroses washout
FNH Iso-, slightly Iso/hypoden T1w isointense, T2w iso-, Central scar, wheel spoke Rapid enhancement, then alignment
hyperechogenic possibly hyperintense pattern with liver, late enhancement of scar
Abscess Echo-free to Hypo to T2w hyperintense, T1w Especially at the beginning Marginal CM enhancement
echo-poor with liquid isodens hypointense rather blurred delimitable
fringe with hypodense rim
HCC Echo rich, cirrhosis Slightly Variable, T1w hypointense, T2w Complex imaging for hemor- Irregular arterial enhancement not
of the liver hypodense hyperintense rhages and necroses, rarely only in the tumor margin, portal
also fat detection possible venous wash-out
Liver Often echo-poor Iso/hypoden T1w hypointense, T2w hyperin- Blurred boundaries, often Rim enhancement depending on the
239

metastasis with fuzzy tense multiple degree of vascularization

echo-poor rim
(target sign)
18
 240 C. Vockelmann et al.

18.2.8 Gall Bladder and Bile Ducts CM phase with sonographically and CT-­
morphologically thickened, three-layered
Cholecystolithiasis gallbladder wall.
These are concretions formed mostly in the MRI
gallbladder, of which 80% are cholesterol In MRI, signal extinction occurs in
stones, 20% bilirubin stones. Pigment stones MRCP due to stones; in this case, a very
sediment at the bottom of the gallbladder, sensitive detection of choledocholithiasis is
cholesterol stones float in the gallbladder. possible (. Fig. 18.20).
The prevalence in women is about 15%, in
Gall Bladder Polyp
men about 7.5%. Choledocholithiasis occurs
simultaneously in 10–15%. The gallbladder polyp is a primarily benign
polyp-like growth of the gallbladder wall. In
z Clinic 95% it is not a true polyp, but cholesterol
75% asymptomatic; 25% with colicky com- deposits in the mucosa. A cholecystectomy
plaints in the right upper abdomen, unspe- is recommended from ≥1 cm with an
cific with a feeling of pressure/fullness, increased risk of carcinoma.
intolerance e.g. of fatty foods.
z Clinic
Complications: acute cholecystitis, chol-
angitis; recurrent cholecystitis can lead to Incidental finding.
shrinking gallbladder and porcelain gall-
z Diagnostics
bladder, late complication gallbladder carci-
noma; choledocholithiasis with colicky pain Polypoid thickening of the wall, a DD to
and possible cholangitis. gallstones is possible sonographically by
repositioning the patient.
z Diagnostics
 rimary Sclerosing Cholangitis
P
Sonography (. Fig. 18.20)
(PSC)
An ultrasound is very sensitive with
echo-rich lesions in the gallbladder showing PSC is a sclerosing chronic inflammation
dorsal acoustic extinction. and destruction of the intra- and extrahe-
CT patic bile ducts. It frequently occurs between
Gallstones are often not visible on CT. In the 30th and 50th year of life, the incidence
cholecystitis there is an increased enhance- is approx. 1/100,000/year.
ment of the gallbladder bed in the arterial
z Clinic
In the early stage incidental finding, in the
further course jaundice with itching; biliary
cirrhosis as complication.

z Diagnostics
ERCP (gold standard) or MRCP show a
pearl cord-like duct irregularity. In case of
18 doubt, histological confirmation is required.

Gallbladder Carcinoma
This is a maglinoma of the gallbladder,
mainly >70th year, risk factors: cholelithia-
sis and chronic cholecystitis as well as porce-
..      Fig. 18.20 Cholecystolithiasis on sonography lain gallbladder.
Gastrointestinal Tract
241 18
z Clinic Pancreas anulare is a very rarely occur-
Incidental finding, in case of symptoms late ring malformation with a constriction of the
finding with icterus or palpable tumor in the duodenum. The infantile form is manifested
gall bladder bed. in the first days of life, the adult form
between the 20–50th year.
z Diagnostics
Wall thickening and infiltrative growth into z Clinic
the liver are seen; in the early stages, the car- 55 Pancreas divisum: Mostly asymptomatic
cinoma is often not recognizable on ­imaging. 55 Pancreatic anulare: Stenosis symptoms,
ulcers, chronic pancreatitis.
 holangiocellular Carcinoma (CCA),
C
Klatskin-Tumor z Diagnostics
This malignant tumor originates from the MRCP
bile duct epithelium, and the majority of The MRCP shows a morphological gait
cases are adenocarcinomas. representation.
Classification: Intrahepatic CCA; perihilar MRI
CCA (Klatskin tumor), here further classifica- In anulare pancreas, MRI shows con-
tion according to the Bismuth classification to striction of the duodenum by pancreatic tis-
assess also a potential operability; distal CCA sue.
below the outlet of the D. cysticus.
Acute and Chronic Pancreatitis
z Clinic This is an acute or chronic inflammation of
No early signs. Clinically classic painless the pancreas. Men are more frequently
jaundice and palpably enlarged gallbladder affected than women. Etiology: biliary tract
(=Courvoisier sign); laboratory chemically diseases, e.g. choledocholithiasis, alcohol
abuse, hereditary, drugs.
cholestasis parameter.
Special form: autoimmune pancreatitis,
Diagnostics which leads to chronic pancreatitis due to
z
fibrosis.
Sonography, endosonography, MRI with
MRCP; CT abdomen, ERCP. In all proce-
z Clinic
dures, evidence of the biliary obstruction
Belt-shaped upper abdominal pain, elevated
can be obtained, the tumor itself may be
pancreatic enzymes (especially lipase), asci-
detectable by endosonography, in CT and
tes, fever. Clinic up to hypotension and signs
MRI usually only in relatively large tumors.
of shock, also ECG changes possible.

z Diagnostics
18.2.9 Pancreas Sonography/CT
In the acute situation, sonography and
 ancreas Divisum and Pancreas
P
later a CT scan are performed for further
Anulare clarification. The degrees of severity range
Pancreas divisum is the most frequent mal- from oedematous pancreatitis, which is
formation of the pancreas (prevalence often barely detectable in terms of image
approx. 6%), caused by a lack of fusion of morphology, to exudative pancreatitis with
the ventral and dorsal pancreatic anlagen. peripancreatic fluid accumulation (often
This results in a complete or incomplete sep- misleadingly referred to as “necrotic pancre-
aration with the opening of two ducts in the atitis”), to necrotising pancreatitis with cell
papilla major and papilla minor. death of the pancreatic tissue. This can be
 242 C. Vockelmann et al.

demonstrated on CT by absent or reduced z Clinic

contrast of pancreatic portions. Symptoms usually only at an advanced
In chronic pancreatitis, pancreatic calci- stage. Icterus especially with localization
fications are evidential. Pancreatic duct pancreatic head and papilla.
stones and pearl cord-like changes in the
ductus wirsungianus are also signs of z Diagnostics
chronic pancreatitis. Endosonography
MRI Endosonography is the most sensitive
Autoimmune pancreatitis shows a seg- method and is clearly superior to CT and
mental distention of the pancreas with a nar- MRI. An important sign is a dilatation of
rowed ductus wirsungianus. Late the ductus wirsungianus.
enhancement with late CM accumulation is CT
characteristic in late MRI images. An In CT, an additional CM spiral should
important DD in all forms of (chronic) pan- be run over the pancreas late arterially (delay
creatitis is pancreatic carcinoma, which can 25–30 s), here the tumor can be delineated
often only be excluded surgically. hypodense to the remaining, rapidly accu-
mulating pancreatic tissue. The question of
Pancreatic Laceration vascular infiltration as well as signs of lym-
This is a contusion or rupture of the pancre- phogenic or peritoneal metastasis is impor-
atic parenchyma, especially in the corpus tant for the clarification of operability.
section due to pressure on the upper abdo- Preoperatively, the vascular anatomy of the
men, so that the pancreas is compressed in liver should always be assessed, since variant
front of the spine, e.g. in a bicycle accident vascular supply requires a corresponding
by the bicycle handlebars. adaptation of the surgical procedure.

z Clinic Cystic Pancreatic Neoplasms

History, signs of pancreatitis, possibly active These include primarily cystic tumors that
bleeding. originate from the ductal epithelium. Cysts
arise due to the formation of mucus.
z Diagnostics Classification: IPMN from the main
CT duct (60%), side duct IPMN (mainly proc.
CM-CT is the method of choice for uncinatus), solid pseudopapillary pancreatic
abdominal trauma. In the area of injury, neoplasia (SPN), mucinous cystic pancre-
there is reduced CM enhancement, possibly atic neoplasia (MCN), serous cystic pancre-
also CM leakage in the case of active bleed- atic neoplasia. Overall, about 25–40% are
ing as well as exudates peripancreatitically. malignant tumors.

Pancreatic Carcinoma z Clinic

This is a malignant mass of the pancreas, Usually asymptomatic, possibly clinic as in
usually originating in the ductal system. It is chronic pancreatitis.
most frequently localized in the pancreatic
18 head. The incidence is 15/100,000/year, the z Diagnostics
mean age of onset is 70–75 years. Incidental finding in sonography or
Histologically, most are adenocarcinomas. CT. Clarifying diagnosis with endosonogra-
Papillary carcinomas show a significantly phy and, if necessary, endosonographic cyst
better prognosis. puncture (elevated CA19-9 in the cyst indi-
Gastrointestinal Tract
243 18
cates malignancy), MRCP, ERCP to show supplemented and expanded by power or
communication with the ductal system. DD color duplex procedures and, especially in
e.g. pseudocysts in chronic pancreatitis (cal- the clarification of pancreatic processes, an
cifications?) or serous/mucinous cystade- endosonographic procedure.
noma (both show no connection to the
ductal system). Conventional Diagnostics
In cases of suspected malignancy as well Conventional imaging is increasingly regres-
as IPMN, surgical resection is usually per- sive in the diagnosis of abdominal diseases,
formed. as CT provides disproportionately more
information at increasingly lower doses. For
Pancreatic Endocrine Tumors the detection of free air, the abdominal over-
The group of neuroendocrine tumors of the view must be performed either in the stand-
pancreas are divided into insulinomas, gas- ing position or, more frequently, in the left
trinomas, VIPomas, glucagonomas, etc. lateral position (LSL). In this case, the image
depending on the leading hormone secre- should not be taken before 5 min have
tion. Insulinomas are mostly benign, all elapsed in appropriate positioning, as the air
other endocrine pancreatic tumors are often needs time to collect. Air in the GI tract
malignant. should be low detectable in all bowel seg-
ments. Air-fluid levels in the LSL are indica-
z Clinic tive of ileus in the affected intestinal
Depending on the hormone secretion. segment. However, ileus can also be associ-
ated with fluid-filled loops of bowel only,
z Diagnostics which then escape conventional diagnosis
Sonography/Endosonography and are readily detectable sonographically.
Sonography and endosonography show Oral contrast medium administration as
an echo-poor, well-defined mass in the pan- gastrointestinal passage (MDP) is often per-
creas. Thereby the masses can show an enor- formed in subileus conditions, e.g. postop-
mous size of up to 40 cm in the glucagonoma. eratively, in order to delineate possible
CT passage obstructions. Often the contrast
However, they are often small findings medium also has a therapeutic effect and
(<3 cm) with hypervascularization in the has a prokinetic effect.
arterial, venous or late phase (multiphase
Swallowing Study
CT of the pancreas). Usually there is no
obstruction of the ductus wirsungianus. For the diagnosis of swallowing disorders of
the pharynx, fluoroscopy is performed in the
lateral beam path. It is important to record
the entire pharynx up to the upper esopha-
18.3 Diagnostics
gus (image borders: anterior row of teeth,
hard palate, cervical vertebral bodies, at
18.3.1 Diagnostic Radiology least 3 cm below the epiglottis. For the eval-
uation of the physiological movements of
Sonography the swallowing act with elevation of the
Sonography represents the primary imaging hyoid and closure of the epiglottis, higher
modality for all abdominal diagnostics. A image frequencies of 15–30 images/sec are
systematic approach with adherence to stan- necessary. If necessary, an examination of
dard planes is important. In addition, image the swallowing act with different consisten-
documentation of pathological findings cies (solid, mushy, liquid) is necessary. For
must be performed. B-mode sonography is this purpose, bread or biscuits and yoghurt
 244 C. Vockelmann et al.

mixed with contrast medium can be swal- obscure the caliber jump as a sign of
lowed by the patient during the exposure. mechanical ileus.
A special form of colon diagnostics is
Esophageal Swallow virtual colonoscopy, which should be per-
As a rule, the esophageal swallow is nowa- formed in particular in the case of incom-
days performed with water-soluble contrast plete colonoscopy. For this purpose, rectal
medium. This has the disadvantage of sig- air or, because it is better tolerated, CO2 is
nificantly poorer assessability of the mucous insufflated. Butylscopolamine suppresses
membranes, but this is the domain of endos- peristalsis and leads to dilatation of the
copy anyway. The pure function with assess- intestine. The evaluation is done with special
ment of contractility and reflux are usually computer programs, where a virtual colo-
sufficiently detectable with water-soluble noscopy and other special reconstruction
contrast medium. If there is a tendency to are calculated. The examination is usually
aspiration, imaging of the neck with detec- performed in the supine and prone position.
tion of the upper esophageal orifice is cru- A low dose is sufficient for the evaluation of
cial. In principle, all sections of the the colon, but at least in the absence of con-
esophagus should be imaged in two planes; traindications and previous images, it is
the thoracic section is better imaged in an advisable to perform the supine series as a
oblique image than in the lateral beam path. diagnostic CT with also intravenous con-
For reflux testing, the patient must be placed trast.
in a head-down position during the exami-
nation. Reflux can sometimes also be pro-  olonic Contrast Enema,
C
voked in the prone position and under Conventional and MR
Valsalva maneuver. An esophageal exami- Defecography
nation usually includes an image of the Nowadays, colon contrast enema has been
stomach with documentation of the outflow replaced by endoscopy and, if necessary, CT
of the contrast medium into the duodenum diagnostics. One of the few remaining indi-
and the downstream loops of the small cations is the examination of an ­anastomosis
intestine. in case of suspected insufficiency or prior to
re-displacement, whereby CT is increasingly
CT Abdomen used here as well.
CT examinations for clarification of the Defecography is again gaining in impor-
abdomen are performed after intravenous tance with increasingly differentiated treat-
and oral (negative) contrasting whenever ment of pelvic floor disorders. For this
possible. If malignancy is suspected, a mul- purpose, rectal contrasting and, in the case
tiphase CT with arterial coil should be per- of conventional imaging, also oral and, if
formed over the upper abdomen. A necessary, vaginal contrasting is performed.
multiphase CT with a late spiral, if neces- The advantage of conventional imaging is
sary, is also helpful in the search for bleeding the natural sitting position, the advantage
in order to be able to detect a contrast of MR defecography is the lack of radiation
medium leak. Liver and pancreas diagnos- exposure and excellent soft tissue assess-
18 tics are also performed as multiphase CT in ment. The images are taken in the lateral
the case of suspected tumors. Rectal con- beam path or in sagittal slice guidance.
trast fillings are helpful in the evaluation of Single images at maximum tension of the
inflammatory or tumorous colonic pro- pelvic floor and during the Valsalva maneu-
cesses. In cases of suspected ileus, oral or ver are helpful. Subsequently, a series of
rectal contrast is disturbing because it can images is taken during defecation.
Gastrointestinal Tract
245 18
MRI Liver tense in the perirectal fat tissue. Contrast
Liver lesions can be very well differentiated medium is usually not necessary and tends to
using an MRI scan of the liver. The use of overestimate the extent of the tumor.
fat-sensitive sequences is important, for Important in the evaluation of a rectal MR
example, in the assessment of focal multiple for therapy and prognosis is, in addition to
fatty lesions, usually with an in- and the local lymph node status, the assessment
opposed-phase sequence. Liver-specific con- of the depth of infiltration into the perirectal
trast agent can very accurately differentiate fat tissue and the distance of the tumor exten-
healthy liver tissue that stores the contrast sions from the mesorectal fascia.
agent in the hepatocytes and, for example,
metastases.
18.3.2 Nuclear Medicine
MR-Sellink and MR-Rectum
Small bowel examination is nowadays the Ursula Blum
domain of MRI. A good distension and
fluid filling of the small intestine is neces-
sary. This is achieved by an oral administra- Oesophagus
tion of 1–2 L of mannitol or sorbitol, which Nuclear medical functional examinations of
the patient should drink in the last two the esophagus have become very rare in clini-
hours before the examination. cal routine and have been replaced by endos-
Butylscopolamine is administered to copy, ph-metry and esophageal manometry.
decrease motility of the bowel for the exam-
ination. Typical sequences include fast axial Stomach
and coronary T2w sequences (e.g., HASTE) Gastric Function Examination
and axial and coronary fat-saturated T1w Most diseases of the stomach are detected
images before and after contrast administra- by endoscopic examination. Scintigraphy is
tion. Increasingly, additional diffusion requested in patients with altered gastric
weighting is obtained, which can sensitively passage (e.g. delayed in the context of diabe-
detect pathologic processes as signal tes mellitus or too rapid passage).
enhancement despite the low spatial resolu- The examination is performed with
tion. T2w images provide a good overview either radiolabelled liquid, semi-solid or
of the intestine, inflammatory small bowel solid meal (. Table 18.4). The various tech-
processes show wall thickening with niques and meals have not been standard-
increased enhancement. Fistulas can also be ized to date. Therefore, both test meals and
detected well in an MR-sellink. the standard values of gastric emptying vary
For local staging of rectal carcinoma, an greatly.
MRI of the rectum is nowadays usually per- Normal half-life is about 30 min for liq-
formed in addition to endoscopic and endo- uids and about 90–120 min for solid meals.
sonographic diagnostics. Rectal contrasting is
helpful; sonogel, which the patient can hold Gastric Carcinoma, Gastrointestinal
relatively well and which provides a high T2 Stromal Tumors (GIST)
signal, is usually used for this. In addition to The 18F-FDG-PET/CT shows only limited
sagittal and, if necessary, coronal sequences, sensitivity in the staging of gastric carci-
paraaxial sequences T1w and T2w tilted noma. In particular, lymph node metastases
towards the tumor are mainly prepared. It is can only be assessed to a limited extent.
important to avoid fat saturation, as the In the case of GIST tumors, a strong
tumor extensions can then be detected hypoin- enhancement is found, here PET/CT is used
 246 C. Vockelmann et al.

atobiliary function scintigraphy or choles-

..      Table 18.4 Procedure for gastric scintigra-
phy
cintigraphy to assess bile production and the
biliary excretory system are very rarely per-
Patient Sober, nicotine abstinence, suspend formed today. Liver blood pool scintigraphy
Prepara- tablets if necessary for the differentiation of various liver
tion tumors has also been superseded by meth-
Activity Depending on the investigation
ods such as multiphase CT, CM sonography
Liquid: 20–40 MBq 99mTc-DTPA, and MRI with liver-specific contrast
-MAA or nanocolloid medium.
Semi-solid: 70 MBq 99mTc-tin
colloid in 400 mL gruel Liver Perfusion with MAA, Calculation
Solid: 40–100 MBq 99mTc-DTPA,
-MAA or nanocolloid in test meal
of A Liver-Lung Shunt (. Table 18.5)
(boiled egg, scrambled egg) For malignant diseases of the liver (HCC,
Applica- Oral
HCA, metastases), various non-surgical
tion therapy options are available today. These
include chemotherapy (possibly also intra-
Acquisi- Dynamic sequence over
tion 60–90 min, 20 s/frame; 64 * 64
hepatic as TACE), thermal ablation and
matrix SIRT.
In particular, before SIRT, a MAA
Special If both liquid and solid phases are
Features to be assessed in one test, the solid examination of the liver must be performed,
phase can be labelled with including calculation of a liver-lung shunt.
111In-DTPA
The evaluation is performed visually,
Evalua- ROI technique and special attention should be paid to
tion extrahepatic nuclide accumulations. In case
of detectable intra-abdominal accumula-
tions, a repetition of the angiography with
especially with regard to a tumor response occlusion of further collateral vessels (if
to therapy. necessary, surgical intervention) is indicated,
and a repetition of the MAA liver examina-
Liver tion is mandatory.
Liver perfusion scintigraphy to estimate the The lung shunt is calculated quantita-
arterioportal blood flow ratio as well as hep- tively using the following formula:

Counts Lunge
 100  Lungenshunt %
Counts Lunge  Counts Leber

with indication of the mean value from both 55 Cholangiocellular carcinoma (CCC):
projections. Cholangiocellular carcinoma shows
18 more marked enhancement than HCC in
Liver Tumors and PET/CT most cases. Distant metastases can be
55 Hepatocellular carcinoma (HCC): Hepa- visualized relatively reliably, whereas
tocellular carcinomas show different regional lymph node metastases can only
behavior with regard to FDG storage. So be visualized to a limited extent.
far, there is no general recommendation 55 Metastases: Many primary tumors
for PET/CT. metastasize to the liver. Only for metas-
Gastrointestinal Tract
247 18

.       Table 18.5 Procedure for SIRT ..      Table 18.6 Procedure for scintigraphy with
99mTc-labelled erythrocytes

Patient 30 min before angiography thyroid

Prepara- blockade with 400 mg perchlorate Patient 30 min before the examination
tion First angiography of the liver with Prepara- thyroid blockade with 400 mg
occlusion of existing collateral tion perchlorate
vessels, catheter left in place
Activity In vitro labeling of erythrocytes:
Activity 150 MBq 99mTc-MAA Draw sufficient patient blood
(<1,000,000 particles) (heparinized tube)
Marking with tin pyrophosphate
Applica- Intra-arterial via the horizontal
according to manufacturer’s
tion catheter in the liver
instructions
If necessary, division of the
Incubation for 30 min or
activity according to the vascular
according to manufacturer’s
supply of the tumor
instructions
Acquisi- Static images ap, pa of the Add 700 MBq 99mTc-pertechnetate
tion abdomen or whole-body Test for mark yield (>85%), then
scintigraphy Reinjection
Static images ap, pa of the thorax In vivo labelling or in vivo/in vitro
including the liver labelling is possible in emergency
SPECT(/CT) of the abdomen cases, but the labelling yield is
LEHR significantly worse than in vitro
labelling
Evaluation Visual, quantitative
Applica- i. v.
tion:
Acquisi- Dynamic 1 min/image over 60 min
tion from ventral (Kuwert)
tases of colorectal cancer there are suffi- Thereafter, ventral static images
cient studies. Here, PET/CT is of great every 15–30 min up to a maximum
of 24 h p. i.
importance, especially for therapy plan-
From bleeding detection dynamic
ning. A single liver metastasis can in recording over 30–60 min
principle be cured by surgical resection. 128 * 128 matrix
In these studies, PET/CT usually showed
Evalua- Visual
a higher sensitivity than CT or MRI. In tion
addition, previously unknown extrahe-
patic metastases can be detected. In the
case of recurrence, PET/CT also allows a
more precise diagnosis due to the altered
anatomy of the liver; in addition, ther- Here, scintigraphy with 99mTc-labelled eryth-
apy monitoring with chemotherapy is rocytes can detect bleeding from 0.05–
possible at an early stage. 1.0 mL/min (. Table 18.6).

Intestinal Carcinomas
Intestine z Carcinomas of the Small Intestine
Bleeding Source Search Carcinomas of the small intestine are rare
Intra-abdominal sources of bleeding are tumors; they are frequently neuroendocrine
easily detectable in endoscopically accessible tumors. These tumors generally have an
sections and may also be directly treatable. increased number of somatostatin receptors,
However, a large proportion of the small which are accessible to nuclear medicine
intestine cannot be reached endoscopically. diagnostics and therapy. Here, either 111In-­
 248 C. Vockelmann et al.

..      Table 18.7 Scintigraphy with 111In-­ ..      Table 18.8 Scintigraphy with 68Ga-­
Ctreotide somatostatin analogues

Patient Discontinuation of somatosta- Patient Discontinuation of somatostatin

Preparation tin analogues Prepara- analogues, not fasting
tion
Activity 111 MBq 111In-octreotide
Activity 100–150 MBq 68Ga-somatostatin
Application Slow i. v.
analogue
Acquisition Whole body scintigraphy and
Applica- i. v.
SPECT 4 h and 24 h p. i.
tion
If necessary, static recordings,
late recordings up to 48 h p. i. Acquisi- 20–60 min p. i.
Medium-energy collimator tion 3–4 min/bed position
Evaluation Visual, ROI technique if Evalua- SUV determination
necessary tion
Special Laxative measures between Special Only in the context of a therapeu-
Features examinations Features tic trial, as the radiopharmaceuti-
High radiation exposure with cal is not approved for diagnostic
12 mSv use
High physiological activity in liver,
spleen and kidneys
Radiation exposure approx.
octreotide can be used (. Table 18.7), or in 2–3 mSv
PET/CT (PET/MRI) radioactively labelled
68Ga-somatostatin analogues (. Table 18.8),

mostly DOTA-TOC; more rarely DOTA-­

NOC, or DOTA-TATE. A 18F-FDG-PET/ Pancreas
CT is only suitable for poorly differentiated, Pancreas diagnostics is the domain of endo-
fast-growing tumors. scopic sonography. In unclear cases, nuclear
Depending on the findings, a nuclear medicine can be used as further diagnostics.
medical therapy with radioactively labelled Especially small pancreatic carcinomas
(90Yttrium or 177Lutetium) somatostatin can be detected by FDG-PET/CT with a
analogues can follow. relatively high specificity and sensitivity.
PET/CT is also useful for the diagnosis of
z Colorectal Carcinomas distant metastases and therapy monitoring.
PET/CT has a 1a-indication in recurrence In the case of neuroendocrine pancreatic
diagnostics and a 1b-indication in therapy tumors, tumors larger than 2 cm can be
monitoring. detected with a high degree of certainty
Limitations exist with changes whose using 111In-octreotide. In PET/CT, Ga-­
diameter is smaller than twice the maximum labelled somatostatin analogues are avail-
resolution of the PET scanner (partial vol- able here with68, showing an even higher
ume effect). As a rule, these are lesions with sensitivity of the diagnosis. If the neuroen-
a diameter of less than 10 mm. docrine tumors show a higher accumula-
18
Gastrointestinal Tract
249 18

.       Table 18.9 Value of the imaging procedures in the gatrointestinal region

Sonogra- Conven- CT MRI Nuk PET

phy tional

Clarification ileus P (P) W N N N

Acute abdomen P N P N N N
Staging of GI tract P N P W W W
tumors
Bleeding search P N P W W N
Clarification of liver P N W W (liver-specific CM, if N W
focus applicable)

N Not indicated, P Primary diagnosis, W Further diagnosis, * CT in contraindications for MRI

tion, a therapy with radioactively labeled therefore necessary to plan the puncture
(90Yttrium or 177Lutetium) somatostatin route sufficiently, in particular to avoid
analogues can be performed. injuring the lung with a pneumothorax.
Sufficient coverage of the findings by healthy
liver tissue must also be aimed for in order
18.3.3 Valence to avoid intraperitoneal bleeding. The punc-
ture itself is usually performed using the
Christel Vockelmann
coaxial technique. For this purpose, a guide
. Table 18.9 once again summarizes the needle is brought forward to the finding,
areas of application of the respective imag- through which several punching cylinders
ing techniques. can then be obtained.
A liver abscess is usually treated by
means of a drainage, a surgical procedure is
18.4 Therapy not necessary. The trocar technique should
be used for liver abscesses. Here, the drain-
18.4.1 Interventional Radiology age catheter is advanced directly with the
puncture needle. The advantage is that no
Christel Vockelmann germs or at least fewer germs are carried
along the puncture path than with the seld-
Puncture and Drainage inger technique. In this technique, the
For clarification or histological confirma- abscess is first punctured with a needle, fol-
tion of liver lesions, these can often be punc-
lowed by dilatation of the puncture path via
tured sonographically or also CT-guided.
an exchanged wire, and then the drainage is
For this purpose, the lesion is localized with
the appropriate procedure and the puncture advanced to the abscess via the wire. This
route is planned. In the case of CT-guided technique is mainly used for difficult punc-
puncture, it must be borne in mind that the ture routes, e.g. retroperitoneal for superin-
puncture is usually performed in a breathing fected pancreatic pseudocysts, if these
position with the patient awake and the cannot be relieved endoscopically via the
puncture route is in the slice plane. It is stomach.
 250 C. Vockelmann et al.

 hermal Ablation of Liver

T thy due to insufficient detoxification of the
Metastasis blood. In this case, the flow through the
Thermoablation is usually performed in the TIPSS can be reduced with a reducing stent.
liver as radiofrequency ablation or micro-
wave ablation. In both procedures, the Acute GI Bleeding
metastasis is punctured with the ablation Duodenal ulcers can usually be controlled
probe and the area around the probe is then endoscopically. However, if this is excep-
heated to 60–80 °C. The metastasis is then tionally unsuccessful, closure of the gastro-
ablated with the ablation probe. Because the duodenal artery with coils can be performed
metastasis is painful and easier to puncture, in addition to a surgical procedure. In this
this procedure is usually performed under case, access is via the coeliac trunk. It is
intubation anesthesia. The smaller the important that the distal parts of the gastro-
metastasis, the better the possibility of cura- duodenal artery are closed first to prevent
tive treatment. From a size of 3 cm, the risk bleeding by retrograde feeding of the gastro-
of local recurrence increases, even though duodenal artery from the superior mesen-
metastases of up to 5 cm can be approached. teric artery. After reaching the desired
Ultimately, the procedure can be used position, anchoring coils, small metal coils
almost as often as desired. A combination chosen large enough to anchor to the site,
with a surgical procedure (e.g. left hemi- are first released. Additional coils are then
hepatectomy and RFA of a metastasis in the inserted until the desired section of the ves-
right liver lobe) is also very possible. sel is occluded. Prior to completion of the
procedure, imaging should be performed via
Transjugular Intrahepatic the superior mesenteric artery to ensure that
Portosystemic Shunt (TIPSS) the bleeding has been adequately managed.
The TIPSS is an artificially created short-­
circuit connection between the portal vein Vascular Occlusions and Stenoses
and the hepatic veins to reduce portal hyper- In the case of occlusion or stenosis of the
tension in liver cirrhosis. Indications for this visceral arteries leading to acute or chronic
are complications of portal hypertension ischemia, the affected vessels are reopened
such as hepatorenal syndrome or massively via catheter intervention, especially in the
bleeding esophageal varices. To create the case of changes close to the origin. In the
TIPSS, a curved puncture needle is inserted case of chronic changes, a stent is usually
into the right hepatic vein via the jugular inserted. In acute thromboembolic occlu-
vein. From here, the puncture is made ven- sions, interventional thrombectomy with
trally in the direction of the right portal vein aspiration catheters and also intra-arterial
branch. Sonographic control of the punc- lysis can be performed in consultation with
ture is helpful here. After the correct reach- surgery. In addition, an exploration of the
ing of the portal vein is ensured by an abdominal cavity is necessary afterwards in
angiographic series, dilatation of the paren- order to resect necrotic parts of the intestine.
chymal tract through the liver and subse-
quent stent insertion is performed. TIPSS Portal Vein Embolization
18 insertion is complex and often unsuccessful In the case of a planned extended right
despite multiple puncture attempts. A com- hemihepatectomy, the remaining left liver
plication of TIPSS is hepatic encephalopa- lobe is often too small. Embolization of
Gastrointestinal Tract
251 18
the right-sided portal vein branches leads Case Study
to growth of the left liver lobe.
Embolization is performed by percutane- An engineer in a responsible position has
ous puncture of a right-sided portal vein worked in a company for many years.
branch. Then the desired portal vein Therefore, he was also assigned special
branches are occluded via various cathe- tasks, such as personnel support. He found
ters. For this purpose, so-­called occluders this activity very nerve-racking, especially
are often used, a kind of double metal when it came to taking into account the
umbrella that effectively serves to occlude holiday wishes of all colleagues equally. To
even larger vessels. relax, he would often have resorted to ciga-
rettes or chocolate, knowing full well that
this would exacerbate the acid regurgitation
and stomach pains that had long plagued
18.4.2 Radiotherapy him. Since he retired, he has been doing
light endurance sports regularly and has
Guido Heilsberg given up sweets in order to get rid of his
excess weight. He has not yet succeeded in
giving up smoking. The only thing that
Oesophageal Carcinoma worries him is his still existing upper
55 Depending on the tumor stage, therapy abdominal pain, which he attributed to
is definitive or neoadjuvant radiochemo- trouble at work when he was working, and
therapy, if necessary with endoscopic which he cannot explain now, because he
clip marking of the tumor for radiation feels absolutely relaxed. Your suspicion
planning. goes in the following direction: the pain
55 Recommended radiation dose: Between could stem from a chronic stomach ulcer or
50 and 60 Gy with a fractionation of even from a deep-seated oesophageal carci-
5 × 2 Gy/week or 5 × 1.8 Gy/week. In noma. A clarification should definitely be
neoadjuvant therapy, dose values of made. In the esophagogastroscopy, the
40 Gy are applied. mucous membrane is assessed and, if there
55 Side effects: Esophagitis, pharyngitis. is a suspicious change, a tissue biopsy is
taken for examination by a pathologist.
Rectal Cancer
55 Tumor stage cT3 and cT4 neoadjuvant
pretreatment with radiochemotherapy.
55 Treatment of tumors in the small pel- Practice Questions
vis: Filling of the organs to be aimed 1. What does a pearl cord-like gait irreg-
at, especially urinary bladder and rec- ularity in ERCP/MRCP suggest?
tum. 2. What are the diverticula of the esoph-
55 Combination with the administration of agus and how they differ?
5-FU as a chemotherapeutic agent. 3. What is a Krukenberg tumor?
55 For preoperative irradiation, the dosage 4. What is typical on imaging for appen-
is 45 Gy with 5 × 1.8 Gy/week. dicitis?
55 Postoperatively, 50.4 Gy are given with 5. When does the coffee bean sign show
additional small-­volume dose increase up?
(boost) to the former tumor region by
another 5.4–9 Gy in the same fraction- Solutions 7 Chap. 27
ation.
 253 19

Urogenital
Carla M. Kremers, Guido Heilsberg, Ursula Blum,
Christel Vockelmann and Martina Kahl-Scholz

Contents

19.1 Anatomical Structures – 254

19.2 Disease Patterns – 254

19.2.1  rinary Tract – 254
U
19.2.2 Urolithiasis – 254
19.2.3 Urothelial Carcinoma – 255
19.2.4 Kidney Diseases – 257
19.2.5 Injuries to the Kidneys and Urinary Tract – 265
19.2.6 Adrenal Gland – 266
19.2.7 Prostate – 268
19.2.8 Testis and Epididymis – 269

19.3 Diagnostics – 271

19.3.1  iagnostic Radiology – 271
D
19.3.2 Nuclear Medicine – 272
19.3.3 Valence – 274

19.4 Therapy – 275

19.4.1 I nterventional Radiology – 275
19.4.2 Radiotherapy – 275

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 254 C. M. Kremers et al.

This chapter deals mainly with the diagnos- 19.2 Disease Patterns
tic but also therapeutic possibilities in dis-
eases of the urogenital tract and the 19.2.1 Urinary Tract
retroperitoneal space. Both the harmless
cyst and renal cell carcinoma are discussed.
Carla M. Kremers
Diseases of the urinary tract such as tumors
and urinary stones as well as diseases of the Urinary Retention
male reproductive organs such as prostate
The most common pathology of the ureter
carcinoma are also covered in this chapter.
is urinary retention, in other words,
obstructed outflow into the bladder, which
can have a variety of causes.
19.1 Anatomical Structures
z Clinic
Martina Kahl-Scholz Kidney/flank pain, urinary retention.

The urogenital system includes the kidneys, z Diagnostics

ureters, bladder and urethra. Sonography
The kidneys lie in the retroperitoneal Initial imaging should be sonography,
space ventral to the 12th rib, the right kidney with which dilatation of the renal pelvis and
being displaced more caudally than the left also of the ureter (which can be seen sono-
kidney by the overlying liver. The kidneys graphically only if dilated) can be well
are about 4 cm thick, 7 cm wide, and 11 cm assessed.
long (like the spleen). They show a lateral Congestion is divided into 4° of severity
and medial margin (margo medialis et latera- (. Table 19.1).
lis), an anterior and posterior surface (facies
anterior et superior) and an upper and lower
pole (extremitas superior et inferior).
The kidney is divided into medulla, cor-
19.2.2 Urolithiasis
tex and renal pelvis. From the renal pelvis,
Urolithiasis is the most common cause of
the ureter carries urine through an abdomi-
painful urinary retention. The exit of the
nal and a pelvic part (pars abdominalis et
kidney stone occludes the ureter at one of its
pelvica) 30–50 cm to the urinary bladder
physiological constrictions (exit from the
(vesica urinaria). The urinary bladder is the
renal pelvis, crossing of the psoas muscula-
most anterior organ in the lesser pelvis. It
ture and iliac vessels and confluence with the
lies adjacent to the symphysis pubica. The
bladder ostium), so that the urine flowing in
urinary bladder is divided into a tip (apex
painfully dilates the proximal part of the
vesicae), a body (corpus vesicae), a base of
ureter. Injuries of the ureter by the concre-
the bladder (fundus vesicae) and a neck of
ment often result in hematuria.
the bladder (collum vesicae), which merges
into the urethra. The urethra is about 3–5 cm
long in women, but 25–30 cm long in men. z Diagnostics
The prostate gland is about the size of a CT (. Fig. 19.1)
chestnut, surrounds the urethra and lies in The diagnostic instrument of choice is a
front of the bladder. It is divided into a base low-dose CT of the abdomen, which,
19 and a conical end (base et apex prostatae). A depending on the device, is hardly higher in
further distinction is made between the isth- radiation dose than an X-ray of the abdo-
mus prostatae and a lobus dexter, sinister et men—which is a diagnostic alternative for
medius. estimating stone size and localization if a
Urogenital
255 19

.       Table 19.1 Severity of the backlog

Grade I Grade II Grade III Grade IV

Renal pelvis Renal pelvis and Renal pelvis and Differentiation between dilated renal
dilated calices dilated calices strongly pelvis and renal calices no longer possible
Renal calices Preserve papillae dilated Parenchyma trophy
normal tips Papilla tip flattened
Parenchyma Parenchyma Incipient parenchy-
width regular width regular mal narrowing

and pelvis to severe diseases like retroperi-

toneal fibrosis (Ormond’s disease), post-­
inflammatory scarred strictures to curious
benign things not relevant for examination
like a pronounced coprostasis (extremely
rare).

19.2.3 Urothelial Carcinoma

Urothelial carcinomas are usually localized

in the urinary bladder and can be detected
there both sonographically and in cross-­
sectional imaging—if they are large enough
..      Fig. 19.1 CT ureteral concretion on the left, and the bladder is well filled so that its wall
dilated ureter proximal to it and edematous surround- texture can be assessed and the tumor (usu-
ing reaction (fatty tissue inhibition) ally low-echo and polyp-like) growing into
the bladder lumen can be detected. More
corresponding computer tomograph is not rarely, urothelial tumors are localized in the
available. The information obtained is rele- renal pelvis or ureter.
vant for further therapy planning: small cal-
culi can be eliminated naturally under z Clinic
analgesia. In the case of large calculi, uro- Painless hematuria, usually late pain and
logical intervention may be necessary. urinary retention.

>>If urolithiasis is suspected, a native low-­ z Diagnostics

dose CT is the diagnostic method of Sonography
choice, if available. The radiation expo- Sonographically a focal widening of the
sure corresponds to an X-ray examina- urinary bladder wall protruding into the
tion of the abdomen in two planes. bladder lumen may be noticeable in a well-­
filled bladder.
Compression: Urinary retention can also be MRI/CT
caused by an external pressure effect.
Reasons for this are manifold and range >>A mass of the urothelium can only be
from malignant tumors in retroperitoneum evaluated well if the cavity is well filled.
 256 C. M. Kremers et al.

Accordingly, in the clarification of a sus- z Clinic

pected urothelial carcinoma (e.g., due to an Urine is not discharged via the urethra, but
unclear hematuria), a urographic phase with via the respective fistula route via the intes-
well-filled ureters and renal pelvis in a CT is tine, vagina or skin.
very helpful to detect contrast medium voids
caused by space-occupying structures. In z Diagnostics
order to assess contrast medium accumula- Transillumination
tion of such a structure (and thus distinguish To check the tightness of the bladder after
it from a blood coagulum, for example), pre- intraoperative injury, a fluoroscopic examina-
ceding (native/arterial/venous or nephro- tion with a few individual images is sufficient
graphic) contrast medium phases are helpful. (retrograde cystography). For this purpose,
the bladder is sterilely filled with contrast
Urography Due to the almost universal medium via a bladder catheter to the extent
availability of computer tomography and the tolerated by the patient. The individual
often significantly greater information gain, i. images should show the filled bladder in dif-
v. urography, which was previously used to ferent planes in order to detect, for example, a
assess the urinary tract, has declined signifi- dorsal leakage of contrast medium.
cantly. This involves conventional X-ray CT (. Fig. 19.3)
images of the abdomen before and after intra- If a fistula is suspected, the question of
venous administration of contrast medium, the exact course of the fistula and also the
which can be used to assess ureters or their end must often be answered, then a CT is
outflow obstructions (. Fig. 19.2). recommended. For this purpose, too, the
bladder is retrogradely filled as well as pos-
Bladder Fistulas and Leaks sible with sterile, diluted contrast medium
These are occasionally undesirable conse- via a permanent catheter and the lower
quences after surgical interventions or, rarely, abdomen is then imaged on the CT. In this
side effects of an underlying disease with fis- way, it may be possible to determine the
tula formation (e.g. in Crohn’s disease). exact location of the fistula opening and
whether there is a connection to the intestine
or other adjacent structures.

 ladder Emptying and Micturition

B
Disorders
z Clinic
Sometimes, e.g. in case of recurrent urinary
tract infections, micturition disorders are
asked for.

z Diagnostics
Fluoroscopy (. Fig. 19.4)
In order to see the bladder and urinary
tract, the bladder is also filled with contrast
medium via a bladder catheter. After remov-
19 ing the bladder catheter, the patient is then
X-rayed during micturition. Important
..      Fig. 19.2 Urothelial carcinoma in the distal ure- landmarks of the examination are the ori-
ter. The dilated and tortuous ureter proximal to the fices of the ureters into the bladder: is there
ureter is clearly visible reflux of contrast medium here (vesicoure-
Urogenital
257 19

..      Fig. 19.4 MCU

amount of residual urine is required, the

procedure is reversed: the patient is asked to
empty the bladder as well as possible and
the amount of fluid remaining in the blad-
der is assessed. An ultrasound with imaging
of the bladder in two planes is sufficient for
this. The amount of residual urine can be
estimated from the diameters measured in
..      Fig. 19.3 a Cystography with postoperative fis- this way (. Fig. 19.5).
tula. b Cystography with postoperative leakage later-
ally

thral reflux)? The bladder itself: Is it round? 19.2.4 Kidney Diseases

Is it compressed anywhere? Does it empty
quickly and completely? And the urethra: Inflammatory Renal Changes
Can the urine flow freely? Are there any con- In most cases, the diagnosis of acute pyelo-
strictions in the urethra? nephritis can be made solely on the basis of
Sonography the patient’s history, clinical examination
If, for example, in neurological diseases and the corresponding changes in ­laboratory
with bladder emptying disorders, the parameters.
 258 C. M. Kremers et al.

a b

Volume Volume

..      Fig. 19.5 Bladder with residual urine. a 1st level. b 2nd level. Formula: a * b * c * 0.5 = bladder volume

z Clinic
Fever, chills, dysuria, flank pain, possibly
belt-like pain as in pancreatitis, possibly
back pain.

z Diagnostics
Sonography (. Fig. 19.6)
Ideally, the diagnosis is made by means
of targeted sonography. Here, the inflamed
kidney is conspicuous by a parenchymal
swelling, i.e. it is enlarged in a lateral com-
parison and due to the edema it shows a
lower echogenicity than the healthy counter-
..      Fig. 19.6 Left pyelonephritis
part. The parenchymal swelling can also
cause the calyces to appear constricted. If
you are already holding the transducer in Signs of chronic pyelonephritis in all
your hand, it makes sense to look for com- imaging techniques are scarring changes of
plications right away: are the ureters dilated? the renal parenchyma in the sense of cir-
Is there a higher degree of urinary reten- cumscribed retractions, especially in the
tion? If there are accompanying abscesses, vicinity of the renal calices.
these are conspicuous by circumscribed,
echo-poor or echo-free areas. Cystic Masses
CT z Clinic
The picture of pyelonephritis is analo- Most often, renal cysts go unnoticed. If nec-
gous to sonography: the kidney is edematous essary, pressure pain, lower abdominal pain,
swollen, thus enlarged and hypodense in lat- urinary retention.
eral comparison. If the entire kidney is
affected, a kind of wheel spoke pattern may Uncomplicated Blanched Cysts
develop. Often the surrounding perirenal fat z Diagnostics
is also oedematously altered (imbibed). CT/Sonography/MRI
19 Perirenal abscesses present the typical pic- These are round, have a delicate (barely
ture of an accumulation of fluid, depending visible), smooth wall that does not absorb
on the pathogen possibly with air inclusions contrast. Their content is watery.
and with a contrasting rim. Accordingly, they are sonographically
Urogenital
259 19
anechoic with dorsal sound enhancement. In water should be. Such bland cysts are usu-
CT, they are imaged fluid isodense and thus ally harmless incidental findings without rel-
have a density around 0 HU. Similarly, on evance. Ultrasound is sufficient as a
MRI, the signal is hyperintense in T2 weight- diagnostic tool. They do not require any fur-
ing and T1-weighted hypointense—just as ther clarification or control.

Complicated Cysts
z Diagnostics
CT/Sonography/MRI (. Fig. 19.7)
These are those whose contents are not
clearly watery, which have a thickened wall,
show septations or are partly calcified. In
order to assess the risk of malignancy, there
is the Bosniak classification, the stages of
which are also associated with correspond-
ing diagnostic and therapeutic recommen-
dations. The classification was originally
intended for CT—however, it can also be
used, at least in part, for sonography and
..      Fig. 19.7 Complicated renal cyst MRI (. Table 19.2).

.       Table 19.2 Bosniak classification

Type Radiological Findings Interpretation or Recommendation

I – Watery – Sitting cyst

– No septa – No further clarification
– Gossamer or invisible wall
– No solid shares
– No contrast medium uptake
II – 
Content not water isodense—i.e. >20 HU Complicated but benign (e.g., hemor-
density (CT), not anechoic (sono) or rhagic) cyst
hyperintense in T1 weighting (MRI)—but
homogeneous
– few, delicate septations
– Small calcifications on septa or cyst wall
– 
No contrast medium uptake compared to
native images
IIF – Slightly thickened cyst wall or septations – 
Complicated but probably benign cyst
– Thick or coarse-grained calcifications – 
Controls at three, six and ten months to
F like
– No contrast medium uptake exclude growth in size or other changes
Follow up
III – 
Irregular, small-nodular thickenings of the – 
A malignancy cannot be excluded, but
zsten wall or septations benign geneses (e.g. infection or
– Optional contrast medium recording hemorrhage) are also possible
– 
Resection if the surgical risk is
acceptable
IV – Irregular solid portions Most likely cystic malignancy. Resection
– Contrast enhancement
 260 C. M. Kremers et al.

Cystic Kidney Disease a

These are diseases in which harmless cysts
can become a problem for the patient or his
kidney function due to their number and
size, as they displace or even destroy the
healthy kidney parenchyma. There are dif-
ferent forms and manifestations of such dis-
eases, which are essentially hereditary.

z Clinic
Symptomatic changes may include arterial
hypertension and hematuria and recurrent
urinary tract infections. Increasing abdomi-
nal girth and flank pain may also occur.
Sooner or later, when there is an increasing
loss of function of the kidneys, the most b
diverse symptoms of terminal renal insuffi-
ciency can occur (edema, performance kink,
pruritus, loss of appetite, nausea/vomiting,
dyspnea …).

z Diagnostics (. Fig. 19.8)

CT/Sonography/MRI
In the adult form (autosomal dominant pol-
icystic kidney disease = ARPKD), in addi-
tion to multiple kidney cysts, cysts are also
..      Fig. 19.8 a,b Polycystic kidneys
found in other organs (pancreas, spleen,
liver). Cerebral aneurysms are also fre-
quently found in these patients. the forefront. First and foremost CT—pro-
vided that the patient’s age permits this.
>>In patients with polycystic kidney dis-
ease, cerebral aneurysms should be z Clinic
excluded by MR or CT angiography. Initially non-specific and depending on the
etiology, possibly hematuria, flank pain,
Medullary sponge kidney is a congenital B-symptoms.
but not hereditary defect of the collecting
ducts with cystic dilatations of the same. z Diagnostics
Thus, the (mostly small) cysts are found CT
mainly in the pyramidal region and less in Depending on the problem, different
the cortex. contrast agent timings may be important. In
This is often accompanied by urolithiasis native CT, calcifications or hemorrhages in
and urinary tract infections with corre- complicated cysts can be well delineated; in
sponding symptoms. addition, in combination with a contrast-­
enhanced phase, it helps to detect or exclude
19 Solid Masses of the Kidney any contrast medium uptake. The arterial
For the clarification of renal masses (and of contrast phase (approx. 15 s after intrave-
course also complicated cysts), cross-­ nous contrast administration) facilitates the
sectional imaging techniques are moving to assessment of the feeding vessels, which can
Urogenital
261 19
be important for preoperative planning, for
example. It also facilitates the search for
highly perfused (hypervascularized) liver
metastases—should it be a malignancy. In
what is usually referred to as the venous
phase (approximately 60–80 s after contrast
administration), there is still a marked dif-
ference in contrast between the cortical kid-
ney and the cortical medulla in most patients
(it is therefore also called the corticomedul-
lary phase in connection with the kidney),
which can mask space-occupying lesions. If
a renal mass is suspected, it is worth waiting ..      Fig. 19.9 Angiomyolipoma
until the contrast medium is homogeneously
distributed (after approx. 100–150 s after
injection of KM). If involvement of the uri- (metastases, infiltration in surrounding
nary tract is suspected, it may also make structures, etc.), an angiomyolipoma may be
sense to image it with contrast. As a practi- present.
cal matter, the contrast agent is usually elim- In all other cases, a definitive diagnosis
inated renally–so you just have to wait long from images is difficult or impossible.
enough for it to get there. The first test scan
(imaging a slice to see if the ureters are con- >>Solid masses of the kidney are always
trasted) is usually worth doing without fur- suspicious for malignancy—unless fat
ther preparation after 5 min at the earliest, can be detected. If there is no further
depending on the patient and kidney. Then evidence of malignancy (no infiltration,
it should be considered to admit the patient no metastases), it is most likely an
again after 20–30 min. Or—if it is known in ­angimyolipoma.
advance that a urographic phase will be
needed—the excretion of contrast medium
can be accelerated and intensified with low-­ Oncocytoma
dose loop diuretics, if necessary in combina- Oncocytoma (. Fig. 19.10) sounds danger-
tion with preceding hydration. ous, but it is a benign, slow-growing tumor.
In most cases, the further clarification On CT, it is homogeneously contrast-­
serves for a more precise assessment of a enhancing and often has a radiating wheel-­
complicated cyst or for staging in the case of spoke pattern converging on a central scar.
a concrete suspicion of malignancy, since Unfortunately, this is not a sure sign of
many solid masses cannot be clearly assigned benignity, on the contrary: oncocytoma and
to a benign or malignant origin. renal cell carcinoma look very similar, so
that the finding requires histological confir-
Angiolipoma mation—which in the vast majority of cases
Angiomyolipoma (. Fig. 19.9) is an excep- results in a (possibly partial) nephrectomy.
tion: as the name suggests, it is characterized
by the fact that it contains fat—fat, however, Lymphoma
is very rarely found in renal cell carcinoma. Lymphomas can also settle in the kidney.
Therefore, if fat tissue is detected (by nega- However, an isolated lymphoma of the kid-
tive density values in CT or by a signal drop ney is rare, since in the examination one
in fat-suppressed sequences in MRI) and always looks at the whole person or the
there is no other evidence of malignancy entire imaging area, the view sooner or later
 262 C. M. Kremers et al.

..      Fig. 19.10 Oncocytoma

falls on paraaortic or mediastinal lymph

node packages. Lymphomas can take many
forms within the kidney (as everywhere
else): for example, in the form of focal find-
ings, which are then usually homogeneously
contrasted, but absorb somewhat less KM
than the healthy renal parenchyma. But dif-
fuse infiltration is also possible, which ulti-
mately leads to an enlargement of the organ.
..      Fig. 19.11 a NCC on the right with thrombi in the
renal vein. b NCC with diffuse pulmonary and pleural
Metastasis metastasis in the same patient in the soft tissue win-
Metastases often occur in groups. Whether dow
a diagnosis must be forced histologically
depends on the oncological therapy plan or renal parenchyma. And since it can also
on the patient’s diagnosis. In individual show cystic parts, anechoic areas are also
cases, a diagnostic puncture may be neces- possible. An important diagnostic criterion,
sary. In a palliative situation, assessment of as can already be seen in the Bosniak classi-
the response to chemo/radiotherapy in the fication, is contrast sonography. In contrast
next staging is often sufficient. Overall, a sonography, a more rapid flow of contrast
metastasis cannot be distinguished from an medium and an even more rapid washout can
NCC image morphologically. sometimes be observed.
CT
Renal Cell Carcinoma (NCC) On CT, it is usually somewhat hypodense
Renal cell carcinoma (. Fig. 19.11) is the compared to the healthy renal parenchyma
most common renal tumor in adults and can and usually also accumulates somewhat less
vary widely in appearance, depending on its contrast medium than the rest of the renal
histology. parenchyma—but hypervascularized areas
are also possible and the image becomes
19 z Diagnostics inhomogeneous at the latest in the case of
Sonography central necrosis or cystic portions. For ther-
On ultrasound, for example, it can be apy/resection planning, an assessment of
hypo-, iso- or hyperechogenic to the healthy the adjacent vascular and renal pelvic struc-
Urogenital
263 19
tures is important. The hypernephroma—as a
the NCC is often called—often grows into
the respective renal vein and therefore often
results in thrombosis of the renal vein or the
V. cava. In addition, filiae (most frequently
in locoregional lymph nodes, lung and skel-
eton as well as skull) should of course also
be excluded in the best case. Staging there-
fore includes a CT of the abdomen from
3 cm tumor diameter supplemented by a
chest CT and a cranial MRI.
MRI
If questions remain (e.g. unclear bone
lesions or liver foci that cannot be clearly
classified, or questionable infiltration into
surrounding vessels), a targeted MRI can
provide clarity. b

Nephroblastoma
Nephroblastoma is the most common malig-
nant renal tumor in childhood (synonym:
Wilms tumor) and occurs mainly in young
children (before the age of four). Since it is
often first noticed by a unilateral painless
swelling of the abdomen, it is often already
extended at the time of diagnosis and dis-
places adjacent structures.

z Diagnostics (. Fig. 19.12)

Sonography ..      Fig. 19.12 Nephroblastoma t2-weighted. a Coro-
Initially, sonography is usually performed, nary, b Axial
which reveals an echo-rich mass originating
from the renal parenchyma with a pseudo- stations and the liver should be assessed
capsule corresponding to the compressed here (as already in sonography).
surrounding renal parenchyma. Large Conventional X-ray
tumors in particular cannot always be Further staging includes the exclusion of
assigned with certainty to an organ by lung metastases—an X-ray of the lung is
sonography—for example, differentiation required for this.
from a neuroblastoma (malignant tumor of
the sympathetic nervous system in child-  ascular Stenoses and Occlusions
V
hood) may be difficult. Renal Infarction
MRI Renal infarction—like infarctions of other
As further (objective because not organs—is often preceded by arteriosclero-
examiner-­ dependent) imaging, an MRI is sis. However, cardiogenic dissemination of
recommended, in which the mass is inhomo- an embolus, e.g. from a thrombus in the
geneous both T1- and T2-weighted—with atrial ear in atrial fibrillation, or a septic
an equally inhomogeneous contrast image. embolism, e.g. in valve endocarditis, are also
In addition, the surrounding lymph node possible.
 264 C. M. Kremers et al.

z Clinic Old renal infarcts can be delineated as

In the acute stage, a renal infarction can be scarring retraction of the renal parenchyma
associated with severe pain. (. Fig. 19.13).

z Diagnostics Renal Artery Stenosis

CT Renal artery stenosis is often conspicuous
If a renal infarction is suspected, the by refractory (renovascular) hypertension
search usually begins with a CT scan or CT and/or by a restriction of renal function.
angiography. Conveniently, other causes of The possibilities of radiological diagnostics
abdominal or flank pain can also be assessed are manifold. Duplex sonography and MR
here. In an arterial contrast phase or CT angiography are at the forefront of diagnos-
angiography, the condition and, if neces- tics—if only because of the lack of ­radiation
sary, the occlusion of the afferent renal dose.
artery can be assessed. In the venous or
nephrographic contrast medium phase, on z Clinic
the other hand, a lack of contrast medium Mostly unspecific, possibly symptoms of
accumulation of the affected (usually wedge-­ hypertension (dizziness, headache, nervous-
shaped) part of the parenchyma or, in the ness, nausea, …)
worst case, of the entire kidney is pathogno-
monic. z Diagnostics
Sonography Sonography
The reduced blood flow can also be visu- Duplex sonography does not require the
alized by duplex sonography. administration of contrast media—it does,
DSA however, require a patient who is “good at
If an interventional therapy (e.g. a sound” and a motivated and/or experienced
local thrombolysis via an intra-arterial examiner.
catheter) is possible, one or the other pro- MRI
cedure can be followed by a DSA in readi- With MRI, the amount of contrast agent
ness for intervention with the aim of required is low and not nephrotoxic, making
preserving the entire organ or its function MRI a good adjunct if renal function is rea-
as far as possible. sonably preserved.

a b

19

..      Fig. 19.13 Renal infarction. a Fresh, b Old

Urogenital
265 19
CT
Of course, CT angiography is also pos-
sible for the detection of vascular stenoses.
If a stenosis is detected, it can be repaired
with (stent) dilatation in the course of con-
ventional angiography. Here, too, however,
the main concern is to preserve renal func-
tion. Arterial hypertension is usually fixed
and does not regress even with revascular-
ization.

Investment Variants
Renal Agenesis
If the kidney should not be paired, this is in ..      Fig. 19.15 Horseshoe kidney
many cases the result of a surgical interven-
tion—but a missing kidney as an anatomical
found in the pelvis, for example. Or (more
norm variant is also possible. The solution is
frequently) that the renal pelvis is not ori-
usually found quickly on the basis of an
ented medially, but ventrally.
anamnesis. If the patient does not provide
any information, a look at the respective Horseshoe Kidney
flank will help in the search for a suitable
This is a fusion of both kidneys at their
scar.
lower poles (. Fig. 19.15), either complete
Malrotation with continuous renal parenchyma or in the
form of a punctate connective tissue bridge.
In the course of embryonic development,
the kidney moves up from the pelvis to the Accessory Vascular Supply
lumbar region and also rotates its axis dur-
This is a relict from embryonic develop-
ing this process. If this rotation does not
ment—as is usual for annex variants—which
occur, it is called malrotation (. Fig. 19.14).
normally obliterates during the ascent from
Then it may (rarely) happen that a kidney is
the pelvis and is replaced by the renal artery.
These vessels become important, for exam-
ple, when planning endovascular vascular
prostheses, e.g. as part of an aneurysm
repair, as “overstenting” of these vessels can
lead to a relevant renal infarction
(. Fig. 19.16).

19.2.5 Injuries to the Kidneys

and Urinary Tract
The question of a kidney injury is usually
preceded by a corresponding history of
“blunt” (fall/stroke) or “sharp” (stab wound/
gunshot) violence. Depending on availabil-
ity, the first imaging is usually sonography
..      Fig. 19.14 Painting rotation or a (polytrauma) CT.
 266 C. M. Kremers et al.

a a

..      Fig. 19.16 a Coronary MIP reconstruction and

VRT of a 5-fold renal artery apposition. b VRT of a
5-fold renal artery apposition

Kidney injuries are classified based on

their severity and the structures involved,
..      Fig. 19.17 a,b Kidney trauma grade IV
such as the American Association for the
Surgery of Trauma, AAST (. Fig. 19.17,
. Table 19.3). Pheochromocytoma
The suspicion of a pheochromocytoma
(primary benign mass with the potential for
19.2.6 Adrenal Gland malignant degeneration) is usually based
on the clinical symptoms and the examina-
See also 7 Chap. 22 (Adrenal adenoma, tion of a 24 h collection urine for catechol-
-carcinoma). amia or its degradation products and, if
The healthy adrenal gland cannot be necessary, further laboratory tests.
assessed in sonography. In cross-sectional However, in order to plan appropriate (sur-
imaging it is visible as a narrow Y-shaped gical) therapy, the surgeon must know
structure in the upper retroperitoneum. where to find it.
19
Urogenital
267 19

.       Table 19.3 Classification of kidney injuries

Organ contusion Cortical Cortical parenchy- Parenchymal Extensive

possibly with bleeding parenchymal mal tear more than injury into the parenchymal
into the parenchyma tear less than 1 cm deep and cavity system (the injury
or below the renal 1 cm deep perirenal hematoma urinary tract) (comminuted
capsule Perirenal (i.e. Arterial or venous kidney)
crossing the vascular injury Vascular
renal capsule) rupture
hematoma Kidney stalk
Mass bleeding

a b c

..      Fig. 19.18 Pheochromocytoma. a T1-weighted. b, c T2-weighted

z Clinic cases when a pheochromocytoma is sus-

Seizure-like high blood pressure (paroxys- pected—but should then be performed
mal hypertension), permanent increase in under appropriate premedication and cir-
blood pressure (persistent hypertension, culation monitoring.
often in children).

z Diagnostics (. Fig. 19.18) CT CT is helpful for localization of the

Sonography tumor(s), which then includes the predilection
Sonographically, the detection is only suc- sites borderline cord and adrenal glands (tho-
cessful in large tumors and sometimes they rax and abdomen). Pheochromocytomas are
occur in several localizations at the same round-oval shaped, smooth bordered and accu-
time—not only within the adrenal glands, mulate contrast agent vigorously and early.
but also along the marginal cord.
MRI On MRI, pheochromocytomas are
>>Pheochromocytomas are hormone-­active fluid isointense—that is, hyperintense in T2
and react to mechanical stimulation—e.g. weighting and hypointense in T1 weighting.
in the course of a biopsy—with a hor- This is particularly impressively visible on
mone release if this is not inhibited in the basis of fluid- or edema-sensitive
advance by medication. A diagnostic sequences such as a T2 weighting with fat
puncture is only indicated in exceptional saturation.
 268 C. M. Kremers et al.

Adrenal Metastases
They are usually detected on CT as part of
the staging of a primary tumor (bronchial
carcinoma or melanoma) and are then still
small (less than 3 cm in diameter). In the CT
morphology they are blurred and absorb
contrast medium inhomogeneously. Fat can-
not be detected. If a definite diagnosis or
histology is necessary, the mass of an adre-
nal gland can be biopsied with CT guidance.

19.2.7 Prostate

The healthy prostate is the size of a chestnut ..      Fig. 19.19 Benign prostatic hyperplasia
(about 3 cm in diameter) and surrounds the
urethra, which arises from the urinary blad-
der. It tapers caudally, which is why its lower raphy as well as in MRI. The obstruction of
end is called the apex, while the broader, the urethra leads to an increased trabecular-
­cranial part is called the base. In addition, ization of the (mainly ventral) bladder wall,
the prostatic parenchyma is divided into sev- in the sense of a so-called barred bladder as
eral zones: the peripheral zone, the transi- well as increased bladder diverticula. In the
tional zone, the central zone and the transabdominal sonography usually only an
periurethral glandular region, which is tiny enlargement of the organ with elevation of
and not so important from the radiological the bladder floor can be seen.
point of view.
Prostate Carcinoma
Prostatic Hypertrophy The prostate carcinoma develops mainly in
Prostate hypertrophy is one of the most the dorsally located peripheral zone.
common diagnoses in the world of urol- Therefore, it leads to obstruction symptoms
ogy—and fortunately benign (BPH = benign much later. Sometimes, the clinical findings
protastahypertrophy). It develops during are already clear: a rough (like a knuckle)
life due to an increase in the central zone palpable nodule on rectal examination and
around the urethra. PSA elevation. Then a transrectal, sono-
graphically guided puncture by the treating
z Clinic urologist usually leads to a definitive diag-
The compression of the urethra by the sur- nosis.
rounding tissue proliferation ultimately
leads to the typical complaints with pollaki- z Clinic
uria, thin (dribbling) urine stream and resid- s. Hyperplasia, possibly hematuria.
ual urine formation.
z Diagnostics
z Diagnostics MRI
19 Sonography/MRI (. Fig. 19.19)
Image morphologically, the prostatic
If the symptoms are unclear, e.g. if the
PSA value is elevated and there is no corre-
hypertrophy is characterized by an increase lation either by palpation or endosonogra-
of the central poratata parts, which have an phy, MRI is required. A prostatic carcinoma
inhomogeneous internal structure in sonog- is then apparent as a T2w-hypointense area
Urogenital
269 19
in the peripheral (rarely in the central) zone. even with the help of the best images—the
Diffusion imaging can visualize the cyto- question can therefore only be clarified his-
toxic edema triggered by the tumor. In addi- tologically.
tion, dynamic series can be used to assess
contrast flooding, in which, as is so often the
case, the tumor is evident by rapid flooding 19.2.8 Testis and Epididymis
and washout. For the classification of such
findings, a classification analogous to the The testis and epididymis are connected to
BIRADS system of mammography, the PI-­ each other by the ductuli efferentes testis.
RADS classification, has become estab- Usually, two such testicular and epididymis
lished. Another development is the packages per man are built together in one
MR-guided biopsy of tumor-suspicious scrotum.
lesions that cannot be reliably detected by Radiology may also involve examination
sonography. This is done with special tran- of the testis and epididymis. Due to the high
srectal biopsy coils, so that specific suspi- radiation sensitivity of the reproductive
cious regions can be biopsied. organ, one will avoid X-ray examinations of
CT this organ as far as possible and try to prog-
CT is not helpful for the diagnostic eval- ress as best as possible with sonography and
uation of the prostate itself. A distinction MRI.
between malignant and benign enlargement
is not initially possible. However, in staging, Hydrocele
it is used to assess any transmural growth One speaks of a hydrocele when the scrotum
and to allow the detection of any metastases has stored fluid that surrounds the testis and
(lymph nodes, lung, bone). Osseous metas- epididymis. This is not infrequently an inci-
tases of prostate carcinoma are typically dental finding of a CT of the abdomen or an
osteoblastic—i.e. more sclerotic and initially MRI of the pelvis that has been “pulled
often localized in the pelvis and lumbar down” a little too far.
spine.
Testicular Torsion
Prostatitis Testicular torsion is a condition that usually
The question of prostatitis is extremely rare occurs in children and adolescents.
in radiology.
z Clinic
z Clinic When the testicles twist around each other,
It is already clinically noticeable by fever, they also wrap their inflow and outflow ves-
pain and dysuria. In the clinical examina- sels around each other—with the result that
tion it is also enlarged palpable and the pal- there is first an obstruction of the venous
pation is very painful for the patient. In the outflow with painful swelling and reddening
laboratory, the PSA concentration is usually of the testicle and in the worst case later also
also elevated. with an occlusion of the arterial inflow—
this results in an infarction or the loss of the
z Diagnostics testicle.
Sonography
Sonographically also an enlargement of z Diagnostics
the organ is visible, with a reduced echo- Sonography
genicity due to the edema (=water). The diagnosis is an emergency that
A chronic prostatitis cannot be distin- requires immediate surgical care to avoid the
guished from a carcinoma of the prostate aforementioned infarction of the testicles.
 270 C. M. Kremers et al.

The quickest way to make a diagnosis is to means of retrograde contrast medium distri-
take the transducer in hand: Duplex sonog- bution and then also closed intervention-
raphy is the quickest way to visualize the ally—by means of an embolus or a sclerosing
reduced or dried-up blood flow. agent.

Inflammatory Changes of the Testis Testicular Retention

Epididymitis is an inflammation of the epi- Testicular retention is defined as the absence
didymis, which rarely also leads to orchitis, of descent of the testes into the scrotum
i.e. an inflammation of the testicle. during the first three months of life.
Depending on where the testis is located, it
z Clinic is named: Abdominal testis or Inguinal tes-
Clinically, the picture is similar to that of tis. If it oscillates between different loca-
testicular torsion: painful swelling and red- tions, it is called a sliding testis.
ness of the scotum. In contrast to torsion,
patients with epididymitis are more likely to z Clinic
be older gentlemen. Mostly asymptomatic, but risk of infertility.

z Diagnostics z Diagnostics
Sonography MRI
Duplex sonography may reveal increased If the sonographic search for a missing
blood flow. In addition, the testis and epi- testis remains unsuccessful, a sectional
didymis are enlarged and echo-poor due to image is requested. MRI is the only method
the accompanying edema. that can be used for this purpose; it is usu-
ally successful in localizing the testis, even if
Varicocele the object of the search is still hidden in the
In the case of varicocele, the radiologist can retroperitoneum.
sometimes take more than just pictures: it is
virtually a matter of varicose veins (i.e. Testicular Tumors
dilated, tortuous veins) in the pampiniform Testicular tumors are diseases of the young
plexus within the testicle. man (age peak between the 20–40 years).
The diagnosis usually already takes place at
z Clinic the urologist. Since the majority of cases are
Mostly no symptoms, but risk of infertility. malignant tumors, the patient requires stag-
ing to detect any metastases (lymph nodes—
z Diagnostics initially parailiac and retroperitoneal, lung)
Sonography with the aid of an appropriate CT of the
A varicocele can be diagnosed by duplex abdomen or trunk.
sonography. With a phlebography, the entire
course of the vessel can be visualized even Seminal Vesicles
more precisely. In order to bring the contrast Seminal vesicles are sometimes visible on
medium specifically to the site of the event, abdominal imaging, both ultrasound and
a catheter is first inserted via the groin into MRI and CT. For the sake of completeness,
the renal vein in order to probe the conflu- they should also be mentioned here. Diseases
ence of the spermatic vein from there. In this of the seminal vesicles are extremely rare.
19 way, the spermatic vein can be imaged all the Issues involving the seminal vesicles, except
way to the scrotal venous convolute by perhaps in homes with major urology, (vir-
Urogenital
271 19
tually) never occur. However, the attentive of the abdomen, even in conventional
eye may notice calcifications of the seminal images, attention should of course always be
vesicles or the vasa deferens, which usually paid to calcifications in the course of the
affect patients with diabetes mellitus. draining urinary tract. Roundish, somewhat
cloudy calcifications in the pelvis of older
women usually correspond to calcified uter-
19.3 Diagnostics ine fibroids, a benign lump of the uterus.

19.3.1 Diagnostic Radiology >>The question of ureteral stones should

be clarified with low-dose computed
Christel Vockelmann tomography of the urinary tract.

Sonography
As already described in the previous chapter, Fluoroscopy/Angiography
sonography is also the most easily available The indications for fluoroscopic examina-
imaging method in the diagnosis of the uro- tions or diagnostic angiographies of the uro-
genital system, which can be used both as a genital system have also become very limited
screening method and for clarifying com- in recent years. A typical indication is cys-
plaints. It is used both as a screening method tography to exclude a urinary bladder injury
and for the diagnosis of complaints. The after surgical interventions in the small pel-
main focus is on spatial damage in the renal vis.
parenchyma and dilatation of the renal pel- A similar examination, namely a mictu-
vis as an indication of urinary retention. The rition cysturethrogram (MCU), is a typical
urinary bladder can also be assessed very examination in pediatrics. Here, the urinary
well when full. Sonography is also used to bladder is also filled with contrast medium.
determine the residual urine. For this pur- In addition, a micturition of the small
pose, the volume of the bladder after empty- patients should then be performed. The
ing is determined sonographically. indication for this is the suspicion of a vesi-
Both the male and female genital organs coureteral reflux, which leads to inflamma-
can be well assessed sonographically. Not tion of the renal pelvis. This reflux occurs
only transabdominal ultrasound is used for mainly with high pressure in the urinary
this purpose. With special transducers, bladder, which arises primarily during mic-
transvaginal or transrectal sonography can turition.
also be performed. In Germany, these are For reasons of radiation hygiene, lateral
generally performed by urologists or gyne- images should be avoided as far as possible
cologists. In other countries, e.g. France, this in children. The imaging frequency and fluo-
is also part of the examination spectrum of roscopy time should also be reduced to a
radiologists. minimum.

Conventional X-ray Diagnostics Computed Tomography

Conventional radiology no longer has any The method of choice is computed tomog-
relevant significance in the context of uro- raphy in the detection of ureteral stones.
genital imaging. The intravenous excretory These are usually calcium dense and can
urogram has been completely superseded by thus be excellently detected in computed
computed tomography in the diagnosis of tomography, even natively and in a low-dose
kidney stones. Nevertheless, in the diagnosis technique. Depending on the CT device, the
 272 C. M. Kremers et al.

necessary radiation dose corresponds Magnetic Resonance Imaging

approximately to an X-ray examination of In contrast to computer tomography, mag-
the abdomen in two planes. netic resonance imaging also allows local
In the diagnosis of renal tumors, com- staging of tumors of the internal genitals.
puted tomography is well applicable. In this Sagittal sequences are useful for differen-
context, the diagnosis of the kidneys is usu- tiating endometrial or uterine carcinomas;
ally performed within the framework of a here, the tumor can be delineated hypoin-
CT abdominal scan. If there is a specific tense to the myometrium after contrast
question about a renal tumor, a native exam- medium administration. The depth of infil-
ination of the kidneys should be performed tration and, in particular, infiltration into
if necessary to evaluate a contrast image. In neighboring organs must be assessed, as this
addition to an arterial coil, a second series can influence the therapeutic procedure.
of examinations is performed in the nephro- Unlike most other tumors that are hyper-
graphic contrast phase approximately 100– intense delineable on T2-weighted imaging,
150 s after contrast administration. CT prostate carcinoma is characterized by
urography can be added for questions of the hypointense signaling on T2-weighted
urinary tract (. Fig. 19.20). For this pur- images. Therefore, thin-slice T2 imaging is
pose, the excretion of the contrast medium necessary for the detection of prostate carci-
into the ureters must be waited for 7–10 min noma, which, unlike benign hyperplasia of
after contrast medium administration. Low-­ the prostate, grows in the outer gland of the
dose administration of furosemide, a loop prostate. This is usually performed axially as
diuretic, can be helpful here. well as coronally and sagittally. The imaging
In the diagnosis of the genital organs in is improved by the additional use of an
the small pelvis, computed tomography only endorectal coil for body array.
plays a secondary role. Here, too, the uterus In addition, the prostate carcinoma can
or prostate are also assessed in every CT be detected with the help of spectroscopy.
examination performed for other reasons. In Here one uses the fact that the prostate car-
the case of sonographically detected malig- cinoma has more choline and less citrate
nant tumors, CT is performed for staging than healthy prostate tissue. However, this
and the search for distant metastases. A technique is certainly only used in a fraction
classic example is the question of peritoneal of patients with prostate carcinoma. In the
carcinomatosis of an ovarian carcinoma. majority of patients, urological-sonographic
diagnostics are sufficient for the therapy
decision.

19.3.2 Nuclear Medicine

Ursula Blum

Renal Scintigraphy
z Renal Perfusion DTPA
(Diethylenetriaminepentaacetic Acid)
19 Diethylenetriaminepentaacetic acid (DTPA)
is purely glomerular filtered. Thus, DTPA
allows a perfusion study as well as the deter-
..      Fig. 19.20 Thick-slice MIP reconstruction of a mination of the glomerular filtration rate
CT urography without pathology (GFR). GFR is a measure of renal function
Urogenital
273 19
(. Table 19.4). Indications for testing Available tracers are 123I-OIH (ortho-­
include suspected impaired renal function, iodhippuric acid) and 99mTc-MAG3 (mer-
possibly prior to chemotherapy or radiation captoacetyltriglycine). Due to its better
therapy, and chronic renal insufficiency. The availability, 99mTc-MAG3 has gained accep-
GFR depends on the age and sex of the tance in clinical routine.
patient.
z Postmicturition Images
z Kidney Function In case of incomplete drainage from the
Renal function scintigraphy is frequently renal pelvicocaliceal system or the ureter,
used. It can easily—and with low radiation static images should be performed after
exposure—provide reliable information on appropriate bladder emptying and a change
blood flow, the position of the kidneys, any of position (at least 15 min in an upright
anomalies that may be present, the side-­ position).
separated function and the drainage condi- These can take place directly after blad-
tions. It is also possible to visualize any der emptying, but in addition, if possible,
reflux (backflow of urine from the bladder always 50–60 min p. i. as static recordings
into the ureter or kidneys). Due to the low over 2 min.
radiation exposure, the examination is also
performed relatively frequently in children z Examination with Furosemide Exposure
and adolescents. If the baseline examination shows a delay in
urine flow, the additional administration of
furosemide is possible. Among other things,
furosemide prevents the reabsorption of
..      Table 19.4 Normal values GFR. water in the kidney, so that the urine can no
(Modified according to Dtsch Arztebl Int
longer be concentrated. Contraindications
2009)
are a known hypersensitivity to furosemide
Babies and Children and low blood pressure (clinically relevant),
a relative contraindication is a kidney stone.
Premature births >0.5 mL/min/kg The examination can be performed fol-
Newborn >10 mL/min/m 2 lowing a baseline examination or directly as
an examination with furosemide exposure in
Week 2–8 16.3–44.6 mL/min/1.73 m2
KOF
the case of known urinary flow disorders.
Dosage:
3rd–12th month >70 mL/min/1.73 m2 KOF 55 Infants: 1 mg/kg bw i. v.
1–20 years >80 mL/min/1.73 m2 KOF 55 Oneyear to 18 years: 0.5 mg/kg bw, max-
Adults (mL/min/1.73 m2 KOF)
imum 20 mg i. v.
55 From 18 years: 0.5 mg/kg bw, maximum
Age [years] Men Women 40 mg i. v.
20–29 77–170 71–165
30–39 70–162 64–149
Time of Injection:
55 F + 20: 20 min after radiopharmaceuti-
40–49 63–147 58–135 cal (e.g. after basic examination)
50–59 56–130 51–120 55 F - 15: 15 min before the radiopharma-
60–69 49–113 45–104
ceutical
55 F0: Simultaneous with the radiopharma-
70–79 42–98 39–90 ceutical
80–89 35–81 32–75 55 F + 2: 2 min after the radiopharmaceuti-
cal
 274 C. M. Kremers et al.

The examination is otherwise performed in sis, the baseline examination would then be
the same way as the basic examination. The invalid.
evaluation is primarily visual. Here, it is best The following parameters should be
to distinguish between “normal” and determined:
“absent”. According to the guideline, all 55 Time until the occurrence of the maxi-
findings in between should be reported as a mum
percentage of the maximum activity before 55 Quotient of activity after 20 min/activity
and after the administration of furosemide, at maximum (norm <0.3)
as well as any post-micturition images that
may be available. The following changes may occur with renal
artery stenosis:
z Examination After ACE Inhibitor 55 Shift of the maximum >2 min or >40%
Administration to the baseline examination
An (atypical) arterial hypertension can be 55 Change in 20 min/max quotient >0.15
caused by a renal artery stenosis. In this 55 Reduction of the relative uptake >10%.
case, an activation of the renin-angiotensin 55 Change in the time-activity curve with
system leads to an increase in blood pres- significantly delayed or undetectable
sure. The therapy of this high blood pres- drop over the affected kidney
sure is carried out, at least in the short course 55 Decrease in calculated GFR >10
of the disease, by eliminating the cause,
namely the renal artery stenosis. Often, z Static Renal Scintigraphy (DMSA)
however, the hypertension is already fixed. Static renal scintigraphy is mainly performed
The following medications should be on children. Here, the focus is not on the
suspended for the study if possible: function per se, but the examination serves,
55 ACE inhibitors depending on their half-­ among other things, to detect kidney tissue
life (3–7 days before) and, if necessary, to detect changes in the
55 Diuretics: A few days before the exami- kidneys. In this way, small functional defects
nation can also be detected, which can occur, for
example, after repeated inflammations of
As part of a one-day protocol, the baseline the renal pelvis.
scintigraphy is performed first according to Even in the case of significantly impaired
the normal examination protocol. The kidney function, it is possible to determine
patient is then administered 25–50 mg cap- the percentage of the side, in this case e.g.
topril p. o. Blood pressure is monitored before a planned surgical measure. The radi-
every 10–15 min because an ACE inhibitor ation exposure of such a renal scintigraphy
can lower blood pressure very dramatically. is 1.2 mSv.
If there is a symptomatic drop in blood pres-
sure, fluid should be infused. After 60 min, a
new renal scintigraphy is performed, if nec- 19.3.3 Valence
essary with increased activity (up to
200 MBq). Christel Vockelmann
In a two-day protocol, the examination
is performed first with ACE inhibitor admin- . Table 19.5 shows the use of the respective
istration. A normal result argues against therapeutic options depending on the prob-
19 renin-angiotensin-acting renal artery steno- lem
Urogenital
275 19

.       Table 19.5 Value of the therapeutic procedures

Sonography Conventional Fluoroscopy/ CT MRI Nuk PET

Angiography

Ureteral stone P* N N P N N N
(urolithiasis)
Renal function N N N N N P N
determination
Kidney tumor P N N W W N N

N Not indicated, P Primary diagnosis, W Further diagnosis

P* Every patient with flank pain as an indication of renal colic is primarily examined sonographically.
However, the actual stone can rarely be detected sonographically

19.4 Therapy years will show whether the ­procedure can

establish itself permanently.
19.4.1 Interventional Radiology
Angiography
Christel Vockelmann Angiographic procedures are also used in
the treatment of uterine fibroids. Indication
Ultrasound/Nuclear Magnetic for this is mostly the rejection of surgical
Resonance Imaging therapy. For embolization, probing of both
For the treatment of uterine fibroids, in internal iliac arteries is necessary. Iliacae
addition to the classic surgical therapy internae is necessary. The uterine arteries
with a myoma enucleation or a hysterec- are then probed and embolized with parti-
tomy, there is a very new procedure called cles. After the procedure, the patients regu-
HIFU (High Intensity Focused larly show a post embolization syndrome
Ultrasound). Here, the target tissue is with severe pain and often fever, which
strongly heated (70–100 °C) within a few requires in-patient pain therapy.
seconds by means of high-­intensity focused
ultrasound. The ultrasound can reach the 19.4.2 Radiotherapy
target area very precisely and surrounding
tissue is spared. In order to treat the target Guido Heilsberg
tissue precisely, the treatment is carried out
in an MRT. This requires an upgrade of a Urinary Bladder Carcinoma
normal MRI with the ultrasound includ- Urinary bladder carcinoma (. Fig. 19.21)
ing the control units. Due to the very pre- is irradiated adjuvantly as radiochemother-
cise therapy with sparing of the surrounding apy for organ preservation to the bladder
tissue, there are also developments to use 54–60 Gy with 5 × 1.8/2.0 Gy per week.
the procedure in other areas (prostate car- The patient is positioned in the supine
cinoma, pancreatic carcinoma and many position, the legs are padded with a stan-
more). The development of the next few dard positioning aid.
 276 C. M. Kremers et al.

Biochemical recurrence: In case of PSA

increase (e.g. three blood samples in a row
increased) radiotherapy is performed.
The patient is instructed to arrive at his
radiation appointment with a well-filled
bladder and, if possible, to empty his bowels
beforehand.
The patient is irradiated in the supine
position, with his arms on his chest so that
they do not lie in the irradiation field in the
case of obliquely incident fields.
Side effects: Diarrhea, dysuria, cystitis
(bladder infection), proctitis, urinary
urgency, urethral strictures, impotence, and
incontinence.

..      Fig. 19.21 Carcinoma of the dorsal and right lat- Testicular Tumors (Seminoma,
eral bladder wall. Incidental finding of urinary blad- Non-Seminoma)
der diverticulum ventrally
Classical seminomas are among the most
radiosensitive tumors and are irradiated
 rostate Carcinoma (Carcinoma
P adjuvantly.
of the Glandular Tissue In stage one seminoma (localized
of the Prostate Gland) involvement) adjuvant radiotherapy 20 Gy
Primary radiotherapy: in the case of low to the para-aortic lymph nodes at 5 × 2.0 Gy
risk, only radiotherapy is performed; in the per week. In stage 2 (retroperitoneal LK
case of intermediate risk, radiotherapy is metastases): 30 Gy for small metastases (up
combined with six months of HAT. In the to 2 cm, stage 2A), 36 Gy for larger metasta-
case of high risk, radiotherapy is performed ses (up to 5 cm, stage 2B) with 5 × 2.0 Gy
in which, if necessary, the pelvic lymph per week as a so-called “hockey stick” on
drainage is also irradiated and hormone the para-aortic and pelvic lymph nodes.
ablative therapy (HAT) is additionally given Before any therapy: cryopreservation
over 2–3 years. On the prostate analogue (the “freezing”)
>72 Gy with 5 × 1.8/2.0 Gy per week as The irradiation is carried out in the
IMRT. supine position, the arms will be placed at
Adjuvant radiotherapy: On the former the side of the body but also above the head
tumor bed 60 Gy and in case of biochemical in a tray.
recurrence 66 Gy. Side effects: Nausea

19
Urogenital
277 19
Case Study

Little Kevin (5 years) suddenly turned pale given a painkiller in the meantime. Then Dr.
while playing in the playground and com- Kremser switches to the higher frequency lin-
plains of severe pain. It is only after asking ear transducer to examine the scrotum. First
more closely that the mother finds out that the healthy side is examined, here the testicle
Kevin has pain in the scrotum. As the boy can be homogeneously delineated with good
cannot be calmed down, Mrs. Huber decides vascularization. Then Dr. Kremser examines
to drive directly to the nearest hospital. the painful side and finds the testicle some-
There the general surgeon Dr. Messer exam- what more echo-­poorly distended, but above
ines Kevin. His suspicion: a torsion of the all: There is almost no blood flow. This makes
testicle. Dr. Messer knows that it has to be it clear that Kevin does indeed have testicular
done quickly if there really is a torsion of the torsion. Dr. Kremser therefore calls Dr.
testicle. Therefore, he personally registers Messer: Kevin is operated on immediately.
Kevin with the radiologist Dr. Kremser for The operation succeeds quickly and the tes-
an ultrasound. Dr. Kremser examines the ticle is supplied with blood again. Kevin can
abdomen for orientation in order to establish go home again after a few days and has
a little contact with Kevin, who has been digested the whole shock quite quickly.

Practice Questions
1. A 20-year-old young man presents to
you with renal colic. What tests do
you perform?
2. Name typical image features of renal
cysts in ultrasound, CT and MRI!
3. How can you distinguish benign pros-
tatic hypertrophy from prostatic carci-
noma?
4. What treatment options for prostate
cancer are you aware of ?
5. How can the radiologist diagnose dia-
betes mellitus?

Solutions 7 Chap. 27
 279 20

Musculoskeletal Diseases
Mirja Wenker, Christel Vockelmann, Ursula Blum
and Guido Heilsberg

Contents

20.1 General – 280

20.2 Anatomical Structures – 280

20.2.1 Bone Structure – 280

20.3 Clinical Pictures – 281

20.3.1 F ractures – 281
20.3.2 Luxation – 286
20.3.3 Inflammatory Diseases – 287
20.3.4 Degenerative Diseases – 290
20.3.5 Tumors and Tumor-like Lesions – 293
20.3.6 Congenital Disorders of the Skeletal System – 296
20.3.7 Diseases of the Infantile Skeleton – 298

20.4 Diagnostics – 300

20.4.1  iagnostic Radiology Services – 300
D
20.4.2 Nuclear Medicine Diagnostics – 302
20.4.3 Valence – 303

20.5 Therapy – 303

20.5.1 I nterventional Radiology – 303
20.5.2 Nuclear Medicine – 304
20.5.3 Radiotherapy – 305

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 280 M. Wenker et al.

This chapter provides an overview of the (e.g. femur), short bones (e.g. carpus), flat
diagnosis of musculoskeletal disorders. An bones (e.g. skull bones) and sesamoid bones.
introductory section covers a brief review of The latter are embedded in muscle layers
anatomy, followed by common clinical pic- and are located in places where tendons are
tures, such as dislocations, fractures, tumors, exposed to high stress (a classic example and
and degenerative diseases. also the largest sesamoid bone in the human
body is the patella). Tubular bones are
divided into three zones, the centrally
20.1 General located diaphysis, the metaphysis adjacent
on both sides, and the epiphysis, which
Mirja Wenker forms the joint and is covered by a layer of
cartilage.
Diseases of the musculoskeletal system lead Between the epiphysis and metaphysis is
the list of causes of chronic pain worldwide. the epiphyseal groove, which becomes bony
In addition to rheumatic diseases, this large after the end of puberty when the growth
group of diseases also includes arthroses, hormone level drops and completes the
fractures and slipped discs. Almost every growth in length.
German has a musculoskeletal disease at
some point in his or her life.
Musculoskeletal diseases are also the 20.2.1 Bone Structure
most frequent cause of days off work and
the second most frequent cause of early The essential components of the bone are
retirement in Germany. This means that the compacta or cortex, which forms the
musculoskeletal diseases not only have a outer layer, and the cancellous bone, which
considerable impact on the quality of life of is made up of delicate bone bellows on the
those affected, but are also a cost factor for inside. This contains the blood-forming red
the healthcare system. bone marrow and the yellow bone marrow,
An estimated 7,000,000 Germans suffer which consists primarily of fat.
from diseases of the musculoskeletal system. Hematogenously metastasizing tumors,
The Federal Statistical Office estimates such as breast or prostate carcinoma, pri-
treatment costs at around 24 billion euros marily attack the red bone marrow, which is
per year. particularly well supplied with blood.
Prevention, diagnosis and therapy of Inflammation-causing bacteria also enter
these diseases are therefore a “societal task”. the bone marrow via the blood and lead to
infection there.
The vertebral bodies consist mainly of
20.2 Anatomical Structures cancellous bone, bounded by compacta in
the base and top plates and the posterior
Mirja Wenker parts of the vertebrae. Bones are attachment
points for tendons and ligaments. Joints
The skeleton provides stability to the body form their movable connection with each
and protects the internal organs from injury. other.
The skeleton is an important mineral Three types of bone cells are involved in
store, especially calcium and phosphorus, the formation, remodeling and breakdown
and inside many bones is the production site of bone. Osteoblasts are responsible for
of blood cells. Humans have over 200 bones. bone formation and subsequent mineraliza-
20 A distinction is made between tubular bones tion and calcification of bone. They secrete
Musculoskeletal Diseases
281 20
calcium, phosphates and carbonates into 20.3 Clinical Pictures
the interstitial space, wall themselves and
are then called osteocytes. This hardens the 20.3.1 Fractures
bone so that it becomes resilient. Damaged
or overaged bone is broken down by the z Definition
osteoclasts. A fracture is the interruption of the continu-
In adults, bone formation and decompo- ity of the bone with the formation of two or
sition are balanced. Approximately 20% of more fragments, usually as a result of direct
the bone mass is renewed annually in healthy or indirect force. Repeated overloading can
adults. Pathological processes can disturb lead to a so-called fatigue fracture (e.g.
the balance. Oestrogen deficiency in older marching fracture). If a fracture occurs
women, for example, leads to decreased without adequate application of force in the
blast activity and thus to reduced formation. presence of underlying pathological bone
In children, metabolism is increased in the processes (e.g. in the presence of osteoporo-
epiphyseal fossa as the site of length growth sis or osseous metastases), it is referred to as
(. Fig. 20.1). a pathological fracture. Fractures can be
classified using the AO classification, but
many fracture classifications also have their
own names (e.g. Neer classification for frac-
tures of the proximal humerus or Pauwels
classification for femoral neck fractures).

Long Bong Bones, Short Bones

z Clinic
Definite fracture signs: Axial malalignment,
open fractures with bone fragments pro-
truding from the wound, steps or gaps in the
bone course, crepitation.
Uncertain fracture signs: pain, swelling,
redness, hyperthermia, limited mobility
(functio laesa).

z Diagnostics
X-ray Image (. Fig. 20.2)
55 Dislocated fractures are very easy to rec-
ognize by the displacement of the frag-
ments against each other and a partly
gaping fracture gap.
55 Non-displaced fractures are character-
ized by sharply demarcated lightening
lines and cortical steps.

>>If a fracture is suspected, X-rays should

always be taken in two planes, as a frac-
ture in one plane can also be overlooked.
In addition, a second plane provides
..      Fig. 20.1 Infantile humerus information about any dislocation or
 282 M. Wenker et al.

a b

..      Fig. 20.2 Distal, dorsally tilted radius fracture

axial deviation of fragments, which can

be important for the trauma surgeon.

Particularly in the case of radial head and

OSG fractures, it may even be necessary to
take images in other planes (radial head tar-
get image, OSG oblique images) in order to
prove a fracture.

CT CT can be used to detect fractures that

cannot be visualized on X-ray. Non-displaced
fractures, particularly of the femoral neck
and pelvis, may escape normal radiographic ..      Fig. 20.3 Fractures of the os ilium not visible in
detection but are readily detectable on CT conventional radiographs due to intestinal gas over-
(. Fig. 20.3). An interruption of the cortical lays
bone is usually seen, but submerged fractures
may also result in a line of ­compression with MRI (. Fig. 20.4) MRI is rarely used to
interruption of the normal trabecular struc- detect fractures of the long bones or short
ture. CT is often also requested by the trauma bones. It is used in cases where a fracture is
surgeon for surgical planning in order to be suspected despite a negative X-ray (occult
able to accurately assess the individual frag- fracture) and to visualize concomitant inju-
20 ments and their position in relation to each ries of the capsular ligamentous apparatus.
other as well as joint involvement. Fracture lines show up in the T1 weighting
Musculoskeletal Diseases
283 20
a b

..      Fig. 20.4 a STIR, fracture of the massa lateralis right os sacrum. b T2, fracture of the massa lateralis right
os sacrum

as a band-shaped signal reduction, and in

the T2 weighting as a band-shaped signal
increase (. Fig. 20.4b). In the STIR
sequence, signal enhancement due to bone
edema can be detected in fresh fractures
(. Fig. 20.4a).

Vertebral Body
z Clinic
Symptoms of a vertebral body fracture can
vary. They can range from severe pain and
neurological deficits to no symptoms in sta-
ble fractures. Sintering of the vertebral body
can lead to increased kyphosis of the tho-
racic spine.

z Diagnostics
X-ray
Conventional radiography may show a
reduction in the height of the vertebral body.
Sharp-edged steps of the leading edge sug-
gest a more recent fracture (. Fig. 20.5). If
a fragment breaks off, usually from the lead-
ing edge, a fracture gap can be demon-
strated. In cervical fractures, widening of
the prevertebral soft tissue shadow may
indicate a fracture.
CT (. Fig. 20.6) ..      Fig. 20.5 Sharp step formation of the anterior
A fresh fracture is shown on CT by edge, fresh ventrally accentuated impression fracture
LWK 1
sharply delineated lightening lines and
sharp-edged step formations. CT is used in
particular to assess the involvement of the must be treated surgically. The sagittal
posterior edge of the vertebral body. If this reconstruction is particularly helpful for
is affected, the fracture is unstable and assessment.
 284 M. Wenker et al.

..      Fig. 20.7 STIR, fresh deck compression fractures

BWK 8 to 11 with oedema

They can range from pain to neurological

symptoms to leakage of cerebrospinal fluid
from the auditory canal. Fractures of the
skull bone usually occur as a result of exter-
nal force in the form of an accident, fall or
blow.

z Diagnostics
X-ray
Intracranial hemorrhage or, in the case
of craniofacial trauma, fractures may occur
as a result of violence, which cannot be seen
in conventional X-rays. Therefore, X-rays to
..      Fig. 20.6 Same fracture on CT exclude fractures in these areas are now
obsolete.
MRI (. Fig. 20.7) CT (. Fig. 20.8)
Particularly in patients with already The method of choice for imaging frac-
known vertebral fractures, such as in osteo- tures in the region of the bony skull is CT. It
porosis, MRI can provide evidence of a can also be used to detect fractures that
fresh fracture or fresh fracture component escape conventional X-rays, as well as intra-
in the case of an already known fracture via cranial processes (bleeding, intracranial
the detection of bone edema. The changes pressure).
in T1 and T2 weighting correspond to those Central midface fractures are divided
seen in fracture of the long tubular bones. into three categories according to Le Fort
Tears of the ligamentous apparatus and (. Table 20.1).
intraspinal hematomas can be detected.
>>If intracranial air pockets are found in
Cranial Bones the course of a skull fracture, this must
z Clinic be reported to the attending physician.
Symptoms vary depending on the affected
20 area: cranial dome, facial skull, skull base.
This is then an open skull fracture, which
must be covered with antibiotics.
Musculoskeletal Diseases
285 20

..      Fig. 20.8 Complex fractures of the right facial

skull with fractures of the orbit, maxillary sinus and
zygomatic arch, accompanying hematosinus on the
right side

.       Table 20.1 Le-Fort classification

I The fracture line runs over the hard palate

through the maxilla
II In this form, the upper jaw is fractured in
the form of a pyramid. The fracture runs
through the ethmoid bone, the floor of the
orbit and the anterior wall of the
maxillary sinus
III The Le Fort III fracture is characterized by
the complete detachment of the facial skull
from the base of the skull with the
involvement of the orbita

..      Fig. 20.9 Bowing fracture of ulna and radius left

Child Fractures
The child’s bone is softer and more elastic,
the periosteum more elastic than that of an X-ray Typical greenwood fractures show
adult, which is why children show different an open cortical bone on the convex side
fracture forms. A distinction is made with preserved periosteum, the concave
between green wood fractures and bulge side is broken. In compressed greenwood
fractures. fractures, the cortical bone is preserved on
both the concave and convex sides. Bowing
Greenwood Fracture fractures (. Fig. 20.9) show only the
Subdivision into typical, compressed and bending of the bone; a fracture gap cannot
curved (“bowing fracture”) greenwood frac- be demonstrated conventionally radiologi-
ture. The long tubular bones are affected. cally.
 286 M. Wenker et al.

Bead Breakage Injuries to the Epiphyseal Fossa

X-ray This is a fracture of mostly long bones These are important because length growth
with preservation of the periosteum. Due to is not complete until the epiphyseal joints are
compression, the cortical bone at the site of closed. If an injury to the epiphyseal joint
the fracture is raised and a bulge is formed occurs beforehand, this can lead to prema-
(. Fig. 20.10). ture closure of the growth plate with restric-
tion of length growth. Involvement of the
joint with formation of a step in the articular
surface may result in early arthrosis. Injuries
to the epiphyseal joint are classified accord-
ing to Aitken or Salter and Harris.

Sonography Fractures in infancy can also

be visualized by ultrasound (. Fig. 20.11).
Bulging and buckling of the bone can be
demonstrated. The displacement of frag-
ments in relation to each other can also be
imaged. Sonography can also be used in the
course assessment to demonstrate callus for-
mation.

20.3.2 Luxation
z Definition
This refers to dislocation in a joint with
complete or incomplete loss of contact

..      Fig. 20.11 Radius fracture with cortical step for-

..      Fig. 20.10 Bead fracture distal radius left mation

20
Musculoskeletal Diseases
287 20
between the joint-forming surfaces. In the of an empty glenoid cavity, clear offset of
latter case, one speaks of a subluxation. This the involved bones against each other and
results in a malposition of the joint. The additional bony injuries can be visualized.
most common form is shoulder dislocation. CT and MRI
CT and MRI may be used in cases that
z Clinic are difficult to assess.
Pain, swelling, functio laesa, visible malpo- Sonography
sition in the joint, recognizable empty Infantile luxations can also be diagnosed
socket, springy fixation in the joint by ultrasound.

z Diagnostics
X-ray 20.3.3 Inflammatory Diseases
Two planes are always obtained to
exclude dislocation, as dislocation can be Spondylodiscitis/Spondylitis
missed in one plane (. Fig. 20.12). Evidence
z Definition
These are infections of the spine. In adult-
hood, the process is called spondylitis.
Secondary development of spondylodiscitis
may occur after infestation of the disc space
per continuitatem. In children, primary
hematogenous discectitis or spondylodisci-
tis is possible because of the still existing
vascular supply of the intervertebral discs.
At any age, a primary discectitis with sec-
ondary spread to the vertebral body as
spondylodiscitis can develop postopera-
tively or postpuncturally. If the vertebral
body and intervertebral discs are affected at
the same time, it is no longer possible to
clearly determine the beginning of the infec-
tion pathway, which is why the terms spon-
dylodiscitis and spondylitis are often used
synonymously. Pathogens can be bacteria
(most commonly Staphylococcus aureus),
fungi and rarely parasites.

z Clinic
At the beginning there are often unspecific
symptoms (subfebrile temperatures, night
sweats, fatigue, unspecific back pain).
Diagnostic clarification is often difficult at
this time. A delayed diagnosis of about six
months after the first appearance of the dis-
..      Fig. 20.12 Ventrocaudal shoulder dislocation ease symptoms is to be expected. If the
with empty glenoid cavity course is progressive, there may be load-­
 288 M. Wenker et al.

dependent pain with concussion, tapping

and pressure pain of the spine over the
affected area. Fever is possible. Elevated
inflammatory signs (CRP and ESR) and
neurological deficits with compression of
nerve roots and spinal cord by inflamed
pannus are also possible signs.

z Diagnostics
X-ray
In the early phase, skeletal changes are
usually still absent. Reduction in the height
of an intervertebral space and increasing
blurring of the adjacent base and top plates
are possible (. Fig. 20.13). In the further
course, destruction of the base and top plate
of the vertebral body, which increasingly
scleroses in the healing stage.
CT (. Fig. 20.14)
Detailed recording of bony structures
and their destruction. In the acute phase,
collapses of the vertebral bodies with moth-­
eaten appearance on base and cover plates.
In the course sclerosis with increase of bone
density. The administration of a contrast
medium makes it possible to distinguish
abscesses in the spinal area, which also
allows the simultaneous image-guided inser-
tion of a drain.
MRI
Method of choice. Pathologies can be
detected at an early stage with high soft tis-
sue contrast and very good anatomical reso-
lution, and their extent can be visualized.
The affected vertebral bodies and inter-
vertebral discs show edema in STIR and T1.
Blurred end plates are seen in T1. Inflamed
tissue clearly absorbs contrast medium
(. Fig. 20.15). In T2, there is iso- to hyper-
intense visualization of abscesses with mar- ..      Fig. 20.13 Blurred end plates, partly with destruc-
ginal contrast enhancement. tion

Osteomyelitis/Osteitis osteomyelitis or as secondary osteomyelitis

This is an infection of bone and bone mar- when soft tissue infections spread to the
row. The onset is in the bone by hematoge- bone. The localization is often at the metaph-
nous pathogen seeding in primary ysis of the long tubular bones.
20
Musculoskeletal Diseases
289 20

..      Fig. 20.14 Arrosion of the end plates BWK 5 and

6, height reduction BWK 5

..      Fig. 20.16 Bone consolidated tibial fracture with

chronic osteomyelitis in the tibia

z Diagnostics
X-ray Image (. Fig. 20.16)
The X-ray shows the following abnor-
malities:
55 Bone destruction
55 Unsharp-edged lesions
55 Lamellar periosteal reaction
55 Compacted soft tissues

On healing, new bone formation occurs,

..      Fig. 20.15 T1-FS after KM, clear enhancement of
ranging from marginal to extensive sclero-
the vertebral bodies and the associated intervertebral
discs sis. In chronic osteomyelitis, the changes
can only be assessed to a limited extent in
z Clinic the context of the surgical or traumatic
55 Acute osteomyelitis: general symptoms changes.
(fever, chills, local pain). Local swelling, Sonography
redness, hyperthermia. Elevated inflam- It is indicated in infancy and allows good
matory parameters. visualization of soft tissue swelling. A
55 Chronic osteomyelitis: frequently post-­ detachment of the periosteum by a fluid
traumatic or postoperative. Redness, fringe is seen, which may develop into an
swelling, hyperthermia in the surgical abscess in the course of time. Sonography
area with disturbance of wound healing, allows visualization of cortical destruction.
pressure pain and restriction of move- In adults, ultrasound diagnostics is limited
ment. Elevated inflammatory parame- to supplementary imaging of the soft tis-
ters, fever. sues.
 290 M. Wenker et al.

stiffness may occur, later joint malposition

and subluxation. A laboratory-chemical
detection of rheumatism factors is useful.

z Diagnostics
X-ray
There is symmetrical bilateral involve-
ment, especially of the finger and toe joints
with soft tissue swelling, osteoporosis near
the joint, transient joint space widening due
to joint effusion and proliferation of the
synovium, later joint space narrowing, ero-
sions, subchondral cysts, ulnar deviation of
the fingers, buttonhole and swan neck defor-
..      Fig. 20.17 T1-FS after KM, marginal enhance-
ment distal fibula, subperiosteal abscess mity of the fingers. The final state is destruc-
tion of the joint with ankylosis.
CT CT
This allows a detailed recording of bony This is used to assess stability (e.g. in the
destructions and sequestra. case of cervical spine involvement) and for
MRI (. Fig. 20.17) preoperative imaging.
In proton-weighted sequences with fat MRI
saturation, small, circumscribed, signal-rich Here, an infestation pattern as in conven-
lesions with hypointense presentation in T1 tional X-ray is shown. In fat-saturated T2
are often found. Marginal edema is always sequences bone marrow isointense signal
present. In T2 and STIR, there may be evi- changes correspond to potentially still
dence of abscesses with marginal hypointen- reversible changes. Erosions in T1 hypoin-
sity and contrast uptake. tense. Signal enhancement in T2 in tendo-
vaginitis. Contrast enhancement of
>>Necrotic sequestra show no signal in T2 synovium in synovitis.
and STIR. Sonography
This allows detection of soft tissue swell-
Rheumatoid Arthritis (RA) ing, joint effusion and tenosynovitis, visual-
z Definition ization of erosions depending on the affected
This is a systemic autoimmune disease joint. Assessment of blood flow is also pos-
affecting the synovium. In the course of the sible, as synovial hyperemia is an indicator
disease, destruction of the adjacent joints of disease activity.
may occur. The incidence is 2% and the peak
age at diagnosis is in the 4th to 5th decade of
life. 20.3.4 Degenerative Diseases

z Clinic Herniated Discs

Non-specific general symptoms occur before z Definition
the first joint inflammation (prodromes: This is a degeneration of the intervertebral
fatigue, weight loss, aching limbs). In the disc with tears of the annulus fibrosus and
case of joint inflammation, acute swelling protrusion of parts of the disc. In the case
and pain of several joints as well as morning of dorsal, intraforaminal or lateral protru-
20
Musculoskeletal Diseases
291 20
sion, depending on the extent, neural struc- Not indicated, as only the bony struc-
tures are affected. Mostly affected are L4/5 tures are imaged. However, it may indicate a
and L5/S1. different genesis of the symptoms, e.g. frac-
In terms of localization, a distinction is ture with posterior edge involvement.
made between median, paramedian, intrafo- CT
raminal and lateral disc herniations. This is reserved for patients in whom, for
example, an MRI cannot be performed due
z Clinic to a pacemaker. The intervertebral disc pres-
Back pain, in case of affection of nerve ents as a soft-partisodense structure.
roots dermatoma-related pain, loss of sensi- Protrusions into the spinal canal or intrafo-
bility and paralysis, bladder and rectum raminal can be visualized (. Fig. 20.18).
weakness. MRI (. Fig. 20.19)
This is the method of choice and is usu-
z Diagnostics ally performed in T2 hypointense annulus
X-ray fibrosus with signal elevated nucleus pulpo-
sus; in the course of degeneration increasing
hypointensity also of the biliary nucleus. A
well-defined protrusion of the intervertebral
disc with possible compression of the
myelon or constriction of the neuroforami-
nae can be detected. Possible contact of the
intervertebral disc with the nerve roots can
be visualized. In the case of sequestration,
disc tissue luxating cranially or caudally is
shown with or without contact to the resid-
ual disc.

Arthrosis
z Definition
..      Fig. 20.18 Right dorsoparamedian disc protru- This is a degenerative change in the joints
sion that can occur increasingly over the course

a b

..      Fig. 20.19 T2, left paramedian disc sequestrum folded over caudally
 292 M. Wenker et al.

of a lifetime due to wear and tear. In younger matous changes. Reactive inflammations are
years, it becomes manifest post-­conspicuous by enhancement after applica-
traumatically, especially with predisposing tion of contrast medium.
factors, e.g. hip dysplasia. Frequent localiza-
tion is the knee and hip joint.

z Clinic
Pain, limited mobility, morning stiffness,
worsening under load. Later also swelling
and joint effusion. Ankylosis.

z Diagnostics
X-ray Image (. Fig. 20.20)
Important features include: Joint space
narrowing, subchondral sclerosis of adjacent
articular surfaces, subchondral debris cysts,
osteophytic marginal attachments, defor-
mity of articular components.
CT (. Fig. 20.21)
The features are similar to those seen on
conventional radiographs (including visual-
ization of free joint bodies).
MRI (. Fig. 20.22)
Cartilage and meniscus damage are ..      Fig. 20.21 Coxarthrosis on the left with partially
clearly visible. There are subchondral oede- abolished joint space and subchondral debris cysts

..      Fig. 20.20 Coxarthrosis on the left with already ..      Fig. 20.22 Gonarthrosis with subchondral edema
incipient deformation of the femoral head of the medial tibial head and inner meniscus lesions

20
Musculoskeletal Diseases
293 20
20.3.5 Tumors and Tumor-like Together with the patient’s medical history
Lesions and symptoms, an initial tentative diagnosis
can be made and, if necessary, further exam-
In benign bone tumors and tumor-like inations can be initiated.
lesions, the findings range from leave-me-­
Examples of Benign Tumors
alone lesions, which are usually incidental
findings due to their asymptomatic nature, and Tumor-like Lesions
to lesions that require treatment due to Juvenile Bone Cyst/Single Bone Cyst
symptoms or the occurrence of pathologic z Definition
fractures. This is a benign cystic cavity formation
Sarcomas are malignant tumors of the which is mostly localized in the metaphysis
musculoskeletal system and occur rather of the long tubular bones. It belongs to the
rarely compared to carcinomas. A distinc- tumor-like lesions with an age peak between
tion is made between bone and soft tissue the 1st and 2nd decade of life.
sarcomas.
Malignant bone tumors are rather rare z Clinic
overall. In adults, they account for 1% of It is an incidental finding as it is usually
all primary malignant bone tumors. In asymptomatic. In some cases, it may become
children, the figure is 5%. Osseous metas- conspicuous due to a pathological fracture.
tases of other tumors are significantly
more frequent, but rarely occur before the z Diagnostics
age of 40. X-ray Image (. Fig. 20.23)
Primary bone sarcomas arise in bone The following features are conspicuous:
sections with particularly large growth. Risk sharply edged lightening, centrally located,
factors may include Paget’s disease or usually with sclerosis fringe, thinning of the
chronic osteomyelitis. Ionizing radiation cortex. In the case of pathological fracture,
after radiotherapy or prolonged diagnostic fragments may fall into the bone cyst and
use can also induce bone sarcoma. “float” there (“Fallen Fragments”,
If a bone change is detected in the X-ray, . Fig. 20.23).
the following criteria should be included in CT
making a possible diagnosis: CT is suitable for the determination of
55 Type of lesion (osteolytic, osteoplastic, the density of the cyst contents and for the
mixed, “moth-eaten”, permeative) detection of fluid or unilocularity.
55 Border of the lesion (smooth, blurred) MRI
55 Changes in the cortical bone (thinning, MRI is used to detect fluid in the lesion,
destruction) which presents as signal-rich in T2. There is
55 Periosteal reaction (solid, Codman tri- a marginal contrast enhancement.
angle, “onion skin”, spicules, sunburst
phenomenon) >>Differentiation from the aneurysmal
55 Codman Triangle bone cyst: This is multi-chambered as it
55 Onion skin pattern is divided by septa. Due to blood in the
55 Sunburst phenomenon cyst contents, fluid levels within the
55 Assessment of the matrix (bone, carti- lesion occur because of the different
lage) density, which can best be detected with
55 Growth rate as an expression of aggres- fat-saturated T2 sequences. Cortical
siveness destruction with soft tissue involvement
55 Localization may occur.
 294 M. Wenker et al.

..      Fig. 20.24 Nidus in the proximal femur

..      Fig. 20.23 Pathological fracture in juvenile bone

cyst, “Fallen Fragments” in the interior ..      Fig. 20.25 T2-Spair, hyperintense nidus

Osteoid Osteoma z Diagnostics

z Definition X-ray
This is a benign osteogenic tumor of small Within a sclerosis, a typical central oste-
size, often localized to the tibia and femur. olysis, the so-called nidus, is seen. Often an
The age peak is in the 1st to 3rd decade of intracortical location is found.
life, the prevalence is 2–3% of all primary CT
bone tumors. This is the method of choice with good
visualization of the nidus even in conven-
z Clinic tionally radiologically not well visible areas.
There is severe pain, especially at night, An early contrast image of the nidus is typi-
which responds very well to acetylsalicylic cal (. Fig. 20.24).
acid. MRI (. Fig. 20.25)

20
Musculoskeletal Diseases
295 20
The nidus presents with little signal in z Clinic
T1. The signal intensity in T2 varies depend- Pain and swelling that increase over weeks
ing on the extent of calcification. and months.

 xamples of Malignant Bone

E z Diagnostics
Tumors X-ray
Classic Osteosarcoma There is circumscribed osteolysis with
z Definition destruction of the cortical bone, the margins
Osteosarcoma is a highly malignant, intra- may be sharp or blurred. An accompanying
medullary tumor, which is mostly found on periosteal reaction is possible. In about 50%
the metaphysis of the long tubular bones irregular spotty calcifications occur.
and is the most common malignant primary CT (. Fig. 20.26)
bone tumor with 40%. The peak age is The presentation is similar, but disten-
between 15 and 25 years. sion and destruction of the bone can be
shown better.
z Clinic MRI (. Fig. 20.27)
Increasing pain and swelling in the affected MRI allows good visualization of the
area. cartilage cap and soft tissue component.

z Diagnostics Osseous Metastases

X-ray z Definition
Osteosarcoma has a highly variable Osseous metastases are the most common
appearance, often osteosclerotic is found secondary bone tumors caused by the spread
next to osteolytic parts, a fuzzy border and of other tumors to the bones, e.g. breast car-
periosteal involvement with formation of cinoma, prostate carcinoma, bronchial car-
spicules. Codman triangle. cinoma. They can occur in all bones, but the
CT preferred site is the axial skeleton. Osseous
The characteristics are similar, but a bet- metastases rarely occur in the first three
ter differentiation between tumor mass and decades of life.
reactive changes is possible.
MRI
Signaling is dependent on the degree of
sclerosis. Information about intramedullary
spread, skip metastases, soft tissue and joint
involvement is possible.

Chondrosarcoma
z Definition
Chondrosarcoma is a malignant cartilage
tumor and with 20% the second most fre-
quent malignant primary bone tumor.
Frequent localization is the pelvis and ..      Fig. 20.26 Chondrosarcoma of the right lateral
femur. The age peak is found in the 6th massa with marked destruction, presacral margin cal-
decade of life. cified soft tissue component
 296 M. Wenker et al.

55 Osteoblastic metastases (prostate, breast

carcinoma): fuzzy-edged compression of
the bone, can be small and patchy, but
can also affect the whole bone.
55 Mixed osteolytic-osteoblastic metastases
(breast, prostate, bronchial carcinoma):
coexisting osteolytic and osteoblastic
foci that may [Link]

The image is similar, but clearly superior to

the conventional X-ray image in detection.
..      Fig. 20.27 Bone cement inserted into chondrosar- MRI (. Fig. 20.29)
coma of right lateral massa with signal effacement, Osseous metastases show low signal in
presacral hyperintense soft tissue component T1, high signal in T2 with fat saturation as
well as STIR. They show contrast enhance-
ment.

20.3.6 Congenital Disorders

of the Skeletal System
Congenital Hip Dysplasia
z Definition
This is a congenital developmental disorder
of the acetabulum and the most common
congenital skeletal maldevelopment. Girls
are affected six times more often. In 1/4 of
cases there is a bilateral manifestation. In
..      Fig. 20.28 Diffuse osteoplastic metastasis of a the absence of treatment, dislocation of the
prostate carcinoma femoral head with subluxation to luxation
occurs.
z Clinic
Dull pain. General symptoms in the context z Clinic
of the tumor disease (weight loss, fatigue). Asymmetry of the gluteal folds, abduction
Can be noticeable due to pathological inhibition, leg length discrepancy. Positive
­fracture. Ortolani test.

z Diagnostics z Diagnostics
X-ray Image (. Fig. 20.28) Sonography
55 Osteolytic metastases (bronchial, renal, This is performed as part of the U3
thyroid carcinoma): circumscribed light- examination, and often also as part of the
eningwithout marginal sclerosis, arrosion U2 examination in children, and is used to
of the cortical bone with possible spread visualize the cartilaginous preformed femo-
into the adjacent soft tissues. ral head, cartilaginous acetabular notch

20
Musculoskeletal Diseases
297 20
a b

..      Fig. 20.29 a T2, diffuse osseous metastasis, hypointense changes. b T1-FS after KM administration,
enhancement of osseous metastases

with labrum acetabulare, and bony and car- Congenital Foot Deformities
tilaginous acetabular roof in defined sec- z Definition
tional planes. Sonography can be used to This is a congenital deformity of the feet
visualize the bony shape of the acetabulum with malposition of the bones and typical
and acetabular notch as well as the overlap changes in the arches of the feet. With a
of the femoral head by the cartilaginous prevalence of 0.1%, clubfoot is the most
acetabular roof. The classification is accord- common congenital foot deformity and the
ing to Graf. second most common congenital skeletal
X-ray deformity after hip dysplasia. Early diagno-
The procedure is performed from the 9th sis and initiation of treatment are crucial for
month of life with measurement of the hip prognosis.
with regard to the acetabular roof geometry
and the centring of the femoral head in the z Clinic
acetabulum and determination of the ace- Usually at birth there are already visible
tabular roof angle according to Hilgenreiner deformities of the foot.
(AC angle). This becomes smaller with For example:
increasing ossification of the acetabulum. 55 Clubfoot (Pes equinovarus): complex
MRI foot deformity with pointed foot, varus
MRI is used for preoperative planning in position of the heel, sickle foot with
therapy-resistant hip dysplasia. Obstacles to inward rotation of the metatarsus and
reduction can be detected. A femoral head hollow foot.
necrosis can be excluded after forced reduc- 55 Flatfoot (talus verticalis): Malformation
tion. with a vertically standing talus and luxa-
 298 M. Wenker et al.

tion of the os naviculare to the cranial

side.
55 Other examples are sickle foot (Pes
adductus), hollow foot (Pes excavatus),
heel foot (Pes calcaneus) and pointed
foot (Pes equinus).

z Diagnostics
X-ray
It is used to evaluate the axes and angles
of the tarsal bones in the dorsoplantar and
lateral rays.
MRI
Because the bone nuclei are still carti-
laginous in infancy, MRI is the method of
choice for visualizing the malposition in
..      Fig. 20.30 Perthes’ disease on the right with flat-
three planes. tened epiphysis
CT
With advanced ossification of the foot 55 Gage sign: Lightening at the lateral
skeleton, a good spatial view of the extent epiphysis and the adjacent metaphysis in
of the deformity can be obtained with 3D the form of a recumbent “V”
reconstruction. 55 Calcification lateral to the epiphysis
55 Diffuse metaphyseal reaction: either in
the form of ligamentous lightening close
20.3.7 Diseases of the Infantile to the joint or in the form of cystic defects
Skeleton 55 Lateral subluxation
55 Horizontal epiphyseal fissure.
Perthes’ Disease/
Legg-Calvé-Perthes’ Disease Sonography
z Definition It is used to detect the joint effusion.
This is an idiopathic necrosis of the femoral MRI (. Fig. 20.31)
head. The peak age is between the 4th and In the initial stage, MRI can detect the
8th year of life. Boys are affected four times disease by bone marrow edema in the pineal
more often than girls. gland with still inconspicuous X-ray find-
ings. There is a drop in signal from the
z Clinic epiphysis in T1. Signal irregularities of the
Pain with claudication. Restricted move- cartilage, possibly also cartilage thickening,
ment of the affected hip. an effusion and inflammation of the synovia
can be detected. Incipient femoral head
z Diagnostics deformities can be delineated.
X-ray Image (. Fig. 20.30)
Changes in the conventional radiograph Epiphysiolysis Capitis Femoris
depending on the stage. z Definition
Risk factors for an unfavorable course The epiphysis of the femoral head loosens
are the so-called “head-at-risk” signs: and slips, usually in a medio-dorso-caudal
20
Musculoskeletal Diseases
299 20

a b

..      Fig. 20.31 a STIR, Perthes’ disease with edema in epiphysis and metaphysis. b In lateral comparison, clearly
flattened and hypointense epiphysis on the right

direction. The peak age is between the 10th

and 15th year of life. Boys are more fre-
quently affected than girls. Bilateral involve-
ment occurs in about 50%. Obesity
predisposes to the disease.

z Clinic
Painful restriction of movement. Limping.
Restricted internal rotation.

z Diagnostics
X-ray
It is recommended to take an a.p. and
Lauenstein image (. Fig. 20.32). Anterior-­ ..      Fig. 20.32 Lauenstein image, step formation
posteriorly there is a widening of the epiphy- between metaphysis and epiphysis with slipping of the
seal fossa. The epiphysis appears narrowed epiphysis
by the dorsal tilt. A tangent applied to the
superolateral femoral neck does not inter- Sonography
sect the epiphysis. A good representation of Here, the step formation between the
the tilting of the epiphysis is possible in the femoral neck and the epiphysis is a sign of
Lauenstein image. slippage.
 300 M. Wenker et al.

a b

..      Fig. 20.33 a Epiphysiolysis capitis femoris left with slippage of the epiphysis. b Lateral comparison of
edema at epiphysis and metaphysis left and widened epiphyseal fossa

MRI (. Fig. 20.33) This can be done to exclude differential

Here, an earlier image of the changes can diagnoses, the symptoms are similar to
be made than in the conventional X-ray Perthes disease and epiphysiolysis capitis
image. MRI can be used in cases of clinical femoris.
suspicion and inconspicuous X-ray findings.
In T2, there is signal enhancement and wid-
ening of the epiphyseal fossa. Bone oedema 20.4 Diagnostics
may be detectable.

Coxitis Fugax 20.4.1 Diagnostic Radiology

z Definition Services
This is the so-called “hip rhinitis”, a non-­
infectious inflammation of the hip joint Sonography
that heals spontaneously. Coxitis fugax is Sonography represents the simplest option
often preceded by an infection of the for the initial diagnosis of muscular prob-
respiratory tract or the gastrointestinal lems. Increasingly, ultrasound is also used in
tract. The age peak is in the 3rd to 10th joint diagnostics. Thus, a joint effusion can
year of life. be easily detected sonographically. Ligament
structures can also be viewed sonographi-
z Clinic cally, at least in the first step. Ultrasound is
Schonhinken. Hip pain, often projected into used less frequently in fracture diagnosis,
the knee. Painful restriction of movement, although sternal fractures or forearm frac-
especially internal rotation. Negative inflam- tures, for example, can be detected very well
matory parameters. in pediatric patients.

z Diagnostics Conventional X-ray Diagnostics

Sonography The basis of skeletal diagnostics is still con-
Here there is an effusion of the joint, the ventional X-ray diagnostics. It can be used
capsule is lifted from the bone. to detect fractures. The healing process of a
X-ray fracture is assessed. Conventional diagnos-
20
Musculoskeletal Diseases
301 20
tics is also very well suited for diagnosing tance for stability in the event of a vertebral
luxations. body fracture. CT diagnostics of interverte-
Another important field of application is bral disc disease is only an exception in
functional diagnostics, e.g. of the spine. patients who are not amenable to an MRI
Conventional radiography is justified in examination.
soft tissue diagnostics for the detection of Computed tomography of joints should,
foreign bodies. if possible, be performed in the neutral zero
position, e.g. with the elbow extended.
Fluoroscopy/Angiography However, there are often limits here due to
As a rule, fluoroscopic examinations of the pain or also plaster casts.
skeletal system tend to be performed by In the context of fracture diagnostics,
orthopedic surgeons or trauma surgeons. CT diagnostics plays an important role in
This mainly involves intraoperative position the bony pelvis, since numerous fractures of
checks and checks of osteosynthesis materi- the pelvis cannot be detected in conven-
als. In hospitals with a large spine or neuro- tional X-rays.
surgery, however, myelography and Plasmocytoma is a malignant disease of
discography are often performed as fluoro- the bone marrow that can lead to multiple
scopic examinations. Both examinations osteolysis throughout the skeleton. Until a
have their justification in the differential few years ago, extensive conventional X-ray
diagnosis of back complaints. Discography diagnostics, e.g. according to the Paris
is nowadays mainly a provocation test. After scheme, were performed for this disease.
puncture of the intervertebral disc via a flu- This included radiographs of the entire
oroscopically controlled dorsolateral spine, pelvis, long bones, and skull. Despite
approach, 1–2 mL of contrast medium is these numerous images, a large number of
injected into the disc. The patient is asked the small osteolysis, often only 1–2 cm in
whether the pain experienced is known and size, could not be detected. Only the patho-
corresponds to that which now leads him to logical fracture has often revealed the find-
the doctor. In this case, the radiologist ings. Therefore, the primary diagnosis of
speaks of a positive discography, the affected plasmacytoma is nowadays performed by
disc contributes to the discomfort symptoms CT of the entire skeletal status.
of the patient.
Myelography is used to detect spinal Magnetic Resonance Imaging
constrictions. Compared to MRI, which can Magnetic resonance imaging is the examina-
of course also show a narrowing of the spi- tion method of choice for the assessment of
nal canal very well, myelography has the intervertebral disc disease. MRI also has the
advantage of functional diagnostics. highest sensitivity in the detection of verte-
Myelography can also be used to detect spi- bral body metastases. The disadvantage com-
nal canal stenoses that occur, for example, pared to scintigraphy is the limited
only when the lumbar spine is inclined. examination section and the lower a­ vailability.
In the diagnosis of ligament injuries and
Computed Tomography joint damage, MRI also shows the most
Computed tomography is primarily used for accurate results. Another advantage of MRI
the precise assessment of complex or con- is that medullary edema can be detected.
ventionally questionable fractures. In the This shows the involvement of the bone
spine, computed tomography is used to after a trauma, for example, even if there is
accurately assess the posterior edge of the no cortical interruption in the sense of a
vertebral body, which is of central impor- fracture.
 302 M. Wenker et al.

In the case of primary bone tumors, an >>Only ten days after trauma are repair
MRT examination is performed in addition processes detectable by scintigraphy.
to the indispensable conventional X-ray
diagnosis. While a fresh fracture shows increased stor-
age in the blood pool and mineralization
phase, the activity enrichment of old events
20.4.2 Nuclear Medicine is only detectable in the mineralization. The
Diagnostics positive finding should be confirmed by a
control after four weeks.
Ursula Blum
Denture Loosening 3-phase skeletal scintig-
Skeletal Scintigraphy raphy can be used to assess the strength of
To prepare the 99mTc
labeled bisphospho- an endoprosthesis and the resulting need for
nates, the generator eluate is combined implant replacement. Cementless prostheses
with an industrially prepared kit contain- show band-like activity along the prosthesis
ing the inactive carrier and a reducing tin II shaft up to two years postoperatively, which
salt in nitrogen inert gas atmosphere and is related to new bone formation on the
freeze-­dried form. To ensure reduction of prosthesis.
the inert 99mTc O4− into a reactive compo-
nent, the generator eluate must be intro- > Osteonecrosis
duced into the kit under exclusion of air. They show low storage in perfusion and
The amount to be applied depends on age, blood pool, later with higher storage or
weight and disease. The limit value is normalized.
500 MBq for benignity and 700 MBq for
malignancy.
> Osteomyelistis
The labelled biphosphonates are taken
On 3-phase skeletal scintigraphy, osteo-
up superficially into the hydroxyappatite
myelitis acute and chronic is notable for
matrix of the bone via osteoblast activity,
increased arterial perfusion, increased
depending on thickness, blood flow and
blood pool accumulation, and increased
bone remodeling.
tracer uptake in the mineralization phase.
The level of activity uptake gives an indi-
Recording The image is taken in the supine
cation of the inflammatory activity of the
position, with the patient’s arms lying next to
process.
the body and the legs symmetrically rotated
inwards.
> Detection of Skeletal Metastases and
Assessment Pelvis, WS and ileosacral joints Primary Bone Tumors
accumulate physiologically increased as Because of its high sensitivity, the exclu-
places of increased stress. Tubular bones sion or detection of skeletal metastases is
absorb the activity more strongly than spongy the most frequent indication for skeletal
bones. scintigraphy. Bone metastases in breast
carcinoma, for example, can be detected
Traumas Fracture detection by skeletal scin- six months before conventional radiologi-
tigraphy is performed primarily in cases of cal diagnosis, while those of prostate car-
occult fractures, unexplained complaints, cinoma can often be detected years earlier.
child abuse, determination of fracture age, 3-phase scintigraphy is also used for pri-
20 and detection of fatigue fractures. mary bone tumors (e.g. osteosarcoma).
Musculoskeletal Diseases
303 20

.       Table 20.2 Value of the diagnostic procedures

Sonography Conventional CT MRI Nuk PET

Fracture N P W W W N
Herniated Disc N N N(*) P N N
Ligament/Muscle Injuries P W N P N N
Metastases N N W W P W
Plasmacytoma N N P W N N
Primary Bone Tumor N P W P W W

N Not indicated, P Primary diagnosis, W Further diagnosis, * CT in contraindications for MRI

Inflammatory Scintigraphy 20.5 Therapy

of the Skeleton
Radioactively labeled anti-granulocyte anti- 20.5.1 Interventional Radiology
bodies or in vitro labeled autologous leuko-
cytes can be used to detect bacterial Mirja Wenker
inflammation after implantation of a joint
prosthesis. They accumulate in the granulo- Tumor Embolization
cytes and their precursors in the hematopoi- Osseous metastases of hypervascularized
etic bone marrow. They are unsuitable in the tumors lead to extensive blood loss during
trunk skeleton due to the physiological surgical therapy. To reduce these blood
accumulations to be expected there. losses, such metastases are treated angio-
111In or 99mTc-labelled leukocytes and
graphically with particles and other emboli-
99mTc-­labelled monoclonal anti-granulocyte
zation materials one to two days
antibodies are used to detect a granulocytic preoperatively. After superselective probing
inflammatory reaction. Whole-body scintig- of the tumor-supplying vessels, emboliza-
raphy with non-specific antibodies is per- tion material is introduced until stasis in the
formed to clarify chronic inflammation, in vessel as evidence of vessel occlusion. A
chronic febrile episodes and to search for the classic example of this is metastases of renal
fever-causing focus. cell carcinoma.

Computed Tomography-Guided
20.4.3 Valence Bone Tumor Treatment
In particular, painful osseous metastases,
Christel Vockelmann regardless of the tumor entity, are nowadays
approached interventional radiologically.
. Table 20.2 shows the use of the respective There are two procedures: an injection of
diagnostic options depending on the prob- bone cement into lytic metastases or ther-
lem. moablation, i.e. burning of the metastasis by
 304 M. Wenker et al.

20.5.2 Nuclear Medicine

Ursula Blum

Radiosynoviorthesis (RSO)
RSO is an effective method for the local
therapy of chronic joint inflammations. The
aim is to remodel the connective tissue of
the synovium. This is achieved with good
results by injecting a radioisotope, which
decays by emitting β− radiation, into the
joint space (e.g. 90Y, 186Re, 169Er). The choice
of radiopharmaceutical depends on the size
of the joint. The smaller the joint, the
..      Fig. 20.34 Thermoablation of an osteoid oste- shorter the range of the β– radiopharmaceu-
oma, probe tip inserted into the nidus tical should be. The maximum/average range
is 11 mm/3.6 mm for 90Y, 3.7/1.2 mm for
186Re, 169Er 1.0 mm/0.3 mm.
electricity, which is also suitable for lytic or
mixed osseous metastases. The radiopharmaceutical is injected
Thermoablation is now the treatment of intraarticularly. At the same time, a corti-
choice for osteoid osteoma (. Fig. 20.34). sone preparation may be injected for transi-
CT-guided therapies of osseous metasta- tional therapy.
ses can be used very well together with
radiotherapeutic therapies and do not Palliative Therapy of Bone
replace them as a rule. The advantage of Metastases
CT-guided therapy is the very rapid reduc- Osteoplastic metastases of prostate, breast
tion in pain symptoms. or bronchial carcinoma can be treated palli-
atively with osteotropic radiopharmaceuti-
Pain Management cals if they do not respond to other available
Degenerative spinal diseases are one of the therapies. The goal of palliative bone pain
main reasons for sick leave in everyday therapy with short-range β– radiotherapy is
working life. to improve the patient’s quality of life or
In the case of diseases of the interverte- reduce pain medication. Nuclear bone pain
bral discs with nerve root irritation or dis- therapy is contraindicated in cases of exist-
eases of the facet joints, pain therapies ing or impending spinal cord compression
controlled by computer tomography are due to vertebral metastases or unstable frac-
used. A fine needle is inserted dorsally into tures, existing bone marrow depression or
the affected spinal segment and a local renal insufficiency.
anesthetic and, if necessary, a corticoste- The following radiopharmaceuticals are
roid are introduced into the facet joint, applied via a venous catheter (. Table 20.3).
peripherally to the nerve root or epidurally The respective radiopharmaceutical is
under CT-controlled control. In recent injected over one to 2 min, after which the
years, however, there has been a decline in venous catheter is flushed with 0.9% NaCl
such interventions, especially in the outpa- solution.
tient sector, since health insurance compa- For radiopharmaceuticals containing a
nies and associations of panel doctors γ-component, a whole-body scintigram is
20 require a presentation to a pain therapist obtained to document activity uptake six to
prior to therapy. 24 h after application.
Musculoskeletal Diseases
305 20

.       Table 20.3 Venous catheter-applied radiopharmaceuticals

Radiopharmaceuti- Maximum Medium Physical Amount of Activity to Be

cal Range Range Half-life Applied

89Sr-Strontium 6.7 mm 2.4 mm 50.5 days 1.5–2.2 MBq/kgKG

chloride
153Sm—HEDP 3.4 mm 0.6 mm 1.9 days 37 MBq/kgKG
186Re—HEDP 4.7 mm 1.1 mm 3.7 days 18.5 MBq/kgKG
188Re—HEDP 11 mm 2.7 mm 0.7 days 1295 MBq
32P 7.9 mm 3 mm 14.3 days 175–400 MBq
117Sn—DTPA 7 mm 2.4 mm 13.6 days 5–10 MBq/kgKG
223Ra—chloride Few mm 11.4 days 50–100 kBq/kgKG

Blood counts are required every one to 20 Gy, single dose at 2 Gy. The boost is usu-
two weeks posttherapeutically for up to six ally irradiated percutaneously, but some
weeks. clinics apply it during the operation (IORT
intra operative radiotherapy), other clinics
treat it with brachytherapy.
20.5.3 Radiotherapy Storage is usually in a vacuum cushion.
Side effects: Skin reactions, fibrosis,
Guido Heilsberg lymphedema …

Soft Tissue Sarcomas Bone Sarcomas

Soft tissue sarcomas are nowadays treated Chondrosarcomas are not chemosensitive.
multimodally. Preoperative radiotherapy is Chondrosarcomas and chordomas of the
given for very large tumors with a total dose skull base are treated with protons or heavy
of 50 Gy + boost treatment between six and ions.

Case Study

Benjamin is ten years old and a big fan of father takes him to the doctor. The pedia-
video games. He gave up playing football trician, Dr. Menne, questions Benjamin in
for it some time ago. Since then, he usually detail and examines the mobility in the hip
sits at home in the afternoon in front of the joint. After the examination Dr. Menne
computer with a bag of chips (or two!). His suspects an epiphysiolysis capitis femoris.
left hip has been hurting him for a few days Because the complaints could also be from
now, so he’s been moving very carefully coxitis fugax or Pertes disease, Dr. Menne
and hasn’t participated in school sports orders both a sonography of the hip joint
either. When the pain doesn’t improve, his and an x-ray of the left hip from the pedi-
 306 M. Wenker et al.

atric radiologist, Dr. Ass. The sonogram epiphyseolysis capitis femoris can affect
shows a small effusion in the left hip joint, both hips, an X-ray of the right hip is also
which occurs in both coxitis fugax (also taken. Fortunately, this is not affected.
called hip flare) and epiphyseiolysis capitis Nevertheless, Benjamin has to be operated
femoris. The x-ray shows slippage of the on, the left hip is stabilized with drill wires
epiphysis of the left femur, so Dr. Menne so that there is no risk of femoral head
was right, it’s not just the sniffles! Since necrosis.

Practice Questions 3. What classification of herniated disc

1. Name safe and unsafe fracture signs! do you know?
What should be considered when ask- 4. What radiological interventional
ing about fracture with regard to con- options do you know for musculo-
ventional X-ray diagnostics? skeletal diseases? Give examples.
2. What criteria should be included in
the assessment of a bone lesion? Solutions 7 Chap. 27

20
 307 21

Cardiovascular Diseases
Mirja Wenker, Ursula Blum, and Christel Vockelmann

Contents

21.1 Anatomical Structures – 308

21.2 Disease Patterns – 308

21.2.1  eart – 308
H
21.2.2 Vessels – 313

21.3 Diagnostics – 321

21.3.1  adiological Diagnosis – 321
R
21.3.2 Nuclear Medicine – 322
21.3.3 Valence – 325

21.4 Therapy – 326

21.4.1 Interventional Radiology – 326

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 308 M. Wenker et al.

Patients with cardiovascular diseases make divides into two branches, the R. interven-
21 up a large proportion of the patient popula- tricularis anterior (RIVA) and the R. cir-
tion. At over 40%, they are one of the lead- cumflexus (RCX). The RIVA runs on the
ing causes of death in Germany. In this anterior surface of the heart and supplies
chapter, the essential possibilities of radio- the anterior wall of the right ventricle and
logical diagnostics and therapy of the heart the anterior and middle portions of the ven-
and vessels will be presented. First, a brief tricular septum. The RCX runs on the left
overview of the anatomy is given. This is fol- side towards the diaphragm and supplies the
lowed by a presentation of common dis- left atrium and the wall of the left ventricle.
eases. Arteries are divided into those of the
muscular and elastic type.
The veins have a narrower wall structure
21.1 Anatomical Structures and are partially equipped with venous
valves that prevent the backflow of blood.
Mirja Wenker

The heart and blood vessels together form 21.2 Disease Patterns
the cardiovascular system. A distinction is
made between a large circulatory system Mirja Wenker
(systemic circulation: left ventricle—aorta—
arteries—arterioles—venules—veins—v.
cava—right atrium) and a small circulatory 21.2.1 Heart
system (pulmonary circulation: right ventri-
cle—pulmonary arteries—lungs—pulmo- Acute Myocardial Infarction
nary veins—left atrium). The latter serves z Clinic
primarily to enrich the blood with oxygen Acute coronary artery occlusion leads to
and remove carbon dioxide. reduced perfusion of the dependent myocar-
The heart has the appearance of a three-­ dium and, in the further course, to tissue
sided pyramid with a base (basis cordis) and destruction. Almost all cases are caused by
an apex (apex cordis). It is divided into the arteriosclerotic changes. Acute myocardial
two atria (atrium sinistrum and dextrum) infarction is fatal in about 1/3 of cases and
and ventricles (ventriculus sinistrum and remains the most common cause of death in
dextrum) by the cardiac septa (septum inter- industrialized nations.
atriale, interventriculare and atrioventricu- Patients present with acute thoracic pain
lare). Blood flows through the mitral and (“annihilation pain”), which may also move
aortic valves in the left heart and the tricus- into the jaw and the left arm. In women, the
pid and pulmonary valves in the right heart. symptoms may also be diffuse (nausea, mal-
The heart is covered by a network of ves- aise, etc.). Cold sweating and signs of heart
sels called the coronary arteries. The coro- failure are also symptoms.
naries supply the myocardium with blood.
The right coronary artery (A. koronaria z Diagnostics
dextra, RCA) runs across the posterior wall X-ray
of the heart and supplies the wall of the Conventional radiography often shows
right and left ventricle as well as the poste- no changes. In extensive infarction, signs of
rior section of the ventricular septum. The cardiac decompensation with pulmonary
left coronary artery (A. coronaria sinistra) venous congestion, pulmonary edema, and
Cardiovascular Diseases
309 21
associated pleural effusions may be seen. Cardiomyopathies
Cardiomegaly may be seen. Cardiomyopathies are diseases of the heart
Echography muscle that are associated with a functional
Reduced ventricular function can be limitation of the heart. They lead to a thick-
demonstrated with cardioechography. Local ening of the heart muscle and/or a dilatation
wall motion abnormalities are also seen. of the heart cavities. The WHO distinguishes
There may be evidence of thrombi. five forms of cardiomyopathy.
CT
CT is used primarily to exclude other Dilated Cardiomyopathy (DCM)
causes of acute chest pain. Arteriosclerosis z Clinic
of the coronary arteries can already be This is the most common form, there is dila-
detected on normal chest CT. With coro- tation of the left, sometimes also the right
nary CT angiography, the coronary arteries ventricle, the functional impairment appears
can be examined in detail and stenoses can as heart failure. In the primary form, the
be detected. Thrombi and reduced perfusion cause is unclear; in about one third of cases,
in the affected myocardial area may be visi- there is a genetic predisposition.
ble.
MRI z Diagnostics
The cardiac MRI shows the perfusion Echocardiography
disturbance of the infarcted myocardium in The simplest and most cost-effective
addition to the findings that can be delin- method of assessing the heart is echocar-
eated in the echography. A local edema pro- diography. It can quantify impaired function
vides a signal enhancement in the T2 as well as dilatation of one or both ventri-
weighting. The infarct area shows delayed cles.
contrast enhancement (. Fig. 21.1). Conventional X-ray/CT (. Fig. 21.2)
Angiography Conventional X-ray as well as CT often
Conventional coronary angiography is show only global dilatation of the heart.
the method of choice for imaging the coro- Depending on the stage of heart failure,
nary vessels. In the course of the interven- pleural effusion may be present. Possibly a
tion, therapy can be performed directly by dilatation of the pulmonary vessels can be
means of PTCA and, if necessary, stent detected.
implantation. Cardio-MRI (. Fig. 21.3)

a b

..      Fig. 21.1 a, b Posterior wall infarction with contrast image of the infarcted area
 310 M. Wenker et al.

ventricles. If constriction of the left ventricu-

21 lar outflow tract occurs, this is called hypertro-
phic obstructive ­cardiomyopathy (HOCM).

z Diagnostics
Echocardiography
Here, too, echocardiography is the first
tool of choice. In addition to myocardial
hypertrophy, impaired function can be dem-
onstrated. The HOCM shows an anteior
movement of the anterior mitral valve leaf-
let in systole, so-called SAM phenomenon
(“systolic anterior motion”).
Conventional X-ray
..      Fig. 21.2 DCM with dilated left ventricle Conventional radiography may show a
raised left cardiac contour as an indirect sign
of hypertrophy. Only in advanced disease
does an enlarged cardiac shadow and signs
of heart failure become apparent.
Cardio-MRI (. Fig. 21.4)
Cardiac MRI shows the same changes as
echocardiography. In addition, a delayed,
non-segmental focal enhancement of the
myocardium is seen.

HCM with Hypertrophied Left

Ventricular Myocardium
Synonym: Arrhythmogenic right ventricular
cardiomyopathy (ARVC).
..      Fig. 21.3 DCM with dilated left ventricle

Cardiac MRI can most accurately depict

cardiac morphology and contrast behavior.
Delayed contrast enhancement results in
patchy or striated focal KM images of the
myocardium. In contrast to ischemic
changes, these areas are localized subepicar-
dially or intramurally.

Hypertrophic Cardiomyopathy (HCM)

z Clinic
HCM is genetic, mostly autosomal dominant.
There are structural changes in the contractile
units. Hypertrophy of the myocardium is ..      Fig. 21.4 HCM with hypertrophied myocardium
often asymmetric and may affect one or both of the left ventricle
Cardiovascular Diseases
311 21
z Clinic altered signal behavior or an accumulation
This disease is defined by markedly reduced of contrast agent can be seen.
right ventricular function. The right ventri-
cle is dilated and shows fatty or connective Unclassified Cardiomyopathies
tissue remodeling of the myocardium. These include isolated left ventricular non-
compaction and Tako-Tsubo cardiomyopa-
z Diagnostics thy. These are also diagnosed mainly by
Echocardiography echocardiography and cardiac MRI.
Echocardiography shows dilatation of
the right ventricle with thinning of the wall. Myocarditis
Due to the remodeling processes, individual z Clinic
wall sections may show A or dyskinesia, so-­ Myocarditis is an inflammatory disease of
called microaneurysmata. The trabeculae the heart muscle. Viruses are the most com-
show hypertrophy. mon cause. The disease can be asymptom-
Cardio MRI atic or mostly shows non-specific symptoms.
The cardio-MRI shows additional fatty Patients may present with cardiac
areas, which appear hyperintense in the arrhythmias, heart failure or cardiogenic
­
T1-weighting. These are localized subepi- shock, among other symptoms. Other car-
cardially. Connective tissue dysplasias show diac diseases must therefore be excluded.
a delayed enhancement after contrast
medium application. z Diagnostics
Conventional X-ray/CT
Restrictive Cardiomyopathy (RCM) X-ray chest and CT are not infrequently
z Clinic unremarkable. In some cases there is a peri-
This is defined by diastolic dysfunction with cardial effusion. If the inflammation spreads
normal systolic function. The ventricles are to the lungs, pulmonary infiltrates and
normal in size and the atria are dilated. lymphadenopathy are seen.
High ventricular filling pressures occur due Echocardiography
to endocardial fibrosis. RCM may be sec- Echocardiography may also be unre-
ondary to amyloidosis or sarcoidosis, for markable. If functional impairment occurs,
example, as part of storage or infiltration diastolic and later systolic dysfunction is
processes. seen. In some cases, a pericardial effusion is
seen. The myocardium may appear thick-
z Diagnostics ened.
Echocardiography Cardio MRI
Cardioechography demonstrates normal The same findings as in echography can
systolic and altered diastolic function. The be detected in cardiac MRI. In addition, the
ventricles are normal in size. affected areas show a T2 signal enhance-
Conventional X-ray/CT ment due to edematous and inflammatory-­
Conventional x-ray and CT show infiltrative changes. After contrast medium
enlargement of the atria and signs of pulmo- application an enhancement occurs.
nary venous congestion with accompanying Since there is no specific therapy so far,
pleural effusion. the treatment aims at symptom improve-
Cardio MRI ment. In most cases, the disease heals spon-
Cardio-MRI is used in cases of sus- taneously. However, the disease can also
pected secondary cardiomyopathy. Here, lead to the development of DCM or even
depending on the underlying disease, an death.
 312 M. Wenker et al.

Cardiac Tumor
21 Cardiac tumors are rare overall. They are
benign in 75% (atrial myxoma, thrombi).
10% of all tumor patients have cardiac
metastases.

Atrial Myxoma
Atrial myxoma is the most common pri-
mary tumor of the heart, accounting for
approximately 50%. The often pedunculated
tumor is benign and usually originates from
the interatrial septum, but it can also be
located at the heart valves. The majority are
..      Fig. 21.5 Hypodense tumor in the left atrium
located in the left atrium, but in rare cases
the right atrium may also be affected. The
peak age is between 40 and 60 years.

z Clinic
Atrial myxomas can often remain asymp-
tomatic and are frequently discovered as an
incidental finding during echocardiography.
If the tumor interferes with normal blood
flow, symptoms range from arrhythmias and
dyspnea to general symptoms such as fever
and weight loss. Because thrombi may be
superimposed on the atrial myxoma, wash-
out can lead to peripheral emboli.
..      Fig. 21.6 Slightly inhomogeneous view of an
z Diagnostics atrial myxoma in the left atrium
Conventional X-ray
Conventional chest X-ray may show dil- location close to the valve may lead to valve
atation of the affected atrium. Calcifications insufficiency or obstruction.
of the tumor can be delineated. However, Cardio-MRI (. Fig. 21.6)
the findings are often unremarkable. In addition to the CT and echocardio-
CT graphic findings, the tumor shows enhance-
On CT, the atrial myxoma is inhomoge- ment on cardiac MRI. In T1-weighting it
neous. The tumor is mostly hypodense presents hypo- to isointense, in T2-­weighting
(. Fig. 21.5) with partly cystic, necrotic or it mostly appears hyperintense.
hemorrhagic parts. In a small percentage
calcifications can be detected. >>Contrast MRI is the important distin-
Echocardiography guishing feature from intraatrial
On echocardiography the tumor may thrombus.
appear broad-based or pedunculated. It is
usually rich in echoes and presents as lobu- Therapeutically, surgical excision and, if nec-
lated. Thrombotic deposits may occur. A essary, valve reconstruction are ­performed.
Cardiovascular Diseases
313 21
21.2.2 Vessels
Aortic Dissection
In aortic dissection, there is a proximal tear
of the intima, allowing blood to enter the
media. A second “false” lumen forms, which
progresses distally and usually reconnects to
the true lumen. The most frequent cause is
arteriosclerosis.

z Clinic
Aortic dissection presents as acute chest
pain radiating to the back. Depending on
the involvement of the aortic vascular out- ..      Fig. 21.7 Aortic dissection with dissecting mem-
lets, neurological deficits, ischemia of the brane in the ascending aorta
bowel and extremities, and, if the aortic
valve is involved, aortic valve insufficiency aorta and possibly also of the aortic valves.
may occur. Stanford type B dissections are mostly
treated endovascularly by means of an aor-
z Diagnostics tic prosthesis, but may also be treated con-
CT Angiography servatively in the absence of complications
An aortic dissection can be depicted (. Fig. 21.7).
most quickly and best with CT angiography,
as this also shows the outgoing vessels with Aortic Aneurysm
the dependent organs well. The aorta is seen Aneurysms are localized bulges in the vessel
to be dilated. The dissection membrane can wall of more than 50% of the normal vessel
be easily demonstrated as a detachment of lumen. A distinction is made between three
the intima from the vessel wall. Depending types of aneurysm.
on the affected vessel section, aortic dissec- 1. In an aneurysm verum, all three layers of
tion is classified into three types according the vessel wall are affected. In the ascend-
to DeBakey, simplified in the Stanford clas- ing aorta, an aneurysm is defined as hav-
sification into two types. ing a width of more than 40 mm, and an
The true lumen is usually smaller than abdominal aortic aneurysm is defined as
the false lumen and shows a faster accumu- having an infrarenal diameter of more
lation of contrast medium. If the false than 30 mm. The main risk factor is aor-
lumen includes vascular outlets, there is a tic sclerosis. As the vessel becomes
reduced supply or complete lack of blood increasingly bulky, wall thinning occurs
supply to the dependent organs with a threat with the risk of rupture. Treatment is
of ischemia. usually indicated when the vessel diame-
MR Angiography ter exceeds 50 mm.
MR angiography and DSA show the 2. Aneurysm dissecans: see also Aortic dis-
same changes as CT angiography, but are section (section Aortic dissection).
not the means of choice due to the fact that 3. In the case of a spurium/falsum aneu-
they are not available everywhere or take rysm (false aneurysm), an injury to the
more time. intima and media results in a walled
Stanford type A dissections require hematoma, whereby the adventitia
immediate replacement of the ascending remains intact. This can be caused by
 314 M. Wenker et al.

blunt injuries or also by surgical inter- a

21 ventions on the vessels (e.g. puncture in
the course of an angiography).

z Clinic
A large number of aneurysms are asymp-
tomatic. They are often discovered as an
incidental finding. Thoracic aneurysms can
cause difficulty swallowing, hoarseness,
coughing and difficulty breathing. An
abdominal aortic aneurysm can cause
abdominal pain, back pain, and urinary
urgency. If it ruptures, there is a cutting b
pain.

z Diagnostics
CT/MR Angiography (. Figs. 21.8 and
21.9)
CT and MR angiography show circum-
scribed or generalized dilatation of the
aorta. Diameter and length can be well visu-
alized on multiplanar reconstructions.
Thrombosed portions and perfused lumen
can be quantified. Involved arterial branches
..      Fig. 21.9 a, b Aneurysm verum of the infrarenal
can be visualized.
aorta with markedly dilated lumen
Sonography
Sonography can be used for progress
monitoring. be performed. Angiographically, only the
DSA perfused lumen can be visualized, not the
DSA is reserved for cases in which direct extent of thrombosis.
interventional treatment by stent graft is to Surgical or interventional treatment of
an aortic aneurysm should be considered,
depending on the location, when the aneu-
rysm reaches a certain size or increases in
size by more than 10 mm/year. A ruptured
aortic aneurysm requires immediate treat-
ment.

Traumatic Aortic Rupture

Traumatic aortic ruptures occur in the con-
text of extreme shear forces. In most cases,
the transition between the aortic arch and
the descending aorta is affected.

z Clinic
Complete ruptures lead immediately to
..      Fig. 21.8 Mural thrombosed aneurysm verum of death. In a covered rupture, bleeding is ini-
the infrarenal aorta tially limited by the still intact adventitia.
Cardiovascular Diseases
315 21
z Diagnostics tine, usually the superior mesenteric artery,
Conventional X-ray or by thrombosis of the mesenteric vein.
Patients who have suffered a severe The non-occlusive form (NOMI) is due to
trauma (usually a traffic accident) are usu- reduced perfusion with reactive vasospasm.
ally given a conventional chest X-ray in the This leads to a circulatory disturbance of
shock room for initial assessment of poten- the corresponding intestinal segment with
tial injuries. On this image, a widening of the consecutive ischemia. Causes are e.g. cardio-
mediastinum due to hemorrhages can vascular diseases.
already be detected. The trachea shifts to the
right, the left main bronchus to the caudal. z Clinic
Often a left-sided hematothorax is visible. Patients with acute mesenteric vessel occlu-
CT sion initially present with severe cramping
The method of choice for the evaluation abdominal pain and possibly bloody diar-
of a traumatic aortic rupture is CT, which is rhea and symptoms of shock. In the latent
performed as a contrast-enhanced whole-­ stage, the pain symptoms subside, the so-­
body CT in the context of the trauma. Due called ‘rotten peace’. In the late phase, the
to the capping of the rupture by the adventi- signs of irreparable intestinal ischemia from
tia, a pseudoaneurysm forms at the rupture paralytic ileus to peritonitis and death
site. The contour may be very irregular due become apparent.
to wall hematomas. The detached portion of
the vessel wall (flap) protrudes into the ves- z Diagnostics
sel lumen, it can be of varying thickness. CT (. Figs. 21.10 and 21.11)
DSA Acute mesenteric ischemia is an acute
DSA should only be performed for endo- emergency and should be evaluated by CT
vascular therapy. Purely diagnostic DSA is as soon as possible. A contrast-enhanced
not indicated. examination with arterial as well as venous
A traumatic aortic rupture is treated phase is recommended for the assessment of
with a stent graft or open surgery. the arteries as well as the veins. The vessels
can be assessed well and an occlusion can be
Acute Mesenteric Ischemia directly visualized due to a lack of contrast.
Acute mesenteric ischemia is caused by In addition, there is a thickening of the intes-
occlusion of the arteries supplying the intes- tinal wall with accompanying distension.

a b

..      Fig. 21.10 a, b Acute mesenteric ischemia with thrombus in the superior mesenteric artery (arrows)
 316 M. Wenker et al.

thrombosis can also be treated by local lysis.

21 The irreversibly damaged parts of the intes-
tine are resected surgically.

 eripheral Arterial Occlusive

P
Disease (PAVD)
Disruption of arterial blood flow to the
extremities is caused by plaque and calcium
deposits with subsequent stenosis or occlu-
sion of the vessel. In addition to smoking
and diabetes, risk factors include disorders
of lipid metabolism and hypertension. The
..      Fig. 21.11 Mesenteric vein thrombosis with risk increases with advancing age.
thrombus in the superior mesenteric vein (arrow)
z Clinic
The intestinal wall is increasingly perfused. Patients show the typical picture of inter-
Air pockets in the bowel wall (pneumatosis) mittent claudication with load-dependent
also indicate bowel ischemia. In later stages pain distal to the stenosis. In the advanced
free air in the abdomen or air in the portal stage, pain at rest occurs, followed by necro-
vein system can be detected. sis or gangrene of the acras. The stages are
Doppler Sonography classified according to Fontaine or
Doppler/duplex ultrasonography may Rutherford.
indicate vascular occlusion in the absence of
signal, but imaging is often not possible in z Diagnostics
ileus. CT Angiography (. Fig. 21.12)
MRI CT angiography shows both calcifica-
The use of MRI is in principle possible tions and atheromatous plaques along the
for the clarification of mesenteric ischemia, iliac artery. In the lower leg, the arteries are
but due to the time factor, CT should be often more difficult to assess because of
given priority. their narrow diameter and decreased con-
DSA trast compared with the iliac and femoral
DSA should be performed if the CT arteries. Collaterals indicate stenosis and
results are inconclusive or if NOMI is sus- occlusion. Multiplanar reconstructions and
pected. Narrowed branches of the superior curved-planar reformations on which cal-
mesenteric artery as well as an alternating cium is extracted should be performed for
image of vessel stenosis and dilatation in the assessment. The disadvantage of CTA is
sense of a pearl cord-like pattern can be metal artefacts, e.g. in the case of hip TEP,
detected. Delayed perfusion also indicates with consequently limited assessability of
reduced intestinal perfusion. At the same the vascular section running in this area.
time, angiography can be used for therapeu- MR Angiography
tic measures. MR angiography after contrast agent
Interventional radiology may include application exclusively depicts the vessel
aspiration embolectomy or intra-arterial lumen. Calcium is not depicted due to the
lysis. An implanted stent can recanalize the lack of signal and is therefore more difficult
affected artery. In the presence of NOMI, to assess. As with CT angiography, the diag-
selective administration of vasodilators can nostic quality of the arteries in the lower leg
be performed via a catheter. Mesenteric vein is limited. MIP reconstructions are used for
Cardiovascular Diseases
317 21
a b

..      Fig. 21.12 a Long-stretch occlusion of the super- stretch occlusion of the superficial femoral artery on
ficial femoral artery on both sides with pronounced both sides with pronounced collaterals, vessel recon-
collaterals, vessel reconstruction with lime. b Long-­ struction after removal of the lime

better assessment. The advantage over CTA stenotic turbulence. The application is
is the use of non-iodine contrast media and limited to the extremities, as the pelvic floor
the lack of radiation exposure. However, the can often only be viewed to a limited extent
examination takes significantly more time due to intestinal gas overlays.
and is more prone to motion artifacts. Interventional radiology can be used to
DSA (. Fig. 21.13) perform lysis or thrombectomy for acute
DSA also exclusively depicts the vessel occlusion. In chronic disease progression,
lumen, calcium does not show up. Stenoses, stent implantation can be performed in the
occlusions and collaterals can be imaged pelvis and balloon angioplasty (PTA) with
well. By positioning the catheter tip in the paclitaxel-coated balloons and, if necessary,
superficial femoral artery, selective imaging subsequent stent implantation in the thigh.
of the arteries of the lower leg and foot can In the lower leg, PTA can recanalize the ves-
be performed. The advantage of DSA is a sel in question.
directly subsequent intervention.
Doppler Sonography Leriche Syndrome
Doppler/duplex sonography can detect Leriche syndrome is an occlusion of the
calcifications along the arteries. Within ste- infrarenal aorta with involvement of the
noses, there is flow acceleration with post- aortic bifurcation. In chronic Leriche’s syn-
 318 M. Wenker et al.

a b
21

..      Fig. 21.13 a Long-segment occlusion of the superficial femoral artery, collateral circulation. b Superficial
femoral artery after PTA and stent implantation, recanalized lumen, collaterals no longer contrasted

drome, the occlusion develops slowly on the angiography. The occlusion of the infrarenal
floor of pAVD, usually allowing strong col- aorta including the aortic bifurcation and
laterals to form to maintain perfusion of the the iliac arteries can be easily visualized. In
lower extremity. chronic Leriche’s syndrome, the usually pro-
nounced collaterals supplying the periphery
z Clinic are also shown.
Patients present with intermittent claudica- Doppler Sonography
tion, sometimes with pain at rest, and blad- Doppler/duplex ultrasonography reveals
der and rectal dysfunction and erectile aortic occlusion. Collaterals can often only
dysfunction. Acute occlusion leads to the 6 be depicted to a limited extent.
P symptoms according to Pratt. DSA
1. Pain DSA can only be performed through an
2. Pallor (pallor) upper extremity access route. Depending on
3. Pulselessness (loss of pulse) the placement of the catheter tip, collaterals
4. Paresthesia (sensory disturbances) and the distal outflow can be visualized.
5. Paralysis (inability to move) Vascular surgery is indicated for therapy.
6. Prostration (shock) In acute cases an embolectomy is performed.
If this is unsuccessful or in chronic cases, an
Acute occlusion is usually caused by an arte- aortofemoral bypass (y-prosthesis) can be
rial embolic event. created.

z Diagnostics Deep Vein Thrombosis of the Leg

CT/MR Angiography (. Fig. 21.14) This is a complete or incomplete occlusion
Acute Leriche syndrome represents a of the deep leg veins, which can rise proxi-
vascular surgical emergency and should be mally to the pelvic floor. There is a risk of
clarified as soon as possible by CT or MR pulmonary embolism or post-thrombotic
Cardiovascular Diseases
319 21
a b

..      Fig. 21.14 a, b Leriche syndrome with occlusion of the infrarenal aorta and the iliac arteries

syndrome. Risk factors of thrombosis are

..      Table 21.1 Wells score for suspected deep
insufficient exercise, e.g. after operations but vein thrombosis
also during longer air travel, coagulation dis-
orders, smoking, taking certain medications. Malignancy active or <6 months 1
Paralysis, plaster 1
z Clinic
Patients report a feeling of heaviness in the Bedridden (>3 days), surgery (<12 weeks) 1
legs, pain, increase in the circumference of Sensitivity along vein strand 1
the leg, redness of the affected limb.
Whole leg swollen 1
However, particularly in the case of throm-
bosis of the lower legs, the disease may also Calf circumference difference >3 cm 1
be silent. A pretest probability is first deter- Impressible edema only on the symptom- 1
mined using the Wells test (. Table 21.1). atic leg
Three or more points have a high pretest Superficial collateral veins 1
probability of deep vein thrombosis (75–
85%), one to two points have a moderate Other diagnosis equally likely −2
probability (17–33%), and less than one
point has a low probability (5–10%).
The D-dimers should also be checked. A z Diagnostics
lack of elevation and a medium to low pre- Sonography (. Fig. 21.15)
test probability allow deep vein thrombosis The method of choice for the imaging of
to be ruled out by more than 95%. a leg vein thrombosis is sonography.
 320 M. Wenker et al.

21

..      Fig. 21.15 Vena popliteal thrombosis, the vein

cannot be compressed by the ultrasound probe

The vessel lumen is clearly dilated and the

vein cannot be compressed due to the intra-
luminal thrombus. The thrombus may
appear echo-poor to echo rich. A flow signal
with respiratory modulability is absent.
Phlebography (. Fig. 21.16)
Phlebography is often used in unclear
cases or when the extremity cannot be seen
(obesity, oedema, veins in the lower leg).
Thrombi appear as contrast medium cavities
in this case. Individual veins may also be
completely non-contrasted or show collat-
eral circulation.
CT/MRI (. Fig. 21.17)
CT and MRI are mainly used to visual-
ize the pelvic floor, which is otherwise often
difficult to see. As in sonography, a disten-
sion of the affected vein is seen here, often
with imbibition of the adjacent fatty tissue.
In contrast to the perfused veins, the throm-
bosed vein shows a lack of contrast.
Causative masses can be visualized.
Patients with DVT are initially treated
with low-molecular-weight heparin, fol-
lowed by secondary prophylaxis with vita-
min K antagonists. Possible causes should
be eliminated. ..      Fig. 21.16 Thrombus surrounded by contrast
medium in the femoral vein (arrow)
Cardiovascular Diseases
321 21
heart and cardiac output. This is supple-
mented by further examinations with ultra-
sound and especially MRI.

Fluoroscopy/Angiography
Phlebography as the basic diagnostic
method for suspected leg or arm vein throm-
bosis has now been replaced by sonography.
It is still performed for certain questions
that cannot be answered by sonography
alone or in the case of unclear sonographic
findings.
Nowadays, diagnostic angiography has
..      Fig. 21.17 Thrombus surrounded by contrast been increasingly displaced by sonography
medium in the common femoral vein (arrow)
and cross-sectional imaging. Nevertheless,
angiography is still considered the “gold
21.3 Diagnostics standard” and is also used for diagnostic
purposes, particularly in unclear cases. Due
Christel Vockelmann to the existing risk of bleeding when punc-
turing an artery, coagulation parameters
(Quick/INR, PTT, platelets) should be
21.3.1 Radiological Diagnosis checked before the procedure. As with any
administration of contrast media, the renal
Sonography retention parameters (creatinine, GFR) and
Sonography is the basic building block in the TSH value should be known.
the diagnosis of the heart and blood vessels.
In Germany, ultrasound examinations of Computed Tomography
the heart are performed almost exclusively Computed tomography is a very good
by cardiologists. The same applies to the method for non-invasive and rapid arterial
transesophageal echocardiogram (TEE). and, to a limited extent, venous vascular
The ultrasound diagnosis of arteries and diagnostics. The advantages of computed
veins falls to radiology. This is carried out as tomography compared to MRI are its avail-
color-coded duplex sonography in order to ability everywhere and its rapid presenta-
determine flow velocities. The degree of ste- tion, especially in emergencies.
nosis of the vessels can be derived from this. A frequently performed examination is
The assessment of the veins is supplemented CT angiography of the iliac artery. The dis-
by compression ultrasound. Since thrombus advantage of CT compared to DSA and
material cannot be compressed, a vein that MRI is that calcium plaques make it diffi-
cannot be compressed by the ultrasound cult to assess the vessels. They must first be
probe can be diagnosed with thrombosis. extracted by further processing of the
Veins that can be freely compressed are not images. Nevertheless, CT angiography has
thrombosed. its justification as a non-invasive proce-
dure, especially with regard to the planning
Conventional X-ray Diagnostics of interventional radiological interven-
In the diagnosis of vascular diseases, con- tions.
ventional X-ray diagnostics has no signifi- A newer field of investigation is CT
cance. However, the X-ray thorax is still a coronary angiography, which can be per-
basic examination for the assessment of the formed in good quality with modern CT
 322 M. Wenker et al.

equipment. Radiation exposure is compa- used in exceptional cases due to the signifi-
21 rable to diagnostic coronary angiography cantly higher radiation exposure.
under optimal equipment and examina- In PET, 18F-FDG (as a metabolic marker)
tion conditions. However, the examination is predominantly used. Rarely, 15O-­H2 O or
is prone to artifacts. For example, an 13NH are used as pure perfusion markers.
3
extrasystole can lead to the fact that the In addition, lipid metabolism and sympa-
evaluation of the coronary vessels is not thetic and parasympathetic innervation can
possible in the entire course of the exami- be depicted with other markers.
nation. The radiation emerging from the heart is
weakened to varying degrees by the sur-
Magnetic Resonance Imaging rounding tissue. This attenuation can lead to
Due to its high soft tissue contrast and the an incorrect assessment of the blood flow
lack of radiation exposure, magnetic reso- conditions. There are several ways to miti-
nance imaging is suitable for vascular diag- gate these attenuation artifacts. Here, a
nostics. The vessels are made directly visible change of position (examination in supine
by the applied contrast medium. Due to the and prone position) or a low-dose CT in
lack of signal, calcifications cannot be modern hybrid devices can be used. Another
assessed. option for attenuation correction is the use
In the context of cardiac diagnostics, of radioactive transmission sources. The use
MRI can detect findings that cannot be of a CT or transmission attenuation correc-
proven with any other imaging method. For tion makes the examination more accurate,
example, in the case of myocarditis, intra- but increases the radiation exposure.
mural contrast enhancement in the myocar- Usually, the examination is performed in
dium can be detected, indicating scarring in two runs, once after exercise and once at
the course of the inflammation. Cardiac rest. Both one-day and two-day protocols
muscle motion can be imaged more objec- are used.
tively and reproducibly than with ultra- Exercise is either physical (bicycle ergom-
sound. The perfusion of the heart can be eter, treadmill) or medicinal. Vasodilators
examined by means of stress MRI, which (e.g. adenosine, regadenoson) or catechol-
shows reduced perfusion of the heart muscle amine derivatives (e.g. dobutamine) can be
under stress. used for the medicinal stress.
The SPECT recording triggered by ECG
is called gated SPECT. Gated SPECT
21.3.2 Nuclear Medicine allows statements to be made about the
mobility of the left ventricle, and the follow-
Ursula Blum ing parameters are determined:
55 End-diastolic volume EDV [mL]
55 End systolic volume ESV [mL]
SPECT Cardiac and PET Cardiac 55 Stroke volume [mL]: EDV—ESV
Myocardial scintigraphy is primarily per- 55 Ejection fraction (LVEF) [%]: (stroke
formed in patients with suspected stenosis volume/EDV) * 100
of the arteries of the heart (coronary heart
disease CHD) or if stenosis has already been In addition, statements can be made about
detected. the wall movement and the changes in the
Suitable SPECT tracers are 99mTc-­Sestambi heart muscle in the individual parts.
and 99mTc-Tetrofosmin (. Table 21.2). The Before a planned intervention on the
previously used 201thallium should only be coronary vessels, an assessment of the ben-
Cardiovascular Diseases
323 21

..      Table 21.2 Cardiac SPECT with 99mTc-MIBI or -Tetrofosmin

Patient Preparation Sober (at least 4 h)

Discontinue medication if necessary
– Ergometry: beta blockers, vasodilators
– M
 edicinal: theophylline, dipyridamole; no caffeine, tea, chocolate (12–24 h
before)
Anamnesis
Place and fix indwelling venous catheter
Adjusting the ergometer to the patient
Create ECG
Measuring blood pressure and pulse
Load according to the standard of the department
Activity: One-day protocol:
– 250 + 750 MBq 99mTc-MIBI or -Tetrofosmin
Two-day protocol:
– 400 MBq each 99mTc-MIBI or -Tetrofosmin
Application i. v.
Acquisition: Start of recording (15 min) 45–60 min p. i.
Supine position, arms above head
SPECT
LEHR, 2- or 3-head, collimator tight adjustment
64 * 64 matrix, projections depending on camera system
ECG-triggered
Evaluation SPECT reconstruction: Filtered back projection or iterative reconstruction
Reorientation along the heart axis
Representation of the sectional views:
– Short axis: From the tip of the heart to the base
– Horizontal longitudinal axis: From bottom to top
– Vertical longitudinal axis: From septum outwards
EDV, ESV, LVEF, SSS, SRS
Bulls eye view
Special Features: In obese patients, adjustment of the dose if necessary
Radiation Exposure: MIBI: 0.008 mSV/MBq
Tetrofosmin: 0.007 mSv/MBq

efit should be made. Here, living (vital) or 3–4 h p. i. (or 24 h p. i.) due to its reuptake
damaged (hibernating) tissue is distin- into the heart muscle (redistribution).
guished from scarring changes. Only the Thallium protocols start a few minutes
function of vital or hibernating areas can be after exposure, in addition to a late exposure
improved by the intervention. of 3–4 (possibly 24) hours.
The highest accuracy is provided by
18F-FDG-PET. Myocardial SPECT with Ergometric Load
99mTc markers should be performed under Step test: Start with 25 (50)watts, increase
special resting conditions (complete medica- every 1–2 min. Termination when target
tion of the patient, in addition sublingual heart rate is reached or according to the ter-
nitrate administration if necessary). Only mination criteria. After the injection, the
very rarely is 201thallium used for this pur- load should be maintained for 1–2 min.
pose, which allows vitality to be assessed Target heart rate: 0.85 * (220 − age).
 324 M. Wenker et al.

z Termination Criteria 55 Left bundle branch block (if possible

21 Absolute Termination Criteria always pharmacological load)
55 ST-routes reduction >3 mm 55 Physical and/or mental impairments
55 ST elevation >1 mm 55 Ventricular pacing rhythm
55 Blood pressure drop >10 mmHg with
angina pectoris or ST depression
55 Moderate to severe angina pectoris Pharmacological Exposure
55 Severe respiratory distress Adenosine: 140 μg/kg/min i. v. via perfusor
55 Cyanosis over (4-) 6 min, injection of the radiophar-
55 Ventricular tachycardia >30 s maceutical after (3-) 5 min; allow adenosine
55 Exhaustion of the patient to continue for at least 1 min afterwards. If
55 Technical problemsRelative Termination necessary, combine with light ergometric
Criteria exercise.
55 Elevated blood pressure (RRsyst > 230–
260 mmHg, RRdiast > 115 mmHg) z Contraindications
55 Blood pressure drop >10 mmHg without Absolute Contraindications
angina pectoris or ST depression 55 Acute coronary syndrome
55 Polymorphic extrasystoles, pairs (2 sub- 55 Medium- to high-grade ventilatory dys-
sequent VES), volleys (>3 subsequent function
VES) 55 Bronchial asthma
55 Supraventricular tachycardia 55 COPD requiring theophylline
55 Bradyarrhythmia 55 AV block II and III without pacemaker
55 Occurrence of block patterns (AV block, 55 Sick sinus without pacemaker
thigh block) 55 Low blood pressure (RRsyst < 90 mmHg)

z Contraindications Relative Contraindications

Absolute Contraindications 55 Bradycardia (rate <40/min)
55 Acute coronary syndrome 55 Mild COPD
55 Unstable angina pectoris 55 Fresh cerebral infarction or fresh reduced
55 Symptomatic arrhythmias blood flow
55 Decompensated heart failure
55 Acute pulmonary embolism, myocardi- Regadenoson (Rapiscan®): Injection of 5
tis, pericarditis, aortic dissection mL Rapiscan (=0.4 mg regadenoson) over
10 s, followed by 5 mL NaCl, after 10–20 s
55 Relative Contraindications injection of the radiopharmaceutical. If
55 Main stem stenosis necessary, combine with light stress.
55 Valve diseases Dobutamine: Infusion via a perfusor at
55 Electrolyte disorders 3-min intervals. Start with 5 μg/kg/min,
55 Arterial hypertension (RRsyst > 200 mmHg, increase to 10, 20, 30, 40 μg/kg/min until tar-
RRdiast > 110 mmHg) get heart rate is reached. If this is not
55 Tachyarrhythmia, bradyarrhythmia reached, atropine is given (4 * 0.25 mg to
55 Outflow tract obstruction, e.g. in hyper- max 1 mg i. v.). Injection 2 min before the
trophic cardiomyopathy end of the infusion, discontinuation criteria
55 Higher-grade AV block see ergometry.
Cardiovascular Diseases
325 21
Polar Tomograms The Summed Stress Score (SSS) and the
In the polar tomograms, the short-axis sec- Summed Rest Score (SRS) are given. From
tions of the entire left ventricular myocar- this, the difference can be calculated, the
dium are mapped onto a circle. This circle is Summed Difference Score (SDS).
divided into 17 (-20) segments. Especially on the basis of the SSS, an
This is followed by a semi-quantitative individual risk assessment for the respective
evaluation of the individual segments for both patient is possible. The higher the SSS, the
the stress test and the rest test (. Table 21.3). higher the risk of a cardiac event.
The normal collective should be created Especially on the basis of the SDS, an
by yourself if possible. individual risk assessment for the respective
patient is possible. The higher the SDS, the
..      Table 21.3 Graduation of perfusion higher the risk of a cardiac event. The SDS is
disturbance, modified according to guideline an aid in deciding, in the case of proven isch-
emia, whether the patient is more likely to
Score Perfusion
Description Uptake in Standard
benefit from drug therapy or intervention.
% of Deviation V. With an SDS between 10–12, the patient is
Maximum Normal more likely to benefit from conservative ther-
Collective apy; with an SDS of 13 or higher, the patient
Normal ≥70% <1.5 is more likely to benefit from intervention.
1 Slightly 50–69 1.51–2.1
reduced
21.3.3 Valence
2 Moderately 30–49 2.11–4.0
reduced
Christel Vockelmann
3 Signifi- 10–29 4.1–7
cantly (. Table 21.4 shows the use of the respec-
reduced
tive therapeutic options depending on the
4 Missing <10 >7 problem.

.       Table 21.4 Value of the therapeutic procedures

Sonogra- Conven- Fluoroscopy/ CT MRI Nuk PET

phy tional Angiography

TVT P N W N N N N
Pulmonary N N N P N W N
embolism
pAVK P N W W W N N
CHD N N P P* W W N

N Not indicated, P Primary diagnosis, W Further diagnosis

P* Cardio-CT can be used as a primary procedure in certain risk constellations to exclude CHD. Another
area of application is in the context of so-called triple rule-out diagnostics: This is used in patients who
come to the clinic with very severe acute thoracic pain, in which the admitting physician cannot distin-
guish whether an aortic dissection, a fulminant pulmonary embolism or a myocardial infarction is
present.
 326 M. Wenker et al.

21.4 Therapy
21 symptoms. First, the family doctor
Mirja Wenker examines Mr. Topcak and finds a miss-
ing foot pulse on the right side. He refers
his patient to the angiologist. The latter
21.4.1 Interventional Radiology determines with duplex sonography that
Mr. Topcak has a short-segment occlu-
Angiography sion of the distal superficial femoral
artery on the right. The angiologist sends
Angiography is an excellent procedure for
the patient to hospital for treatment.
the treatment of vascular diseases. This
Here, an angiographic intervention is
mostly involves vasodilator interventions. In
performed to recanalize the vessel and
the case of aneurysms or vascular injuries,
treat it with a drug-eluting balloon.
however, vaso-occlusive measures are also
Since the intervention, Mr. Topcak has
taken.
been taking ASA 100 mg daily. In addi-
Angiography is most often used for the
tion, the family doctor has improved his
treatment of peripheral arterial occlusive
blood pressure and forbidden him to
disease. Depending on the location of the
smoke. On the other hand, he is sup-
stenosis, the puncture is performed ante-
posed to walk the dog extensively and
grade or retrograde. The stenosis or vessel
thus exercise his v­ essels.
occlusion is probed with a wire and a cathe-
ter is advanced over the wire. After a con-
trast agent is administered to ensure that the
catheter is back in the vessel lumen behind
Practice Questions
the occlusion, balloon dilatation or stent
1. What classifications of aortic dissec-
implantation is performed. In addition to
tion are you familiar with?
these standard procedures, there are also
2. What is the procedure for suspected
newer methods such as atherectomy. This
deep vein thrombosis?
involves a catheter that peels and collects the
3. What is the best procedure for imag-
plaque from inside the vessel so that the
ing the aorta?
material can be removed along with the
4. What interventional options are you
catheter. In the case of an acute arterial
aware of for treating lower extremity
occlusion, a lysis catheter can be advanced
arterial occlusion?
into the thrombus. A thrombolytic agent is
then applied via this catheter over a period
Solutions Chap. 27
of several hours.

Case Study

Mr. Topcak is 68 years old. When he

retired, he got a dog. Lately, he has
noticed pain in his right calf when walk-
ing the dog. These get better when he
stops. In the meantime, however, he has
to take a break every 100 m at the latest
on his round with the dog. Therefore he
turns to his family doctor. He suspects
intermittent claudication because of the
 327 22

Endocrinological System
Martina Kahl-Scholz, Christel Vockelmann, Ursula Blum
and Guido Heilsberg

Contents

22.1 Anatomical Structures – 328

22.2 Disease Patterns – 328

22.2.1 T hyroid Goiter – 328
22.2.2 Thyroid Carcinoma – 329
22.2.3 Adrenal Adenoma – 329
22.2.4 Adrenocortical Carcinoma – 329
22.2.5 Pituitary Adenoma – 330

22.3 Diagnostics – 330

22.3.1  iagnostic Radiology – 330
D
22.3.2 Nuclear Medicine – 332
22.3.3 Valence – 334

22.4 Therapy – 335

22.4.1  adiotherapy – 335
R
22.4.2 Nuclear Medicine – 335

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 328 M. Kahl-Scholz et al.

This chapter deals with the essential possibili- 55 Grade II: visible enlargement with nor-
ties of radiological diagnostics, nuclear medi- mal head posture
cine and radiotherapy for the diagnosis and 55 Grade III: massive enlargement with
22 therapy of the endocrinological system. An
introductory section gives a brief overview of
compression and congestion

anatomy and function, and a concluding part z Clinic

contains some case studies from practice. The clinic depends on the size and the under-
lying disease (metabolic state).

22.1 Anatomical Structures z Diagnostics

Sonography
Martina Kahl-Scholz Here, autonomous adenomas can be seen as
nodules of varying echogenicity (. Fig. 22.1).
z Thyroid Gland (Glandula Thyroidea) Conventional X-ray
The thyroid gland consists of two lobes (lobus Conventional X-ray is of no value in this
dexter et sinsister), which are connected by a case, but a goiter may be detected on the
narrow connection (isthmus glandulae thyroi- basis of a different question (. Fig. 22.2).
dea). The isthmus is located at about the level
of the 2nd-4th tracheal cartilage. A healthy
thyroid gland weighs about 15–20 g in an adult.

z Parathyroid Gland (Glandulae

Parathyroidea)
The parathyroid glands are about the size
of a lentil and are dorsally attached to the
thyroid lobes.

z Adrenal Glands (Suprarenal Gland)

The adrenal glands lie on the upper poles of
the kidneys and are about 5 cm long, 3 cm ..      Fig. 22.1 Large struma node on the right in the
wide and 1 cm thick. They are triangular or B-scan
crescent-shaped and are also divided into
cortex and medulla.

22.2 Disease Patterns

Martina Kahl-Scholz

22.2.1 Thyroid Goiter

Goiter describes an enlargement of the thy-
roid gland, which can be divided clinically
into different degrees:
55 Grade I: palpable goiter (Ia = not visible ..      Fig. 22.2 Trachea displaced to the right (arrow)
even with reclined neck; Ib = only visible with left retrosternal dipping goiter with widening of
with reclined neck) the upper mediastinum
Endocrinological System
329 22
>>X-ray contrast media should be avoided, metastasis can otherwise no longer be
especially in the case of hyperthyroid goi- performed and radioiodine therapy is
ter, since the iodine contained in them can no longer possible for a period of two to
exacerbate hyperthyroidism and lead to a three months after administration of a
thyrotoxic crisis. contrast medium.

22.2.2 Thyroid Carcinoma 22.2.3 Adrenal Adenoma

There is a subdivision into: These are benign tumors that are usually
55 Differentiated carcinoma (papillary thy- hormonally inactive.
roid carcinoma, follicular thyroid carci-
noma) z Clinic
55 Undifferentiated carcinoma (anaplastic Usually no symptoms.
thyroid carcinoma)
55 C-cell carcinoma z Diagnostics
CT
z Clinic On CT, adenomas appear hypodense and
Larger carcinomas may cause hoarseness, absorb contrast. However, differentiation
difficulty swallowing and difficulty breath- from carcinoma is difficult.
ing (in- and expiratory stridor). If a goiter MRI
grows rapidly in size and does not move the On MRI, adenomas are usually not very
swallow, one should think of a carcinoma. signal-intense on T2 images, whereas carci-
nomas present hyperintensely.
z Diagnostics
Sonography
In sonography, above all an irregular, 22.2.4 Adrenocortical Carcinoma
possibly destructive tumor structure should
suggest a carcinoma. Furthermore, a fine z Clinic
needle aspiration or a punch biopsy can Carcinomas of the adrenal gland are usually
show whether malignant cells are present. clinically silent at first. In later stages, they
CT/MRI may become conspicuous by infiltrating the
CT and MRI are used for precise diagno- neighboring organs.
sis of tumor extension, staging and follow-
­up if the suspicion is confirmed. Malignancy z Diagnostics
can only be detected in both procedures by Sonography
means of the tumor growth crossing the There is an inhomogeneous mass which
organ; there are no other criteria for malig- contains echo-poor and echo rich parts.
nancy of a struma node. CT
Scintigraphy There is a strong contrast enhancement
Scintigraphy is the tool of choice for dif- in the tumor itself. Furthermore, the exten-
ferential diagnosis. sion and destruction of other organ parts
can be better assessed.
>>Here too: no administration of iodine- MRI
containing contrast medium. Various Since adrenal carcinomas have a low fat
scintigraphic examinations to detect content, they present with a high signal.
 330 M. Kahl-Scholz et al.

22.2.5 Pituitary Adenoma Classical for adenomas is that they accumu-

late less contrast medium than the rest of the
Adenomas of the pituitary gland are divided pituitary tissue and show a reduced washout
22 according to size into: effect (on late images a higher intensity is
55 Microadenomas (<10 mm) and shown, because the once absorbed KM is
55 Macroadenomas (>10 mm). only slowly “washed out” again).

z Clinic
About ¼ of the adenomas are hormone- 22.3 Diagnostics
active and can cause corresponding symp-
toms depending on the hormone produced. If 22.3.1 Diagnostic Radiology
the adenoma bleeds into the pituitary gland,
headaches and visual disturbances may occur. Christel Vockelmann

z Diagnostics Sonography
Conventional X-ray Sonographically, the adrenal glands and
Here, a double contour of the sella and thyroid are amenable to ultrasonography
a displacement of the sella floor towards the (. Fig. 22.1). During abdominal ultra-
caudal as well as destructions of the bony sonography, the kidneys are positioned.
structures may be visible. Attention is paid to whether a mass can be
MRI demarcated at the upper pole of the kidney.
The tool of choice is MRI (. Fig. 22.3). Normal-sized adrenal glands cannot usually
Indirect signs of a mass (which could also be be visualized percutaneously by sonography.
detected on CT) include: The thyroid gland can be excellently
55 Impression of the Sella floor assessed sonographically. The main focus here
55 Elevation of the diaphragm sellae is on nodules. Cysts of the thyroid gland are
55 Pituitary stalk translocation also common, but are not hormone-­active.
Sonography is often performed in addition to
thyroid scintigraphy in nuclear medicine. The
purpose here is to differentiate cold nodules
on scintigraphy, which may correspond to
either a cyst or a mostly echo-deficient nod-
ule. These cold, non-cystic nodules should
then be histologically clarified, as thyroid car-
cinomas can be hidden underneath.

Conventional X-ray Diagnostics

Endocrinological diseases have no place in
conventional X-ray diagnostics. Sometimes,
however, a goiter can be seen on a conven-
tional X-ray (. Fig. 22.2). This is when the
thyroid gland is markedly enlarged and dips
into the upper mediastinum. Then there is
a tracheal shift to one side or even a com-
..      Fig. 22.3 Hemorrhagic macroadenoma of the pression of the trachea, in the worst case
pituitary gland in a sagittal T2 TSE sequence. Note a so-­called tracheomalacia. In this disease,
the level at the base of the mass as a relative clear indi-
cation of hemorrhage
the cartilage clasps of the trachea are soft-
Endocrinological System
331 22
ened so that the trachea can collapse. This The thyroid gland as another organ of
becomes audible mainly through an inspira- the endocrinological system is often imaged
tory stridor. in computed tomography. However, just as
with magnetic resonance imaging, only a
Fluoroscopy/Angiography statement about the presence of nodes or
In certain diseases of the adrenal glands, e.g. cysts is possible. A malignancy can only
Conn’s syndrome, it is necessary to take blood be proven in the case of tumor growth
from the adrenal veins in a side-­ separated that extends beyond the organ. Contrast
manner before surgical therapy for adrenal enhancement is not indicative of this.
enlargement. This ensures that the affected
adrenal gland is also responsible for the exces- Magnetic Resonance Imaging
sive production of the hormone aldosterone. As with a computed tomographic exami-
For selective venous blood sampling, a nation, adrenal space findings can also be
diagnostic catheter is advanced into the vena detected very well by means of magnetic reso-
cava via the femoral vein. The right adrenal nance imaging. The advantage of the adrenal
vein opens directly into the vena cava, the left gland is that it is embedded in the retroperito-
one opens into the left renal vein, via which the neal adipose tissue and can therefore be very
adrenal vein is then probed. Blood is drawn well delineated in non-fat-­saturated sequences.
selectively from both sides to then determine Actually, one sequence is also sufficient for the
the aldosterone level in both samples. question of an adrenal space requirement.
The question of fat content can be answered
Computer Tomography at the same time if a T1 in- and opposed phase
Computed tomography can delineate adre- sequence is acquired. If the adrenal space
nal space lesions very well. The assessment requirement shows a significant signal drop
of the dignity is also successful in most in the opposed phase, the evidence for fat is
cases. However, just like magnetic resonance provided. Thus, an adenoma and no metas-
imaging, computed tomography cannot con- tasis is present. However, magnetic resonance
tribute to hormone activity. Dignity can be imaging cannot provide any information on
proven by detecting fat in an adrenal mass. hormone activity. More frequently, an MR
For this purpose, a native examination of the examination is performed to clarify hyperten-
adrenal glands is sufficient in the first step. If sion. MR angiography of the renal arteries is
the density of an adrenal mass is less than performed. It is always a good idea to include
15 HU, an adenoma is present. A dynamic an axial planning sequence over the adrenal
CT scan with coils venous and after 10 min glands. Then the potential question of an
can be performed if the native coil detects adrenal space requirement, which arises in the
a mass with a greater density. If the adre- next step, is answered at the same time and the
nal mass has a density of less than 37 HU patient does not have to be examined again.
venously and the contrast medium washes Magnetic resonance imaging is a very
out by more than 50% in the late image, an good way to examine another organ of the
adenoma is also present. In another constel- endocrinological system: the pituitary gland.
lation, at least a malignant tumor may be Here, not only macroadenomas, which could
present. However, since nodular masses in also be delineated on CT, can be detected,
the adrenal glands very often occur with- but also microadenomas. However, this
out clinical relevance, all findings with a size requires an adaptation of the examination
<3 cm are referred to as incidentalomas— to the question “pituitary adenoma”, a rou-
i.e. incidental findings—provided that no tine cranial MRI does not help.
underlying malignant disease is known in The basis for the diagnosis of (hormone-­
the patient. active) microadenomas is the different con-
 332 M. Kahl-Scholz et al.

trast medium uptake of pituitary tissue and Saturation of the thyroid gland with non-
adenoma. The pituitary accumulates con- radioactive iodine, e.g. after an examina-
trast agent rapidly and strongly, adenomas tion with iodine-containing contrast media
22 delayed. So we need a dynamic measure- 6–8 weeks before the diagnosis, iodine-con-
ment over the pituitary. Coronary slices taining medications (especially amiodarone,
have proven best for this. Since the pituitary iodine-containing eye drops) or extremely
gland accumulates so much, the examina- iodine-containing food interfere with thyroid
tion should be measured with a reduced scintigraphy. A correspondingly long waiting
contrast medium dose (50%). period should be taken into account. Thyroid
therapeutics can also alter a scintigraphy and
should be discontinued as long as possible
22.3.2 Nuclear Medicine beforehand, depending on the problem.
Fifteen to 20 min after application of
Ursula Blum 70 MBq 99mTc, the metabolic distribution
pattern is recorded with a thyroid special
Thyroid Scintigraphy
collimator or a high-resolution low-energy
Thyroid function is scintigraphically depicted collimator (LEHR collimator). To deter-
predominantly with 99mTc-pertechnetate. mine the position of the thyroid gland, a
Classic indications are palpable or sonograph- radioactive point source is used to mark
ically detectable nodular changes >10 mm, the jugulum (and clavicle and palpable
clarification of latent or manifest hyper- nodes if necessary) in the same position. To
thyroidism (focal/disseminated autonomy), determine the technetium-thyroidal uptake
unclear differentiation of an autoimmune thy- (TcTU), so-called regions of interest (ROI’s)
reopathy or a Marine-­Lenhardt syndrome, or are placed around the thyroid gland, in
as a therapy control after radioiodine therapy an underground region and, if necessary,
(less frequently after surgery). One domain of around focal multiple accumulations.
123I scintigraphy is the visualization of ectopic

thyroid tissue (base of tongue, intrathoracic, SD impulse – UG impulse

struma ovarii), or if necessary in the case of Netto Activity
connatal hypothyroidism.
99mTc-pertechnetate is taken up via the The percentage uptake of the injected activ-
sodium-iodide symporter in the thyro- ity depends on the iodine supply. With suf-
cytes, but is not metabolized. After approx. ficient iodine supply in Germany, a TcTU
15 min a so-called steady-state (equilibrium with a normal TSH up to a maximum of
of uptake and release) is reached. Iodine 2% is considered normal. Ectopic thyroid
isotopes (131sodium iodide and 123sodium tissue is easier to localize with 123J because
iodide), on the other hand, are actively trans- it is fixed in the organ and the scattered tis-
ported into the thyroid tissue, bound to thy- sue and there is no overlap with the salivary
roglobulin and incorporated into the T3/T4 gland region as with 99mTc-pertechnetate.
hormones. In routine diagnostics, the 99mTc- Uptake can occur no earlier than 2 h p. i.
123J is a cyclotron product and is only used
pertechnetate has become established. It is
available as a generator product at any time, for special, rare indications.
is a pure gamma emitter with a short half-
life (sixhours) and is not bound in the thyroid z Assessment of Quantitative Thyroid
gland. This results in a low radiation expo- Scintigraphy
sure of 0.01 mSv/MBq for adults (reference Normal Findings
activity 70 MBq). For 123I, the effective dose Homogeneous distribution of the radio-
is 0.2 mSv/MBq (reference activity 10 MBq). pharmaceutical in both thyroid lobes, the
Endocrinological System
333 22
TcTU is in the normal range. The salivary A relevant autonomy is assumed from a
glands present with. TcTU of 1–2%.
Pathological Findings Thyroid puncture: Thyroid puncture is
Globally elevated TcTU is found in iodine performed as a fine needle puncture. There
deficient areas, disseminated autonomy or is a technique with aspiration as well as
Graves’ disease. Thyrostasis can also lead without aspiration. The indication is based
to an increased TcTU. A focally increased on the clinical findings. In the case of a
uptake is found in autonomic areas. A dis- suspected malignancy, puncture should
tinction is made between so-­ called warm always be performed; other indications may
and hot nodules. Warm ­nodules are com- be a relief puncture of a large cyst, a node
pensated autonomous areas, i.e. the healthy after radiotherapy in the neck region, pos-
areas of the thyroid are still displayed. In sibly an elevated calcitonin value or unclear
most cases, the TSH is not yet completely cervical lymph nodes. Contraindications
suppressed. Hot nodules are decompensated are anticoagulation (with the exception of
autonomous areas that are no longer subject acetylsalicylic acid up to a maximum of
to the regulatory circuit. The healthy areas 100 mg/die) and lack of patient cooperation
of the thyroid gland are no longer detectable or consistency of therapy. Usually, FNP is
by scintigraphy (suppressed), and the TSH is performed under sonographic control under
also usually reduced or no longer detectable. aseptic conditions. The complication rate is
55 A globally reduced uptake is found in low, with mild pain and bleeding being the
cases of acute inflammation of the thy- most common. In aspiration, cannulas of
roid gland (e.g. thyroiditis de Quervain), about 22–23 G are used, and aspiration is
iodine contamination, thyroid hormone performed by creating a negative pressure.
administration, after radioiodine ther- In non-aspiration, cannulas of 25–27 G are
apy or radiation therapy of the neck used. Cytological examination can be per-
region including the thyroid lodge, or formed either as a smear or by the thin-prep
possibly in the context of a chronic auto- method. A minimum of six cell clusters,
immune thyreopathy. each containing at least ten thyrocytes, is
55 A focal under-enrichment (cold nodule) considered sufficient material for examina-
may correspond to a solid thyroid nodule tion. If the material is sufficient, molecular
(with increased risk of malignancy), a thy- genetic examinations (in particular detec-
roid cyst, the Z. n after radioiodine therapy tion of BRAFV600E) can also be carried
of an autonomous adenoma, or possibly a out on the basis of the FNP.
focal inflammation or metastasis. Hypofunctional areas in the 99mTc-­
55 Ectopic thyroid tissue may occur intratho- pertechnetate scintigraphy and sonographi-
racically, as well as predominantly along cally partly solid nodes are malignant with
the median line from the larynx to the a probability of about 2% and therefore
base of the tongue. Ectopic tissue lateral require further clarification. In this case,
to the median line is rare, as is struma ova- FNP should be performed as standard.
rii (usually benign teratoma of an ovary). If FNP is not possible due to contraindi-
cations, a scintigraphy with 99mTc-MIBI
z Further Investigations (2 methoxyisobutylisonitrile) can be per-
Suppression scintigraphy: TSH production formed. MIBI accumulates in the mito-
is suppressed by oral administration of thy- chondria of cells. Malignant tumors and
roid hormones, then thyroid scintigraphy metastases usually have a significantly
is performed again and the TcTU is deter- increased cell division and are mitochondri-
mined. If the thyroid gland or node is sub- ally more active than healthy tissue. These
ject to the control cycle, the TcTU decreases. changes can be visualized by imaging. The
 334 M. Kahl-Scholz et al.

scintigram is recorded 20, 60 and 120 min p. Assessment of Quantitative Parathyroid

i., the recording parameters correspond to Scintigraphy
the 99mTc Pertechnetat study. The assessment is either a so-called sub-
22 The increased metabolic activity of traction scintigraphy: The 99mTc-pertechnetate
malignant thyroid changes can also be scintigraphy is subtracted from the 99mTc-
detected in the 18F-FDG-PET. In the MIBI scintigraphy (acquisition in the same
­synopsis of the findings, further diagnostics position and session). The second assessment
or surgical resection can therefore be dis- is to compare the planar 99mTc-pertechnetate
pensed with if necessary. scintigraphy with the planar MIBI scintigra-
phies over time. While a rapid MIBI wash-out
>> Thyroid scintigraphy and the determined is seen in healthy thyroid tissue, retention is
99mTc TU provide information about func- increased in parathyroid adenoma. It is pos-
tion, size, shape and location of the thyroid sible to generate a 3-D image of MIBI scintig-
gland. In the presence of hot nodules, a sup- raphy using SPECT. The SPECT technique
pression scintigram can be added to clarify increases the sensitivity of the procedure
the relevance of therapy. Hypofunctional (Deutsche Gesellschaft für Nuklearmedizin
solid nodules with suspicious findings show e. V. Leitlinien, Verfahrensanweisung für
an increased risk of malignancy and should Parathyroid Scintigraphie).
be further clarified by FNP.
>>Especially adenomas that cannot be ade-
 arathyroid Glands (Glandulae
P quately detected preoperatively by sonog-
Parathyroideae) raphy, CT and MRI, or those that could
z Examinations of the Parathyroid Gland not be found intraoperatively, are submit-
99mTc Pertechnetate/99mTc MIBI Scintigraphy ted to 99mTc MIBI scintigraphy.
Adenomas and hyperplasias of the para-
thyroid gland can be visualized by means
of a combined 99mTc-pertechnetate and 22.3.3 Valence
99mTc-­MIBI (methoxy-iso-butyl-isonitrile)

scintigraphy. The mitochondria-rich, oxy- Christel Vockelmann

philic cells of parathyroid adenomas take
up more 99mTc-MIBI (compared to thyroid . Table 22.1 shows the use of the respec-
tissue). In addition, the retention is more tive therapeutic options depending on the
pronounced problem

.       Table 22.1 Value of the therapeutic procedures

Sonography Conven- Fluoroscopy/ CT MRI Nuk PET

tional Angiography

Goiter P N N N N P N
Adrenal Space P N N W W W W
Demand
Pituitary Space N N N N P N N
Requirement

N Not indicated, P Primary diagnosis, W Further diagnosis

P* Cardio-CT can be used as a primary procedure in certain risk constellations
Endocrinological System
335 22
22.4 Therapy functional similarity to thyroid tissue. This
is the case with papillary (approx. 70% of
22.4.1 Radiotherapy malignant thyroid tumors) as well as fol-
licular (approx. 20% of malignant thyroid
Guido Heilsberg tumors), the so-called differentiated thyroid
carcinomas.
Thyroid Carcinoma Undifferentiated malignancies such as
In thyroid carcinoma, percutaneous radio- medullary or anaplastic thyroid carcinoma
therapy is used only in a small group of are not amenable to radioiodine therapy.
high-risk patients: when surgery and radio- They are treated postoperatively with exter-
iodine therapy could not achieve complete nal radiation or chemotherapy.
tumor cell destruction, in recurrence or in The dose applied during radioiodine
the palliative situation of skeletal metastases therapy depends on the type of disease. The
with risk of fracture, brain metastases, and individual determination takes place within
upper influence congestion. the framework of the so-called radioiodine
test. Before starting, sufficient iodine absti-
nence must be ensured. Iodine contamina-
22.4.2 Nuclear Medicine tion from medicinal iodine sources, food
supplements, toothpaste or fish and seafood
Ursula Blum dishes must be avoided. If necessary, the
therapy is carried out in a euthyroid meta-
Radioiodine Therapy bolic state.
Iodine is selectively stored in thyroid and After administration of a small amount
thyroid tissue-like tumors and metastases of radioiodine (1–5 MBq 131J or 5–10 MBq
123J), the absorbed activity is determined at
via the sodium iodide symporters. This
behavior is used in radioiodine therapy. The different times with the aid of a measuring
131J used here transitions to 131Xe by emit- probe, the essential components of which
ting beta-minus radiation with an average are a 5 cm thick NaJ crystal and a suitable
range of 0.5 mm and a gamma component collimator (e.g. after 24, 48, 72 and 96 h, in
(energy 364 keV) that can be used for imag- Graves’ disease 4–8 h). The volume to be
ing and a half-life of 8.04 days. The most treated is determined by sonographic and
important benign indications for radioio- scintigraphic imaging, in case of tumor
dine therapy are functional autonomies, recurrence or metastases by CT- or MRI-­
Graves’ disease and euthyroid strumen. A based volumetry. The subsequent dose cal-
corresponding indication for the therapy culation is performed using the so-called
of malignant tumors is the still existing Marinelli formula:

radiation dose  Gy   volume of the radiated organ  mL 

Activity  K 
maximal enhancement  %,Uptake   effective half  life
 336 M. Kahl-Scholz et al.

The quantity K is a constant with the value z Acute and Chronic Adverse Reactions and
24.67. Their Protective Therapy (. Table 22.2)
The effective half-life can be estimated With increasing cumulative doses over the
22 empirically (approx. 7–8 days, in Graves’ total lifetime, the risk of developing acute
disease approx. 3 days) or determined indi- myeloid leukemia increases. In contrast,
vidually, since the individual differences are the risk of an increase in other malignant
only slight. tumors as a result of high-dose radioiodine
therapy of the thyroid gland is controversial.
>>Radioiodine therapy should be per- After 70 years of therapy experience in the
formed as soon as possible after the field of benign thyroid diseases, an increased
radioiodine test in order to have compa- therapy-related cancer risk could not be
rable conditions of radioiodine kinetics. proven.

If a therapeutic 131J capsule is administered, z Aftercare

admission to an appropriately equipped In addition to history, hormone determi-
ward is required in accordance with national nation (TSH/Tg) and sonography of the
regulations. A decay facility to collect the thyroid lodge and soft tissues of the neck,
excreta, which are initially highly radioac- depending on the risk profile 131J whole
tive, shall be provided. body scintigraphies are performed three
months, one year and if necessary in two
>>Before radioiodine therapy of malignant year intervals after endogenous or exog-
thyroid diseases, surgical removal of the
thyroid gland and affected lymph nodes
is mandatory, not only for histology. If
the thyroid gland were to be preserved, .       Table 22.2 Overview of side effects
the dose would have to be significantly
Gastritis Administration of
higher in accordance with the larger vol- antacids or proton pump
ume, which would be accompanied by an blockers
increased side effect rate.
Sialadenitis Under discussion
Subsequent radioiodine therapy is directed Gonadal load Decrease due to
at the residual thyroid tissue and any metas- administration of
tases that may be present. diuretics and laxatives
The patient is discharged if the measured Intracerebral or Corticosteroids
activity at a distance of 2 m does not exceed intravertebral
250 MBq (guideline in radiation protection). metastases for
edema prophylaxis

>>The selective storage of 131J in benign and Pulmonary Dose restriction in

differentiated malignant tumors and their Fibrosis pulmonary metastases,
especially when
metastases offers the possibility of a ther-
combined with
apy closely related to the pathological chemotherapy
process. While radioiodine therapy is per-
Bone marrow Continuous blood count
formed following surgical removal of a
depression in the control
differentiated thyroid carcinoma, it can treatment of
be an alternative to surgery for benign osseous metastases
tumors.
Endocrinological System
337 22
enous rhTSH simulation. Further exami-
nations may include CT, skeletal and MIBI tion, an MR angiography. Renal artery ste-
scintigraphy and, depending on the molecu- nosis as the cause of the hypertension can
lar tumor entity, FDG-PET, DOTATOC-­ be excluded. However, a mass of the left
PET or octreotide scintigraphy. adrenal gland is found, and the right adre-
PET examination is particularly indi- nal gland is also somewhat enlarged. A
cated when iodine storage of the tumor or pheochromocytoma is suspected. After
its metastases has been lost in the course of laboratory and urine tests, a side-separated
the disease, i.e. the tumor is poorly differen- venous blood sample can be taken from
tiated or de-differentiated. the adrenal veins. In case of ambiguity, a
The prognosis of consistently operated MIBG scintigraphy can also be performed.
and radioiodine-treated differentiated thy-
roid carcinomas is consistently good, since
this tumor form can be irradiated in isola-
tion due to the selective radionuclide storage Practice Questions
of malignant cells, while sparing healthy tis- 1. What would be your tentative diagno-
sue (Deutsche Gesellschaft für Nuklearmed- sis if you find nodules of varying
izin e. V. Leitlinien, Verfahrensanweisung echogenicity on thyroid ultrasonogra-
Radioiodtest, RJT benigne Schilddrüsener- phy?
krankungen, differenzierte Schilddrüsen- 2. What are the features of an NN ade-
karzinome, Ganzkörperzintigraphie 131J). noma on CT?
3. What is the tool of choice to visualize
and evaluate a pituitary tumor?
Case Study
4. What is an important contraindica-
tion to thyroid scintigraphy?
Mr. Press, 35 years old, has recently devel-
5. What substances are used for labeling
oped high blood pressure. His family doc-
in adrenal scintigraphy?
tor sends him to hospital for clarification
6. When is radioiodine therapy used for
and optimal therapy adjustment. First, a
the thyroid gland?
­sonography is performed. However, since
this cannot reliably exclude adrenal space
Solutions 7 Chap. 27
damage, an MRI of the adrenal glands is
also performed and, in the same examina-
 339 23

Lymphatic System
Martina Kahl-Scholz, Christel Vockelmann,
Ursula Blum, and Guido Heilsberg

Contents

23.1 Anatomical Structures – 340

23.2 Disease Patterns – 340

23.2.1 S ystemic Diseases – 340
23.2.2 Hodgkin’s Disease – 341
23.2.3 Non-Hodgkin’s Lymphoma – 341
23.2.4 Lymph Node Metastases – 342
23.2.5 Splenic Cysts – 342
23.2.6 Spleen Abscess – 342
23.2.7 Splenic Infarction – 342
23.2.8 Splenic Rupture – 342
23.2.9 Thymoma – 343

23.3 Diagnostics – 343

23.3.1  adiological Diagnosis – 343
R
23.3.2 Nuclear Medicine – 344
23.3.3 Valence – 347

23.4 Therapy – 348

23.4.1 I nterventional Radiology – 348
23.4.2 Radiotherapy – 348

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 340 M. Kahl-Scholz et al.

This chapter deals with the essential possi- After puberty, the thymus begins to become
bilities of radiological diagnostics, nuclear fatty and the thymic tissue decreases more
medicine and radiotherapy for the diagnosis and more until the gland consists mainly of
and therapy of the lymphatic system. An fatty tissue.
introductory section provides a brief over-
view of anatomy and function, and a con-
23 cluding section contains a case study from 23.2 Disease Patterns
practice.
Martina Kahl-Scholz and Christel Vockelmann

23.1 Anatomical Structures

23.2.1 Systemic Diseases
Martina Kahl-Scholz
There are several diseases that affect a com-
In addition to the lymph vessels, the lymph plex organ system or even the whole body.
node stations (filter stations) and the lymph These systemic diseases are often accompa-
organs (e.g. thymus, spleen, tonsils and nied by a co-reaction of the lymphatic sys-
appendix) are part of this complex system. tem, most likely by enlargement (painful or
The lymph is drained into the venous asymptomatic) of the lymph nodes. Systemic
system. diseases include leukemias, anemias, rheu-
The spleen as an important lymphatic matoid diseases, sarcoidosis, systemic lupus
organ is located in the left upper abdomen in erythematosus and many others. Last but
direct proximity to the stomach, kidney and not least, cancers are also systemic diseases
large intestine. The spleen is about 4 cm if lymph node metastases develop due to
thick, 7 cm wide and 11 cm long. metastasis of the lymphatic channels.

>>“4711”: Thickness (4), width (7) and z Clinic

length of spleen (11) in cm. The clinic depends on the underlying dis-
ease.
It shows a side facing the diaphragm (Facies
diaphragmatica) and a side facing the z Diagnostics
abdominal organs (Facies visceralis), which Sonography
is divided into the Facies gastrica, colica Sonography is the method of choice in
and renalis. At the mizhilus (hilus spleni- lymph node diagnostics. In addition to the
cus), the splenic artery and vein enter and size of the lymph nodes, the blood supply to
leave the spleen, respectively. the lymph node can also be assessed. And
The thymus as another important lym- even a disturbance of the architecture, with
phatic organ is located in the upper medias- the normal fat hilus of a lymph node as an
tinum behind the sternum, extends to the indication of a lymph node metastasis, can
pericardium of the heart and consists of two be detected with high-resolution sonogra-
lobes. It is a primary lymphoid organ and phy—and a little patience—even with only
significantly involved in the imprinting of minor changes.
lymphocytes and the development of immu-
nocompetence. The thymus grows until >>The standard value for an enlarged
infancy and maintains its size until puberty. lymph node is 1 cm.
Lymphatic System
341 23
23.2.2 Hodgkin’s Disease

Hodgkin’s lymphoma is a malignant tumor

of the lymphatic system, which is character-
ized by a painless swelling of lymph nodes.
The presence of a special type of cell
(Sternberg-­Reed cells) distinguishes it from
non-Hodgkin’s lymphoma.

z Clinic
..      Fig. 23.1 Lymph node enlarged to 2.8 cm with In addition to lymph node swelling, B symp-
absent fat hilus in confirmed lymphoma disease toms may develop.

In addition to the fatty hilus, the second z Diagnostics

very important criterion for distinguishing CT
between normal and suspicious lymph Computed tomography is the standard
nodes is their shape. Oval lymph nodes are method for determining the status of the
more likely to be benign, round lymph nodes lymph nodes in cases of suspected diseases
are always suspect. of the lymphatic system. In the staging of a
Typical for pathological lymph nodes is possible lymphoma, not only the thorax and
the absence of a fatty hilus, which can be abdomen should be examined, but also the
detected on ultrasound as a central hyper- cervical lymph nodes. This serves to have an
echogenic zone (. Fig. 23.1). objective and in the course comparable
imaging.
CT/MRI This fine diagnosis makes ultra- As with sonography, computed tomogra-
sound superior to computed tomography and phy can detect the fatty hilus as a fatty
in most cases also to magnetic resonance isodense central zone in the lymph node even
imaging. For this reason, mediastinal lymph in relatively large lymph nodes in the groin.
node enlargements diagnosed by CT are often This is indicative of benignity of the lymph
first assessed by endosonography. node. An absent fatty hilus is a sign of
pathologic change, such as malignancy or
Endosonography Endosonography means inflammation. The shape also plays an
that the gastroenterologist or internist inserts important role in the evaluation of the
an ultrasound probe into the oesophagus, lymph node as in sonography. A further
comparable to an oesophago-­ gastro-­indication of malignancy or benignity
duodenoscopy. In unclear cases, a mediasti- results from the localization of the lymph
nal lymph node can then also be punctured node.
endoscopically using ultrasound. EBUS is MRI
also an option. This refers to the endobron- See CT
chial ultrasound examination. This is some-
what more complex than endosonography
through the esophagus, because air does not 23.2.3 Non-Hodgkin’s Lymphoma
conduct the sound waves and therefore a
sound window must first be created in the The collective term non-Hodgkin’s lym-
bronchus. phoma (NHL) covers all malignant diseases
 342 M. Kahl-Scholz et al.

of the lymphatic system (malignant z Diagnostics

­lymphomas) that are not Hodgkin’s disease. Sonography
An echo-poor and blurred structure is
z Clinic revealed.
7 Section 23.2.2. CT
The density depends on how advanced
23 z Diagnostics the abscess is. A rather hypodense structure
7 Section 23.2.2. is often seen, which absorbs KM in the mar-
ginal area.

23.2.4 Lymph Node Metastases

23.2.7 Splenic Infarction
7 Section 23.2.1.
Splenic infarction results from occlusion of
the lienal artery or its branches with conse-
23.2.5 Splenic Cysts quent tissue death.

z Clinic z Clinic
Splenic cysts are usually an incidental find- Acute abdomen, vomiting and nausea, there
ing and accordingly often behave asymp- may be fever and splenic pain.
tomatically. An exception can be parasitic
cysts. z Diagnostics
Sonography/Duplex Sonography
z Diagnostics Isoechogenic, later anechoic area, often
Sonography wedge-shaped (supply areas of the artery),
On sonography, the cysts appear homo- can be seen on sonography, There may be
geneous and echo-poor. They show a smooth calcification subcapsular and retraction of
border with a dorsal sound enhancement. the splenic tissue. Duplex sonography can
CT assess the blood flow through the splenic
Again, the cysts show smooth bordered arteries and for surgery.
and homogeneously hypodense. They do not CT
take up KM. Again, wedge-shaped hypodense struc-
tures that do not accommodate KM are evi-
>>If it is an echinococcus cyst, multicham- dent.
beredness is the key distinguishing fea-
ture.
23.2.8 Splenic Rupture
23.2.6 Spleen Abscess Traumatic splenic rupture is one of the most
common intra-abdominal injuries that should
In the course of an infection (e.g. by myco- be controlled, especially in cases of poly-
plasma), pus accumulates in the spleen tis- trauma (with, for example, left rib fracture).
sue.
z Clinic
z Clinic Pain in the left upper abdomen (possibly
Nausea and vomiting, upper abdominal with sweeping sign = radiation into the left
pain (capsular pain) and splenomegaly. shoulder).
Lymphatic System
343 23
z Diagnostics along the cervical-vascular nerve sheaths,
Sonography axillary and inguinal can be excellently
A splenic hematoma appears on ultra- examined with a high-resolution transducer
sound as an echo-poor to -free sound-­ (. Fig. 23.1). The abdominal lymph nodes
conducting zone localized in or around the paraaortally and the spleen can be examined
spleen. Smaller hematomas may not be seen. with abdominal ultrasonography. This fine
CT diagnosis makes ultrasound superior to
CT is the tool of choice. A hematoma is computed tomography and, in most cases,
identified by lower density values that to magnetic resonance imaging.
approach the isodense range after a few days.
Conventional X-ray Diagnostics
Conventional X-ray diagnostics have no sig-
23.2.9 Thymoma nificance in the context of a targeted exami-
nation for suspected lymphatic disease.
Thymoma is the name given to tumors of Nevertheless, lymphatic diseases and lymph
the thymus, which account for about 15% of node enlargements can of course also be
all mediastinal tumors (3/4 are benign, only diagnosed in the context of other reasons or
1/4 are malignant). clinical suspicions. Sarcoidosis or Boeck’s
disease, a granulomatous systemic disease,
z Clinic leads to a typical hilar plumpness on con-
Often the diagnosis is accidental, the tumors ventional radiographs of the lungs
grow slowly and rarely cause symptoms. (. Fig. 23.2), where a narrow fringe of lung
can classically be delineated between the
z Diagnostics hilar and cardiac shadows (in contrast to a
Conventional X-ray hilar bronchial carcinoma).
There is an unclear mediastinal mass,
which should be further clarified by CT/MRI. Fluoroscopy/Angiography
CT/MRI Fluoroscopy and angiography play no role
Thymomas and thymic carcinomas usu- in the diagnosis and therapy of diseases of
ally present as a well circumscribed soft tis- the lymphatic system.
sue mass in the upper anterior mediastinum.
Vascular infiltration or sheathing as well as
pleural metastases are indicative of malig-
nancy. Magnetic resonance imaging (MRI)
of the thorax may be helpful in rare cases to
assess vascular infiltration.

23.3 Diagnostics

23.3.1 Radiological Diagnosis

Christel Vockelmann

Sonography
Sonography is also the screening method of
first choice in the diagnosis of lymphatic dis-
eases. The cervical lymph node stations ..      Fig. 23.2 Typical hilar enlargement in sarcoidosis
 344 M. Kahl-Scholz et al.

Computer Tomography Abdomen^01_Abdomen_2_Phases

Study 08.06
Computed tomography is the standard Image

method for assessing the status of the lymph

nodes in cases of v. a. diseases of the lym-
phatic system (. Fig. 23.3). In the course of Spin
Tilt:
therapy, the size of the lymph nodes and
23 also of the spleen is assessed to evaluate the
success of therapy. In addition, it is possible
to detect organ manifestations of lymphoma
better than with magnetic resonance imag-
ing and sonography. In addition to lymph
nodes and spleen, all organs can ultimately
be involved in the disease.
A further indication of malignancy or
benignity results from the localization of the
lymph node. Thus, several lymph nodes are
found mediastinally infracarinally in almost
all patients. These are not to be considered
suspicious per se. However, if these lymph
..      Fig. 23.4 T4 gastric carcinoma with extensive
nodes are found in front of the aortic arch, lymph node metastases
then at least a control examination should
be recommended; depending on further The combination of CT and PET offers
findings, further diagnostics and clarifica- the advantage of combining morphological
tion may also be indicated. Round lymph and biological information.
nodes with relatively strong contrast
enhancement adjacent to a colon carcinoma Magnetic Resonance Imaging
in the percolated adipose tissue are equally Like computed tomography, magnetic reso-
suspicious for lymph node metastasis, even nance imaging is very good at detecting the
if the size of the lymph nodes is less than size of lymph nodes and also a fat hilus as a
1 cm. . Figure 23.4 shows a gastric carci- diagnostic criterion (. Fig. 23.5). The dis-
noma with several lymph node metastases. advantage is the generally limited scope of
the examination. In the case of circum-
scribed cervical lymph node enlargements in
younger patients, however, magnetic reso-
nance imaging is always an appropriate fol-
low-­up diagnostic method to sonography.
The local lymph node status in rectal cancer
can also be detected very well by MRI as
part of local staging.

23.3.2 Nuclear Medicine

Ursula Blum

Sentinel lymph node scintigraphy can be

..      Fig. 23.3 CT image showing mediastinal and bihi- used to detect the relevant lymph nodes
lar lymph node enlargement in sarcoidosis (sentinel lymph nodes) and, if necessary,
Lymphatic System
345 23
system and thus in advanced stages tumor
cells reach the bloodstream, the tumor now
metastasizes hematogenously.

 entinel Lymph Node Scintigraphy

S
Using the Example of Breast
Carcinoma
To visualize the SLN,99m Tc labeled colloids
with a particle size of approximately 20 nm
to 100 nm are injected. These are recognized
by the lymphatic system as foreign bodies
and transported away. The applied amount
of activity must be so high that the lymph
..      Fig. 23.5 Pathologically enlarged lymph node in node can be found intraoperatively with an
HCC appropriate measuring probe. The injection
can be intracutaneous, subcutaneous or per-
lymphatic channels in primarily lympho- itumoral. To date, no application method is
genic metastatic tumors. superior to any other. According to the cur-
rent guideline, 100–200 MBq are injected 24
I ntroduction to Sentinel Lymph hours before surgery, with a radiation expo-
Node Scintigraphy sure of the patient of 0.5–1.5 mSv.
The sentinel lymph node (SLN) is the lymph The recording on a large field camera
node(s) through which a malignant tumor is proceeds as follows:
primarily drained. If these are free of tumor 55 LEHR Collimator
cells, lymphogenic metastasis can be 55 Matrix 256 x 256
excluded with a high degree of probability. 55 Early static images of the thorax and
The histological examination of the sentinel ipsilateral axilla from ventral 300 sec
lymph node has a direct impact on the extent 55 Late static images of the thorax and ipsi-
of resection and, if necessary, the subse- lateral axilla from ventral and lateral
quent therapy. Topographic anatomy using over 300 sec
the example of breast carcinoma 55 The images are usually taken with the
Tumor cells can detach themselves from injection site shielded; acquisition should
the cell structure and enter the lymphatic be performed without it.
system, settle there under unfavorable con-
ditions, divide and form metastases. First of The patient lies on his back, the arm of the
all, there are usually metastases in the side to be examined is spread at a 90-degree
nearby regional lymph nodes, which, in the angle.
case of breast carcinoma, are located within A surface phantom thinly covered with
the breast, in the axilla or parasternally, 57 Co lies under the patient. It is placed so
depending on the location of the tumor. that the contours of the axilla of the affected
Even more rarely, drainage into the contra- side are visible.
lateral axilla is found. The collecting vessel If no SLN can be visualized two hours p.
coming from the regional lymphatic i., the mamma should be massaged and
­drainage area can transport the tumor cells warmed for 10 minutes. The SLN is then vis-
to the secondary, or tertiary lymph node sta- ible in the following 10 minutes, otherwise a
tions. In the venous angle (thoracic duct) the late image is acquired the next morning
lymphatic system enters the venous blood immediately before surgery. The detection
 346 M. Kahl-Scholz et al.

rate depends on the injection, ranging from A glucose analogue, fluorodeoxyglucose

approximately 80% for peritumoral/intrapa- (FDG), is used to represent glucose metabo-
renchymal injection to 98% for intradermal lism. This is obtained by replacing an oxy-
injection in various studies. The SLN shown gen atom in glucose with 18 F. The latter
can be marked on the skin. The surgeon uses decays via a β decay. This decays via a β+
a special gamma probe to locate and remove decay. The two resulting gamma quanta can
23 the SLN. The lymph node is immediately be detected, i.e. made visible, by two oppos-
examined histopathologically. In case of ing detectors in positron emission tomogra-
negative findings or micrometastasis (<2 phy (PET).
mm), axillary dissection is currently not per- For lymphoma detection, the 18 F-FDG
formed according to the latest guideline PET is injected i.v. Since there is a correla-
(AWMF, 07/2013). tion between mitosis, proliferation rate,
tumor aggressiveness and nuclide accumula-
>>The enrichment of the SLN only serves tion, the intensity of the accumulation pro-
to locate this lymph node, a statement on vides information about the metabolic
the dignity is not possible! behavior of the malignancy.
If no current, diagnostic CT is available
The following mistakes must be avoided: (not older than 14 days), this can be acquired
55 Incorrect indication in the same session.
55 Skin contamination
55 Faulty injection Indication for PET
55 Overlay of the SLN through the injec- The 18 F-FDG PET is more sensitive than
tion site other morphologically diagnostic methods
55 Previous operations, manipulations, in both primary staging and restaging.
therapies or additional diseases In the early diagnosis of lymphomas,
55 Covering of lymph nodes close to tumors the 18 F-FDG PET is used to clarify the
by lead shielding spread – in the case of limited spread, a
55 Premature termination of the investiga- short course of chemotherapy or local radi-
tion ation may be sufficient, while longer, more
55 False negative result in case of complete intensive treatment must follow if the
metastasis of the lymph nodes tumor involves several regions of the body.
55 Inadequate reporting of findings After only two cycles of chemotherapy, the
response to therapy can be evaluated, which
Another possible application of sentinel may then lead to a reduction in the number
lymph node scintigraphy is the visualization of chemotherapy cycles in the case of nega-
of the sentinel lymph node in malignant mel- tive or improved PET, or to an intensifica-
anoma, head and neck tumors, penile carci- tion or change in the chemotherapy
nomas, vulvar carcinomas and other tumors. protocol in the case of unchanged or wors-
Here, the visualization of anatomical neigh- ened PET.
boring structures by fusion of SPECT with At the end of intensive chemotherapy, a
CT cross-sections can be helpful for easy negative PET can lead to the waiving of
intraoperative detection of the SLN. additional radiotherapy and thus to a reduc-
tion in toxicity. The waiver is only possible
PET in Lymphoma Diagnostics because in PET the morphologically detect-
Lymphomas are rapidly growing malignan- able residual tissue can be reliably distin-
cies. As a rule, they have an increased energy guished in fibrosis and the residual tumor.
requirement and absorb a corresponding The 18 F-FDG PET can provide a prog-
increase in glucose. nosis estimate. For example, the recurrence
Lymphatic System
347 23
rate for positive post-therapeutic FDG PET z Dealing with Parents
is between 90 and 100%, and between zero The procedure of the examination must be
and 17% for negative findings. In the case of explained in detail to the child and his par-
positive findings, either a lack of remission ents (resting time, duration of admission,
or the occurrence of a recurrence can be details of the examination procedure, neces-
assumed. sity of sedation or anesthesia, presence of
Radiotherapeutically, the 18 F-FDG diabetes mellitus, administration of an
PET can contribute to the exact target vol- iodine-containing contrast medium).
ume definition. Parents must be informed of the urgent need
to abstain from food for four to six hours
Special Features in Pediatrics before the examination. Sweet drinks, chew-
In children and adolescents, lymphoma is ing gum and sweets require special mention.
the third most common cancer. If the parents are involved in the examina-
Due to the high life expectancy of these tion, the children usually cooperate better.
patients, the focus here is on minimizing If the examination is acquired during the
therapy-related late effects, including sec- child’s normal bedtime, sedation may not be
ondary malignancies, cardiovascular events, necessary.
pulmonary fibrosis, and endocrinological
changes. Possible Sources of Error
The 18 F-FDG-PET is used pre-­
therapeutically and intratherapeutically for >>When growth factors are administered,
early clarification of treatment success, so the 18 F-FDG uptake in bone marrow
that a possible attenuation of therapy can be and spleen may be increased. If cell pro-
discussed. liferation occurs in the bone marrow
after chemotherapy, the 18 F-FDG
z Dealing with the Child uptake in the bone marrow is also
Intravenous access should be established increased.
before the child arrives, this minimizes stress.
A warm environment increases the well-­ In children there is physiologically an
being of the child and causes a reduction of increased FDG uptake in the thymus, fur-
the tracer in the brown adipose tissue, which thermore of the lymphatic tissue in the
can be additionally supported by medica- nasopharynx. The chewing muscles can
tion. This preparation optimizes the later store more FDG after pacifier use or after
collection of findings. The activity is raised breastfeeding, the larynx after crying or
according to weight and is a minimum of screaming.
26 MBq in 2D mode and 14 MBq in 3D
mode. Before starting the examination, the
bladder must be emptied or the diaper 23.3.3 Valence
changed. If the PET/CT examination is used
for radiation planning, appropriate posi- . Table 23.1 shows the use of the respec-
tioning must be carried out in consultation tive therapeutic options depending on the
with the radiation therapist. problem
 348 M. Kahl-Scholz et al.

.       Table 23.1 Value of the therapeutic procedures

Sonography Conventional Fluoroscopy/Angiography CT MRI Nuk PET

Lymphoma P N N P W N W

23 Sentinel-node P

N Not indicated, P Primary diagnosis, W Further diagnosis

23.4 Therapy

23.4.1 Interventional Radiology

Christel Vockelmann and Martina Kahl-Scholz

CT-Guided Biopsy
Radiological therapeutic interventions on
lymph nodes are technically feasible, partic-
ularly in the form of thermoablation. In the
overall context of oncological therapy, how-
ever, such an intervention may only make
sense in selected individual cases. In con-
trast, a CT-guided biopsy (. Fig. 23.6) is
often necessary, especially of the paraaortic ..      Fig. 23.6 Biopsy of pathological lymph node aor-
lymph node enlargements. These are often tointercaval with securing metastasis of HCC
not accessible by endosonography. In addi-
tion, only fine-needle aspiration can be per- 23.4.2 Radiotherapy
formed by endosonography. The tissue
obtained in this way is often insufficient to Guido Heilsberg
allow a pathological differential diagnosis
of lymphoma. Therefore, a CT-guided Hodgkin’s Disease
punch biopsy is usually obtained from the Early stages are treated with combined che-
lumbar region. Frequently, a coaxial proce- motherapy and radiotherapy, using the tech-
dure is performed in order to obtain several niques:
samples. It is important to obtain sufficient 55 Involved-field (IF) = technique that
material. includes only the affected lymph nodes
Lymphatic System
349 23
55 Extend-field (EF) = technique that
includes affected lymph node regions with Practice Questions
adjacent, clinically unaffected regions. 1. What features help to distinguish a
malignant from a benign lymph node
Used with a dose between 20–36 Gy/ED on sonography and CT?
1.6–2 Gy/5×. 2. What is the evidence for a multicham-
The side effects depend on the radiation bered, echo-poor structure in the
localization. spleen that does not pick up KM?
3. What features may indicate a thy-
Non-Hodgkin’s Lymphoma (NHL) moma?
Generally, NHL is treated by radiotherapy
and chemotherapy with a total dose between Solutions 7 Chap. 27
24 and 40 Gy.

Case Study

Lars probably has Hodgkin’s disease, i.e.

malignant lymphoma. Since the ultra-
sound already suggests a typical malig-
nant lymphoma of the neck, the
diagnosis is quickly confirmed with a
punch biopsy. To complete the staging, a
PET-CT is primarily performed at the
university. Here mediastinal lymphoma
is still revealed. Lars undergoes a com-
bined radio-chemo therapy as part of a
study. Already after a few days the swell-
ing on the neck goes down. After a few
weeks, Lars has survived the therapy. He
now has to go for regular follow-up care,
but so far no recurrence has occurred.
 351 24

Pediatrics
Esther Münstermann and Christel Vockelmann

Contents

24.1 Thorax – 352

24.1.1  espiratory Distress Syndrome (ANS) – 352
R
24.1.2 Meconium Aspiration – 352
24.1.3 Oesophageal Atresia – 353
24.1.4 Catheter in the Thoracic Region – 353

24.2 Gastrointestinal Tract – 354

24.2.1  ecrotising Enterocolitis (NEC) – 354
N
24.2.2 Duodenal Atresia – 354
24.2.3 Invagination – 354

24.3 Urogenital Tract – 355

24.3.1 Vesicourethral Reflux (VUR) – 355

24.4 Musculoskeletal – 356

24.4.1  hild Abuse (Battered Child) – 356
C
24.4.2 Osteomyelitis – 356
24.4.3 Hip Dysplasia – 356

24.5 Oncology – 356

24.5.1  euroblastoma – 356
N
24.5.2 Nephroblastoma (Wilms’ Tumor) – 357
24.5.3 Medulloblastoma – 357

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 352 E. Münstermann and C. Vockelmann

In the following, a brief overview of impor-

tant pediatric clinical pictures (from the
areas of thorax, GIT, urogenital tract, mus-
culoskeletal diseases as well as oncology) as
well as their radiological diagnostics and
possible technical interventions is given.

24 24.1 Thorax

24.1.1 Respiratory Distress a

Syndrome (ANS)

Surfactant deficiency. Respiratory distress

syndrome (RNS) can occur in premature
infants <28 weeks gestation due to lung
immaturity, in shock situations, and in
infants of diabetic mothers, for example.

z Clinic
Apnea, cyanosis, tachypnea

z Diagnostics
b
X-ray Thorax (. Fig. 24.1)
ANS is divided into four stages:
..      Fig. 24.1 a Respiratory distress syndrome grade
55 Fine granular lung pattern
II, b Respiratory distress syndrome grade III with fine-­
55 I + Beyond the heart contours spotted compressions and positive aerobronchogram.
55 II + Blurring or partial obliteration of Properly inserted gastric tube. Overlay by ECG elec-
the contours of the heart and diaphragm trodes
55 “White lung”

In the first 6 h of life the classification is Meconium aspiration is more likely to

uncertain because of still present lung fluid affect dystrophic and transferred neo-
and after surfactant administration. nates.

>>Sepsis with B streptococci can simulate z Clinic

ANS in clinical and radiographic signs. Depending on the severity from tachypnea
to asphyxia

24.1.2 Meconium Aspiration z Diagnostics

X-ray Chest
Intrauterine hypoxia leads, among other Symmetrically distributed, dense, patchy,
things, to vasoconstriction of mesenteric sometimes nodular pulmonary infiltrates.
vessels and thus to hyperperistalsis and Pulmonary hyperinflation, flattened dia-
finally to premature meconium discharge, phragm, occasionally minor pleural effusion
which inactivates surfactant. or pneumothorax.
Pediatrics
353 24
24.1.3 Oesophageal Atresia
z Clinic
OEsophageal atresia can be suspected prena- a
tally sonographically by a missing gastric bub-
ble and a polyhydramnios. In about 50% of
cases other malformations are also present
(e.g. VACTERL association: vertebral, anus,
cardial, tracheal, esophageal, renal, limbs).

z Diagnostics
X-ray Thorax and Abdomen (. Fig. 24.2)
Esophageal atresia is divided into five
different stages (type I to type IIIc). Type
IIIb occurs in approx. 87% of cases.
b
>>Placement of a gastric tube before per-
forming a chest X-ray is mandatory in
neonates and premature infants!

24.1.4 Catheter in the Thoracic

Region
Wash-in Catheter
The intravenous catheter is placed over a
suitable vein (e.g. V. mediana cubiti, V. basil-
ica) under sterile conditions and should be
positioned in front of the right atrium. The ..      Fig. 24.2 a, b Oesophageal atresia type IIIb with
beginning of the catheter should always be looping of the gastric tube in the blind sac and evi-
dence of esophagotracheal fistula through the air in
imaged as well, since the catheter may have
the included upper GI tract
already coiled up at the beginning.

Umbilical Vein Catheter (NVK) Umbilical Artery Catheter

The umbilical vein catheter is placed via the The umbilical artery catheter is used to mea-
umbilical vein through the ductus venosus sure pO2 in ventilated preterm infants. The
Arantii into the inferior vena cava appropriate position should be above the
(. Fig. 24.3) and is used, among other things, diaphragm, at a safe distance from the outlet
to enable exchange transfusion or measure- of the renal arteries.
ment of central venous pressure. The catheter
should end 1 cm above the diaphragm.
 354 E. Münstermann and C. Vockelmann

pressure-painful abdominal wall with

a Pediatric
venous markings, fresh blood in the stool.
Intensive
z Diagnostics
X-ray Abdomen
NEC is divided into five stages:
55 I: Suspicion of NEC with radiologically
thickened intestinal walls
24 55 IIA: Thickening of the intestinal wall
Cu-Filter

with double contour due to edema for-

mation (pneumatosis intestinalis)
55 IIB: Pneumatosis intestinalis, hepato-
splenomegaly, free fluid
b CU filter Pediatric 55 IIIA: IIB + Pneumatosis intestinalis over
Intensive
several intestinal loops, additionally air
in portal vein
55 IIIB: Pronounced pneumatosis intestina-
lis, free air subphrenic or prehepatic,
indirect visualization of free air by visi-
ble lig. falciforme, central brightening

24.2.2 Duodenal Atresia

Duodenal atresia is defined by occlusion of

the lumen by a membrane, complete disrup-
tion or circular compression from the out-
side by a pancreas anulare. Duodenal atresia
is more common in syndromes and, for
example, in trisomy 21.

z Clinic
..      Fig. 24.3 a Correct and b incorrect installation of
a NPC Bilious vomiting in occlusion below and
clear vomiting in occlusion above the papilla
vateri.
24.2 Gastrointestinal Tract
z Diagnostics
24.2.1 Necrotising Enterocolitis X-ray Abdomen
(NEC) The so-called “double bubble”
(. Fig. 24.4), an air bubble in the stomach
NEC is an acute inflammatory reaction with and in the duodenum, is seen.
pervasive necrosis of the intestinal wall,
which often leads to perforation. Premature
infants are affected up to 90%. 24.2.3 Invagination
z Clinic This is an invagination of a part of the
Often insidious symptoms, deterioration of intestine into the following caudal part of
the general condition, apnea, bradycardia, the intestine. This results in constriction of
Pediatrics
355 24

Cu-Filter 24.3 Urogenital Tract

24.3.1 Vesicourethral Reflux

(VUR)
Incubate

If vesicoureteral reflux is suspected (e.g. in

cases of high fever urinary tract infection in
the first year of life, recurrent UTIs), a mic-
turition cystourethrogram should be per-
formed. For this purpose, the urinary
bladder is filled with water-soluble contrast
medium and, during micturition or even
before, the contrast medium flows back from
the bladder into the refluxing ureter, which
under certain circumstances can extend into
the renal pelvis.

z Diagnostics
Micturition Cystourethrogram (. Fig. 24.5)
There is a classification into five degrees:
55 Grade I: VUR only in the ureter

..      Fig. 24.4 Distended stomach and distended duo-

denum, in the rest of the picture an airless abdomen.
Incidental findings: non-central NPC, gastric tube,
endotracheal tube and CVC via the right arm correct

the mesenteric vessels with oedema, stasis

hemorrhage, intestinal necrosis due to isch-
aemia.

z Clinic
Acute colicky pain and vomiting, rectal
bleeding

z Diagnostics
Sonography
Cocard form (shooting target phenome-
non, target sign) of the intestinal part with
invaginate
X-ray Abdomen
Visible during colonic contrast enema
due to discontinuation of the contrast ..      Fig. 24.5 Micturition cystourethrogram with
agent. reflux
 356 E. Münstermann and C. Vockelmann

55 Grade II: VUR into the ureter and 24.4.3 Hip Dysplasia
pyelon
55 Grade III: VUR into the ureter and All newborns receive a hip sonography at
pyelon with pyelon dilatation U3 in order to enable an early therapy in
55 Grade IV: VUR into the ureter and case of hip dysplasia.
pyelon with pyelon dilatation and pres-
sure atrophy of the parenchyma z Diagnostics
55 Grade V: Massive VUR with extensive Sonography
24 destruction of the parenchyma. The classification is made according to
Graf. For this purpose, the acetabular roof
angle (= alpha angle between the extension
24.4 Musculoskeletal of the os ilium and the tangent to the bony
acetabular roof) and the cartilaginous roof
24.4.1  hild Abuse (Battered
C angle are measured (= beta angle between
Child) the extension of the os ilium and the tangent
to the cartilaginous labrum acetabulare).
In cases of suspected child abuse, imaging
(sonography, X-ray, CT, and MRI) reveals
fresh fractures as well as older fractures. 24.5 Oncology
Diffuse CNS hemorrhages and subdural
hemorrhages of various ages can be detected 24.5.1 Neuroblastoma
in shaking trauma.
Neuroblastoma is a malignant solid tumor
that arises from degenerated immature cells
24.4.2 Osteomyelitis of the sympathetic nervous system. Most
commonly, neuroblastoma arises in the
Osteomyelitis can be caused, for example, by adrenal medulla and in the limiting cord
a hematogenous septic spread of bacterial along the spine, and approximately 70% is
foci, but also post-traumatically or iatrogen- located in the abdomen at diagnosis.
ically. Metastases can be found in the liver, bone
and bone marrow, and lymph nodes. Rarely,
z Clinic metastasis to the brain occurs.
In addition to high fever, there is local pain Newborns, infants and children under
with soft tissue swelling. six years of age are most commonly affected.

z Diagnostics z Clinic
Conventional X-ray Symptoms are varied and may include pal-
The X-ray is usually unremarkable in pable abdominal tumor, bone pain, skin
the acute stage. A lightening of the cancel- lesions.
lous bone may be seen. Later, destruction,
including of the cortical bone, and a perios- z Diagnostics
teal reaction and sequestration become In addition to a clinical and laboratory
visible. examination (catecholamine metabolites
MRI makes early diagnosis possible. and NSE), sonography of the abdomen and
Pediatrics
357 24
neck and an MRI of the affected region, as >>In 5% of cases a vena cava tumor throm-
well as a MIBG scintigraphy are necessary bus occurs.
for diagnosis. A bone marrow aspiration
and a tumor biopsy (N-myc amplification)
are also part of the diagnosis. 24.5.3 Medulloblastoma
Neuroblastoma is divided into six differ-
ent stages (INSS, stage I-IV-S), therapy is Medulloblastoma is the most common
carried out according to the therapy optimi- malignant brain tumor in childhood and
zation protocol. adolescence.

z Conventional X-ray z Pathogenesis

Neuroblastomas often present inhomoge- The preferential location of the tumor in the
neously and with central calcifications and cerebellar vermis in combination with the
necrosis. growth often leads to occlusion of the 4th
ventricle, which results in intracranial pres-
sure increase and consecutive hydrocepha-
24.5.2 Nephroblastoma (Wilms’ lus.
Tumor)
z Clinic
Nephroblastoma is a malignant solid tumor Symptoms may include morning vomiting,
that arises from degenerated primitive tissue nausea, headache and lethargy. In addition,
cells. Infants up to five years of age are most cerebellar signs such as ataxia, disturbed
commonly affected and are usually asymp- gait, nystagmus or dysdiadochokinesia may
tomatic at diagnosis. Nephroblastoma usu- also occur.
ally occurs unilaterally. Metastasis occurs
early to the lungs, otherwise metastases to z Diagnostics
the liver, brain and bone are possible. MRI
For imaging, an MRI of the entire cra-
z Diagnostics niospinal axis must be performed. In the
For diagnosis, in addition to the clinical T2 image, the solid part of the tumor is
examination, a sonography of the abdomen predominantly hyper- to isointense to the
and an MRI of the tumor region is neces- cerebellar cortex and shows a heteroge-
sary. In addition, a chest X-ray is performed neous appearance. The T1-weighted image
in two planes and, if pulmonary metastases shows a predominantly hypo- to isointense,
are suspected, a CT of the lungs. heterogeneous tumor. The contrast image
The staging is done according to the is non-­ specific and inhomogeneous.
SIOP classification. Therapy is carried out Metastases are best detected in the
according to the SIOP therapy optimization T1-weighted image after contrast medium
study. administration.
 358 E. Münstermann and C. Vockelmann

Case Study
Practice Questions
Little Lisa has just turned two years old. 1. What are the different types of cathe-
Now she has a stomach ache and fever. ters in children in the thoracic region
The pediatrician Dr. Rührig examines and how do they differ?
Lisa. The abdomen is soft and without 2. In connection with which clinical pic-
guarding. However, in the ultrasound ture do we speak of the “white lung”?
examination, the left renal pelvis appears 3. You detect a cocard form (shooting
24 somewhat distended. Since Lisa appears target phenomenon, target sign) of the
seriously ill, Dr. Rührig decides to obtain intestinal part in the sonography—
some urine through a one-time catheter- what is your suspected diagnosis?
ization. This shows a massive leukocyto- 4. What imaging is recommended for
sis as well as a slight erythrocyturia. A medulloblastoma and what are typi-
micturition cystourethrogram is per- cal signs?
formed because of the suspicion of
reflux with accompanying inflammation, Solutions 7 Chap. 27
which is confirmed.
 359 III

Testing
Contents

Chapter 25 MC Questions and Answers – 361

Mirja Wenker, Christel Vockelmann
and Martina Kahl-Scholz

Chapter 26 Clinical Cases – 369

Mirja Wenker, Christel Vockelmann
and Martina Kahl-Scholz

Chapter 27 Solutions – 375

Mirja Wenker, Martina Kahl-Scholz
and Christel Vockelmann
 361 25

MC Questions and Answers

Mirja Wenker, Christel Vockelmann, and Martina Kahl-Scholz

Contents

25.1 MC Questions – 362

25.2 MC Responses – 365

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 362 M. Wenker et al.

In this chapter, 20 multiple-choice questions 4. Which answer is incorrect? The Leriche

on the contents of the book are asked for syndrome
practice. When answering the questions, it is A. Refers to an occlusion of the infra-
explained exactly why the answers are cor- renal aorta involving the aortic
rect or not correct. bifurcation.
B. Can occur acutely due to an
embolic event.
25.1 MC Questions C. Can occur in chronic form. Then
the collaterals can be suitably
1. Which statement about fractures is depicted with Doppler sonogra-
25 false?
A. A CT should be performed to
phy.
D. Can only be visualized angio-
assess the stability of a vertebral graphically from the arm.
body fracture. 5. Which answer is correct? The MR car-
B. X-rays to exclude fractures should diography
always be taken in two planes, even A. Is the method of choice for imag-
if the fracture is already visible in ing cardiomyopathies.
the first plane. B. Shows delayed CM accumulation
C. Basic diagnosis of the skull frac- in the affected area during myocar-
ture is the X-ray image. dial infarction.
D. On MRI, fresh fractures show up C. Can only represent morphology.
as bone edema, among other signs. D. Always shows abnormal findings.
2. Which statement regarding bone 6. Which statement about contrast media
tumors is correct? is false?
A. Bone tumors can always be clearly A. Negative contrast agents include
assigned radiologically. carbon dioxide (CO2), nitrogen
B. The “sunburst” phenomenon dioxide (NO2), inert gas, air, water,
describes a reaction of the soft tis- methyl cellulose, paraffin suspen-
sues adjacent to a bone tumor. sions, and sorbitol (or mannitol).
C. Primary malignant bone tumors B. Double contrast refers to perform-
are common overall. ing fluoroscopy with a positive CM
D. Rapid growth of a tumor indicates and a negative CM.
high aggressiveness. C. The edema signal in STIR or
3. Which answer is correct? In aortic dis- TIRM sequences is masked by CM
section administration, so these sequences
A. The true lumen is usually greater must be performed before contrast
than the false. administration.
B. MR angiography should be given D. Sonography is performed with
priority over CT angiography contrast media containing oil.
because of the lack of radiation 7. Which statement is correct? The Löffler
exposure. infiltrate
C. Stanford B dissection can involve A. Shows up in extensive pneumonia.
the aortic valve. B. Can be detected apically in pulmo-
D. May lead to organ ischemia due to nary edema.
involvement of the aortic vascular C. Is typical in ascaridosis.
outlets. D. Can occur as a result of radiation.
MC Questions and Answers
363 25
8. Which statement about fractures of the washed out more quickly, it is used
head and neck is false? for routine diagnosis of the thyroid
A. Fractures of the skull base are gland for scintigraphy.
divided into frontobasal (frontal 11. Rank the different examinations in
sinus posterior wall, ethmoid roof, ascending order of radiation exposure.
sphenoid sinus) and petrous frac- A. MR abdomen – CT skull – X-ray
tures. forefoot – X-ray thorax – CT abdo-
B. Decreased sensation in the supply men
area of the infraorbital nerve, B. X-ray forefoot – X-ray thorax –
motility disorders of the bulb and CT skull – MR abdomen – CT
difficulties in opening the mouth abdomen
may accompany a zygomatic frac- C. MR abdomen – X-ray forefoot –
ture clinically. CT skull – X-ray thorax – CT
C. Imaging of the NNH allows assess- abdomen
ment of the nasal skeleton, orbital D. MR abdomen – X-ray forefoot –
walls, and shadowing/mirroring X-ray thorax – CT skull – CT
(hematosinus) in midface fractures. abdomen
A lateral image allows co-assess- E. X-ray forefoot – X-ray thorax –
ment of the maxilla, ethmoid cells MR abdomen – CT abdomen – CT
and sphenoid sinus. skull
D. In the case of zygomatic fracture, 12. Which statements about imaging in
blow-out fracture may occur. acute stroke are correct?
9. The sentinel lymph node scintigraphy A. The native CT of the skull reliably
A. Is mainly used for prostate carci- allows the exclusion of a hemor-
noma. rhage.
B. Is performed with99m Tc labeled B. Native CT of the skull also shows
colloids. ischemic stroke in the early phase.
C. Is used to detect inflamed lymph C. MRI diffusion imaging is positive
nodes. no earlier than six hours after
D. Can only be performed preopera- stroke onset.
tively. D. CT angiography can detect intra-
10. Which statement about thyroid cancer or extracranial vessel occlusion.
is false? 13. In the case of a subarachnoid hemor-
A. Carcinoma variants include differ- rhage (SAB)
entiated carcinoma, undifferenti- A. …you can’t use contrast material
ated carcinoma, C-cell carcinoma. because of the vasospasm.
B. In sonography especially an irregu- B. A CT angiography must be per-
lar, possibly destructive tumor formed immediately, especially if
structure should suggest a carci- the blood is distributed in the basal
noma. cisterns, in order to detect an aneu-
C. Percutaneous radiotherapy is a fre- rysm as the cause of the SAB at an
quently used treatment option. early stage.
D. Since pertechnetate is available as a C. A delay in vascular imaging must
generator product at any time and, be avoided at all costs, as vascular
as a pure gamma emitter with its spasms develop rapidly due to SAB
short half-life of six hours, results and adequate vascular contrasting
in a low radiation exposure when is no longer possible as a result.
 364 M. Wenker et al.

D. In most cases of aneurysm rupture, D. A renal scintigraphy, since a func-

rapid interventional therapy by means tional impairment of the kidney is
of aneurysm coiling is necessary. to be assumed.
E. The ruptured aneurysm is treated 18. 
For the clarification of hyperprolac-
electively in the interval. tinemia
14. Which statements are correct? For pre- A. The target acquisition of the sella
mature infants turcica in the lateral beam path is
A. The insertion of a gastric tube is necessary.
obligatory before a chest X-ray to B. A routine MRI of the skull is per-
exclude esophageal atresia. formed.
25 B. Hard-beam technique is used to
image the thorax.
C. A contrast CT of the skull is suffi-
cient, since a macroadenoma can
C. An MRI is contraindicated be assumed.
because brain maturation has to be D. A fine-layered examination of the
completed first. pituitary gland with a contrast
D. A common condition is respira- medium is necessary.
tory distress syndrome due to lung 19. A Hodgkin’s disease
immaturity, which can be detected A. Is another term for tuberculosis,
by reduced radiolucency of the named after the discoverer of
lungs on X-ray.
Mycobacterium tuberculosis.
15. Radiotherapy is considered in the treat-
B. Is a malignant lymphoma that
ment of the following tumors:
responds very well to combined
A. Rectal Cancer
radio-­chemotherapy.
B. Carcinoid of the small intestine
C. Can’t be detected on PET-­CT.
C. Esophageal Cancer
D. Can be confirmed without histo-
D. Breast Cancer
logical confirmation with typical
16. Liver metastases
A. Can’t be differentiated sonographi- imaging.
cally. 20. The following statements are correct:
B. Can always be reliably distin- A. The effective dose is expressed in
guished from cysts on CT. sieverts (Sv) and is a measure of
C. Can be treated with transarterial the biological effect of the radia-
chemoembolization due to the tion, since the parts of the body
leading arterial supply. exposed to the radiation are
D. Can be very well delineated in pri- included in the calculation.
movist MRI of the liver. B. The effective dose can be used to
E. Are not detectable in PET-­CT due compare different radiation expo-
to the diffuse tracer uptake of the sures such as a skeletal scintigra-
liver tissue. phy and a skeletal CT.
17. If you suspect urolithiasis, you should C. When procedural instructions for
A. Do an intravenous pyelography. CT examinations have been estab-
B. …and get a CT urography. lished, it is not necessary to record
C. To avoid unnecessary loss of time, the radiation exposure of the
directly perform a low-dose CT examination for each patient.
without prior sonography or labo- D. The incident dose is always equal
ratory diagnosis of the urine status. to the surface dose.
MC Questions and Answers
365 25
25.2 MC Responses excitation of the microbubbles in the
sound field, whereby the microbubbles
1. C is incorrect, X-rays to detect a skull start to oscillate (oscillation).
fracture are obsolete nowadays, CT 7.  Answer C is correct. In ascaridosis
scans are taken instead. Re A: (roundworm infestation with Ascaris
Assessment of the posterior edge on CT lumbricoides), X-rays show confluent
for stability assessment. Re B: Fractures spot shadows that “migrate” across the
can be dislocated in one plane or devi- lungs. This migration is also known as
ated from the axis. Löffler’s infiltrate (which can also occur
2. D is correct. A: Often several differen- with some medications such as penicil-
tial diagnoses are possible, ultimately lin). It is present when the infiltrate is no
clarifying is the histology. B: The sun- longer detectable after a maximum of
burst phenomenon describes a reaction 10 days, eosinophilia is present and rel-
of the periosteum. C: Primary malig- atively minor (pulmonary) symptoms
nant bone tumors account for only 1% are present.
(adults) to 5% (children) of all tumor 8. Answer D is incorrect. In the case of an
diseases. orbital fracture (not a zygomatic frac-
3. Answer D is correct, a supply of aortic ture), if the force is applied directly to
vascular outlets from the false lumen the eye, a so-called blow-out fracture
may result in absent or inferior perfu- can occur, in which the orbital floor
sion of organs. A: The true lumen is fractures and orbital contents can enter
usually smaller than the false one. B: the maxillary sinus.
Because of the urgency of rapid diag- 9. Answer B is correct. To visualize the
nosis, CTA should be given priority. C: SLN, 99mTc labeled colloids with a
Aortic valve involvement may occur particle size of approximately
with Stanford A dissections. 20–100 nm are injected. These are rec-
4. Answer C is wrong. Sonographically, ognized by the lymphatic system as for-
the collaterals can usually be depicted eign bodies and are removed. The
only inadequately, CT and MRI are applied amount of activity must be so
better suited. high that the lymph node can be found
5. Answer B is correct. A: intraoperatively with an appropriate
Echocardiography is the method of measuring probe.
choice because it is inexpensive and 10. Answer C is incorrect. In thyroid carci-
available everywhere. However, cardio- noma, percutaneous radiotherapy is
MRI is increasingly being used for clar- used only in a small group of high-­risk
ification. C: The advantage of patients, when surgery and radioiodine
cardio-MRI is that it can image not therapy have failed to achieve complete
only morphology but also cardiac func- tumor cell destruction, in recurrence or
tion. D: Just like echocardiography, in the palliative situation of skeletal
cardio-MRI may be unremarkable in metastases with risk of fracture, brain
myocarditis. metastases as well as upper influence
6. Answer D is incorrect. Contrast media congestion.
containing oil are used in myelography, 11. Answer D is correct. MRI is a proce-
for example, and gas-filled microbub- dure without radiation exposure. X-ray
bles are used in sonography. The imag- images require very little radiation in
ing of the contrast agent microbubbles the peripheral skeleton, and compara-
in diagnostic sonography is based on tively little radiation is also required in
 366 M. Wenker et al.

body size or weight are used; the hard

.       Table 25.1 Radiation exposures
beam technique would lead to an abso-
Approximate radiation lutely overexposed image in premature
exposure babies.
15. Answer B is incorrect. The small intes-
X-ray extremities 0.01 mSv tine is very sensitive to radiation and, in
X-ray thorax 0.1 mSv addition, due to its high motility, is not
always in exactly the same place in the
X-ray abdomen 0.7 mSv
body, so that exact therapy planning is
X-ray lumbar spine 1.1 mSv not possible. In the case of rectal and
two levels
25 CT skull 2–3 mSv
oesophageal carcinoma, radiotherapy is
used neoadjuvantly before surgical
CT thorax 1–7 mSv therapy, usually in combination with
chemotherapy. In breast carcinoma,
CT abdomen 8–16 mSv
radiotherapy is given after breast-con-
serving therapy in order to reduce the
risk of local recurrence.
the thorax because of the high radia- 16. B, C and D are correct. Primovist is a
tion transparency of the lungs liver-specific contrast agent that is not
(. Table 25.1). CT examinations absorbed by tumor-altered liver cells, in
require considerably more radiation, contrast to healthy liver tissue.
although the skull is associated with Sonographically, metastases can usu-
lower radiation exposure due to its ally be delineated in an echo-rich round
smaller volume and less radiation-sensi- shape. Necrotically decaying metastases
tive organs. or very small metastases cannot be reli-
12. Answer A and B are correct. Diffusion ably distinguished from cysts on CT;
imaging on MRI detects cytotoxic contrast sonography or MRI with pri-
edema and thus the infarct area after movist can then be used for further
only a few minutes. Native CT can only examination. If the metastases show
detect the infarct after a few hours. sufficient storage of FDG depending
13. Answer A and E are incorrect. In the on the primary tumor, liver metastases
case of a ruptured aneurysm, there is can be detected very well on PET-CT.
always a risk of recurrent hemorrhage, 17. Answer C is correct. You should per-
so that rapid diagnosis and therapy form a low-dose CT of the urinary tract
must be performed. Intracranial hem- after prior sonography and laboratory
orrhage is not a contraindication for diagnosis of urine status. Sonography is
contrast administration. mandatory as primary imaging to con-
14. Answer A and D are correct. An MRI is firm the suspected diagnosis of uroli-
contraindicated only in the first trimes- thiasis and to make differential
ter of pregnancy, as there is no evidence diagnoses such as diverticulitis or
yet to what extent the strong magnetic appendicitis less likely.
field can harm the fetus. From the sec- 18. Answer D is correct. Hyperprolactinemia
ond trimester onwards, and thus also in raises the possibility of a pituitary ade-
premature babies, an MRI can be per- noma, which is often a few mm in size.
formed. X-rays of the thorax are per- Therefore, a fine-slice targeted MRI
formed in adults using the hard-beam scan of the pituitary gland with a con-
technique to radiate through the ribs. In trast agent dynamic range is required.
children, tube voltages adapted to the In the early contrast phases, the pitu-
MC Questions and Answers
367 25
itary gland already accumulates the each examination with a radiation
contrast agent, and the adenoma stores exposure, the individual value applied
the contrast agent with a slight delay. A to patient xy must be stated. The effec-
conventional image of the sella turcica tive dose does not have to be calculated,
is obsolete. but e.g. for X-ray examinations the dose
19. Only answer B is correct. PET-CT is area product and for computer tomog-
highly sensitive in the staging of lym- raphy the dose length product of the
phomas. Histological confirmation is respective examination are documented.
essential for precise differentiation. As a The incident dose is the dose which can
rule, an entire lymph node is removed be measured “free air” without scatter-
for this purpose if a lymph node that is ing bodies. The surface dose is the dose
easily accessible by surgery is affected. that occurs on the patient’s skin. Here,
Tuberculosis is also called Koch’s dis- in addition to the incident dose, there is
ease, named after Robert Koch. also the dose component that is scat-
20. Statements A and B are correct. tered back to the surface in the patient.
Statements C and D are incorrect. For
 369 26

Clinical Cases
Mirja Wenker, Christel Vockelmann and Martina Kahl-Scholz

Contents

26.1 Pulmonary Embolism or … – 370

26.2 Swollen Hands – 370

26.3 Pain in the Lower Leg – 370

26.4 Chest Pain and Circulatory Problems – 371

26.5 A Swollen Leg – 371

26.6 Hematuria – 371

26.7 Frequent Urination – 372

26.8 Riding Accident – 372

26.9 Laceration to the Forehead – 373

26.10 Persistent Headache – 374

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 370 M. Wenker et al.

The following chapter presents typical cases the hands for several days. He finds it diffi-
that can occur in practice. Accompanying cult to work on the computer at a large
questions are asked, which serve to apply insurance company, especially in the morn-
what has been learned. ing, because his fingers are very stiff. In the
course of the day the work becomes easier
again.
26.1 Pulmonary Embolism or …
??1. What is your tentative diagnosis?
Mrs. Walter presents to the emergency 2. Which findings in the X-ray are typi-
department with pain at mid-thoracic level. cal?
With concomitant dyspnoea, a CT is ini-
tially performed to rule out pulmonary v 1. They suspect rheumatoid arthritis.
embolism. This is not confirmed, but the 2. Typical symptoms are: symmetrical
26 sagittal reconstruction shows a marked bilateral involvement, especially of
decrease in the height of the 6th spinal cord. the finger and toe joints, soft tissue
The base plate of the 6th spinal cord and the swelling, osteoporosis near the joint,
cover plate of the 7th spinal cord are clearly transient joint space widening due
out of focus and appear to be “pitted”, and to joint effusion and proliferation of
the intervertebral space is narrowed. In the the synovium, later joint space nar-
meantime, the laboratory results are also rowing, erosions, subchondral cysts,
available, which show an increase in the ulnar deviation of the fingers, button-
inflammation parameters. hole and swan-­neck deformity of the
fingers. The final state is destruction
??1. What is your tentative diagnosis? of the joint with ankylosis.
2. How can the diagnosis be further
clarified?
26.3 Pain in the Lower Leg
v 1. Your suspicion is spondylodiscitis.
2. Complementary MRI scans should Mr. Müller, 65 years old, presents to the
be performed as a means of choice emergency department with acute onset of
for visualizing spondylodiscitis; here, pain of the right lower leg. Trauma is not
evidence of edema in the vertebral remembered. The patient reports that he has
bodies and the intervertebral disc as already had a stent inserted in the left com-
well as of contrast enhancement can mon iliac artery and the right internal iliac
be obtained. MRI is also the most artery due to an arterial vein disease.
reliable way to demonstrate epidural Furthermore, the patient is known to have
abscessation, which may require neu- hypertension. On physical examination, the
rosurgical intervention. right lower leg is cold and white discolored.
The inguinal pulse is palpable, the popliteal
pulse is not.
26.2 Swollen Hands
??1. What’s your tentative diagnosis?
Mr. Menert presents to his family doctor. 2. What imaging techniques can confirm
The 47-year-old complains of flu-like symp- this diagnosis?
toms that have been present for several 3. Which radiological therapy methods
weeks. In addition, he has had swelling of are possible?
Clinical Cases
371 26
v 1. Your suspicion is acute arterial occlu- and slightly reddened compared to the side.
sion. When pressing on the calf and on the sole of
2. Other imaging modalities would the foot, the patient clearly states pain. The
be: Sonography: lack of flow, CTA/ patient has a history of renal insufficiency
MRA/DSA: lack of contrast distal to and epilepsy.
the occlusion, if possible CTA before
DSA for treatment planning. ??1. What is your tentative diagnosis?
3. DSA with an attempt at lysis or 2. What is the further procedure?
thrombectomy is an option. If pares- 3. What imaging techniques can confirm
thesias and paresis are already pres- the diagnosis?
ent, surgical thrombectomy must be
considered as an alternative, depend- v 1. They suspect deep vein thrombosis.
ing on the localization, since revas- 2. First, the clinical scores for the prob-
cularization must then be achieved ability of DVT are determined.
within a maximum of six hours. 3. Sonography: lack of compressibility
of the veins, lack of flow signal, CTA
and phlebography, among others, not
26.4  hest Pain and Circulatory
C indicated in renal ­insufficiency.
Problems

Mrs. Tewes is not feeling well at all. This 26.6 Hematuria

morning she suddenly got chest pains that
radiate to her back. She also feels dizzy and Mr. Steinemann is 37 years old and apart
has difficulty forming sentences. She has a from a discrete hypertension, for which,
known history of PAOD. however, according to his family doctor he
does not have to take any medication, he has
??1. What is your tentative diagnosis? no previous illnesses. This afternoon he had
2. What imaging techniques can confirm his wife drive him to the central outpatient
this diagnosis? clinic after he developed severe pains in the
left flank, some of which also extend into
v 1. They suspect aortic dissection involv- the lower abdomen. There is intermittent
ing the supra aortic vascular branches improvement in between, but overall this
with neurological symptoms. discomfort has been going on for about two
2. Immediate CT angiography must be hours. Nausea and vomiting are denied. In
performed to assess the extent of dis- the clinical examination—which is difficult
section and involvement of the outgo- because of the patient’s bent posture due to
ing arteries, exclusion of other pathol- pain—the surgical colleague on duty, Dr.
ogies. The situation is life-­threatening! Immerda, finds an overall soft abdomen
without defensive tension, but there is a
knocking pain in the left renal bed. Dr.
26.5 A Swollen Leg Immerda orders a laboratory examination
of blood and urine and performs an ultra-
Mr. Franke presents to the general practitio- sound of Mr. Steinemann’s abdomen. Here
ner’s office. He reports that his left leg has he notices a dilated renal pelvis. The urine
been noticeably swollen for several days. In status, which has been evaluated in the
addition, his calf hurts at times. On physical meantime, also shows hematuria. Mr.
examination, the left leg is clearly swollen Immerda picks up the phone and calls the
 372 M. Wenker et al.

radiologist on duty in order to initiate a clar- examination the internist on duty notes a
ification of the cause. pressure pain over the bladder. In addition,
the renal bearings are throbbing.
??1. Given the above history, what is the In the meantime, the first laboratory
most likely differential diagnosis? results are back: leukocytes and CRP are
2. What are the possible complications? elevated. In the urine erythrocytes, leuko-
3. What diagnostic methods are avail- cytes and nitrite have been detected.
able? The colleague wants to “play it safe” and
asks for an ultrasound of the abdomen.
v 1. The colicky symptoms and hematuria
are indicative of urolithiasis. ??1. Do you already have a suspected diag-
2. A frequent complication is urinary nosis?
retention. This often leads to accom- 2. Why does it make sense to do an ul-
26 panying inflammatory reactions of trasound? What are the complica-
the obstructed kidney. Injuries in the tions?
course of the ureter can later lead to
scarred strictures. In the case of large v 1. Acute pyelonephritis is suspected in
occluding stones (>5 mm) (and forced the context of an ascending urinary
diuresis), the congestion can lead to tract infection.
a rupture of the calyx. To assess the 2. If a urinary tract infection, which is
risk, imaging is necessary to provide usually uncomplicated in a young
information about stone size and lo- woman, leads to an inflammation of
calization. the renal pelvis, this may be due to a
3. The method of choice is a low-dose disturbed urine outflow with corre-
CT of the abdomen, as it provides a sponding urinary stasis. In addition,
significantly higher information gain perinephritic abscesses may occur in
with a low radiation exposure (ap- the course of renal pelvic inflamma-
proximately two X-ray images of the tion, which may require specific treat-
abdomen). ment and can be detected sonographi-
cally.

26.7 Frequent Urination

26.8 Riding Accident
Mrs. Honeymoon is currently on her honey-
moon in Europe with her newlywed spouse. Clarissa fell off her horse and has been com-
Unfortunately, Mr. and Mrs. Honeymoon plaining of weakness and stomach pains
have to interrupt their trip for a stay in the ever since. As a precaution, her parents take
central emergency room. The newlyweds are her to the outpatient clinic of the nearest
visibly unwell: she has a fever of 39.8 °C, hospital. There Dr. Immerda takes over the
back pain and she is vomiting several times. patient. The blood pressure is 110/90 mmHg,
Until yesterday everything had been won- the heart rate 96/min. The doctor does an
derful, they had breakfast in a small café in ultrasound right in the outpatient clinic. He
Strasbourg and then drove on towards sees free fluid in the abdomen and the right
Germany. Yesterday evening she already felt kidney looks “funny”. He is not sure about
unwell. When asked, the husband remem- the other organs. Clarissa continues to feel
bers that they had to stop frequently to uri- bad, her blood pressure is slowly dropping
nate during the journey. During the clinical and her rate continues to rise. Dr. Immerda
Clinical Cases
373 26
calls and asks for a CT—today he sounds tract, it may make sense to prepare a
very nervous on the phone. He has already urographic contrast medium phase.
alerted his senior physician on background 4. In young women of childbearing age,
duty. pregnancy should normally always
be ruled out. Allergies and renal dys-
??1. According to this history, what inju- function should also be clarified be-
ries are to be expected? fore a contrast agent is administered.
2. In your opinion, is a CT indicated? In this particular case, the falling
3. Do you need contrast media? If so, blood pressure and rising heart rate
which contrast agent phases make indicate a life-­
threatening situation
sense? that does not permit any delay. Only
4. What questions need to be answered an anaphylactic reaction to contrast
before the examination? administration should stop you now.

v 1. A fall from a horse can, of course,

result in a variety of internal and 26.9 Laceration to the Forehead
external injuries. Since the young pa-
tient landed on the grassy ground, she Mrs. Liesegang, a 69-year-old spry pensioner,
may have been spared fractures. The has had to take blood-thinning medication
complaints and examination findings for several years. Dr. Peters, her family doc-
suggest an injury to an internal organ tor, has therefore prescribed her Marcumar.
of the right flank. The kidney and, of Mrs. Liesegang takes the weekly blood
course, the liver are possible candi- checks and the tablet intake seriously, the val-
dates. ues are therefore mostly in the target range
2. Yes, even if the patient is young and with an INR of 2–2.5. This morning Mrs.
one would like to avoid radiation ex- Liesegang tripped over the carpet on her way
posure, the examination findings seem to the kitchen and sustained a laceration to
to indicate an injury to abdominal her forehead. In addition, she has had a slight
organs that requires immediate treat- headache since then and therefore goes to the
ment. On the one hand, the extent of hospital. There, the head laceration is treated
the presumed kidney injury and fur- by the accident surgery resident Dr. Bruch.
ther treatment can be assessed, and She also sends Ms. Liesegang for a CT scan
on the other hand, dangerous con- to check for bleeding.
comitant injuries, e.g. of the liver, the
large abdominal vessels or the spinal ??1. What is the expected bleeding after a
column, can also be recorded. fall in elderly patients?
3. You need contrast medium: on the 2. How do you distinguish an epidural
one hand, to assess the feeding ves- from a subdural hemorrhage?
sels, which may also be injured. After 3. What does the term “ICB loco typi-
administration of contrast medium, co” mean as opposed to atypical in-
the renal and hepatic parenchyma can tracerebral hemorrhage?
be better assessed and any subcapsu- 4. Name causes of intracerebral hemor-
lar hematoma can be clearly differen- rhage.
tiated. In addition, it may be possible
to detect the source of a hemorrhage v 1. V. a. Subdural hematoma.
by contrast leakage into the tissue. In 2. The distinction is possible on the ba-
order to detect injuries of the urinary sis of shape and cranial outline.
 374 M. Wenker et al.

3. The term describes hypertensive Dr. Leucht finds a 5 cm lesion right

bleeding in contrast to atypical bleed- parietal in the cerebrum, which shows
ing in which, for example, a tumor or T2-weighted hyperintensity with finger-
vascular malformation is the cause. shaped extension into the gyri. After con-
4. Causes are: trast administration a garland-shaped
(a) Arteriovenous malformations enhancement is seen.
(b) Cavernomas
(c) Intracerebral tumors or metasta- ??1. What are Dr. Hinnerk’s findings at the
ses back of the eye?
(d) Sinus vein thrombosis (bleeding 2. How is the twitching of the left arm to
in the vicinity of the thrombosed be evaluated?
sinus). 3. What type of contrast agent is used in
MRI?
26 4. What’s Dr. Leucht’s diagnosis?
26.10 Persistent Headache 5. What are the treatment options for
Mr. Meyer?
Mr. Meyer, 58 years old, has had constant
headaches for a few weeks. Until now he has v 1. The reflection of the ocular fundus
always been healthy and maintains a very shows papilledema.
healthy lifestyle with lots of sport. He is very 2. Twitching of the left arm is the mani-
busy at work at the moment, so he initially festation of an epileptic seizure, often
blames the pain on stress. Now, however, he the first symptom of brain tumors.
has noticed a twitching in his left arm that 3. MRI uses contrast medium contain-
has stopped but still worries him. He goes to ing gadolinium, which leads to a
his family doctor, Dr. Hinnerk. He examines shortening of the T1 relaxation time.
him thoroughly, also looking at the back of 4. The most likely diagnosis is glioblas-
his eyes. He then refers Mr. Meyer for an toma, which is a highly malignant as-
MRI because of the headache. As Dr. trocytoma.
Hinnerk is worried about the symptoms, he 5. Treatment options include surgery
calls the radiologist Dr. Leucht to get the with supplemental local chemothera-
appointment for the examination that week. py, if necessary, and radiation therapy.
 375 27

Solutions
Mirja Wenker, Martina Kahl-Scholz, and Christel Vockelmann

© Springer-Verlag GmbH Germany, part of Springer Nature 2023

M. Kahl-Scholz, C. Vockelmann (eds.), Basic Knowledge Radiology,
[Link]
 376 M. Wenker et al.

In this chapter you will find the solutions to an electron-­positron pair, consisting of a
the practice questions asked in each chapter. negatively charged electron and a posi-
tively charged positron. The atomic
z Chapter 1 nucleus remains unchanged. Here, in
1. Photoelectric effect: If photon radiation contrast to the pair annihilation, a pair is
hits matter, the entire energy can be formed which, however, emits two anni-
transferred to an electron of the atomic hilation quanta of 511 keV each with
shell (photoabsorption). The shell elec- one electron of the absorber. The energy
tron is either raised to a shell of higher release via the pair formation effect plays
energy (excitation) or knocked out of the an essential role in radiation therapy
atomic shell (ionization). The latter when ultra-hard photons are used.
occurs when the energy of the photon 2. Incident dose: This describes the dose in
exceeds the binding energy of the elec- Gy that is measured “free air” without
tron to the nucleus. The remaining energy stray bodies. By scattering bodies are
is transferred to the electron (photoelec- meant phantoms or also patients, which
27 tron) as kinetic energy. The photoelectric would lead to a scattering of the radia-
effect is the basis of imaging in diagnos- tion. The incident dose depends on the
tic radiology, which works mainly in the focal distance, energy (in X-rays kV and
energy range up to 100 keV. The radia- filter) and the dose rate. The field size has
tion emitted by the X-ray tube is attenu- only little influence. Surface dose: In
ated differently by tissues of different addition to the incident dose, the back-
density, such as bone, soft tissue, fat or scatter from the irradiated object, e.g. the
connective tissue, so that the resulting patient, is added to the surface dose. On
radiation image has different gray scales the entrance side, the backscatter can be
depending on the attenuation. Compton up to 50%. The backscattering is strongly
scattering: In the so-called Compton dependent on the field size. In radiother-
effect, the photon emits only part of its apy, the surface dose on the exit side is
energy to the shell electron of an outer also important, since this must be taken
shell and is scattered with its residual into account in the case of opposing
energy in a different direction. Secondary fields. More about this later. Depth dose:
electrons of lower energy are emitted in The depth dose describes the dose at a
lateral direction, those of higher energy certain body depth, measured from the
in forward direction. Scattered photons irradiation surface. The relative depth
lead to image degradation in radiologi- dose indicates the ratio of a depth dose
cal, diagnostic and nuclear medical to the dose maximum in percent. The
imaging techniques. Technical aids, such depth dose is particularly important in
as a scattering grid consisting of lead radiation therapy, since here a specific
lamellae in radiological diagnostics or dose at a specific location in the body,
the exclusion of low-energy scattered e.g. a lung tumor, is targeted for thera-
photons by placing an appropriate peutic success. At the same time, sur-
energy window in nuclear medicine, can rounding healthy tissue should of course
minimize the impact of scattering effects. not be damaged.
Pair formation: At high photon energies 3. X-ray deceleration radiation is produced
above 1022 keV, the so-­called pair forma- by the deceleration of electrons at the
tion effect occurs. Here the interaction nucleus into which they cannot pene-
does not take place in the shell but in the trate. Some electrons release radiation as
strong electric field of the atomic nucleus. soon as they hit the anode. Others pene-
Near the nucleus, the photon can form trate deeper into the electron material,
Solutions
377 27
give off part of their energy and produce Accordingly, there is a threshold dose.
X-rays only afterwards. As a result, the This is defined for each tissue. From the
electrons produce X-rays with different point of view of radiation protection,
wavelengths. How much X-ray radiation deterministic damage must not occur.
is released depends on how strongly the From the point of view of therapy, how-
electron is decelerated. The immediately ever, it is precisely this damage that is
produced X-ray deceleration radiation “desired”, since research results can
has a smaller wavelength than the radia- prove when the threshold dose of a
tion produced by the initially decelerated tumor is also reached. In radiation ther-
electrons. Characteristic X-ray radiation apy, deterministic damage to malignant
is produced in addition to the X-ray tumors is specifically set.
deceleration radiation and is a so-called
line spectrum, which depends exclusively z Chapter 2
on the anode material. It is therefore 1. An X-ray system always consists of the
characteristic for this material. following components: an X-ray source
4. Since the Linear Energy Transfer (LE) that generates the radiation, an X-ray
serves rather the physical consideration generator that supplies the X-ray source
of the radiation effect, there is also the with high voltage, an X-ray application
term Relative Biological Effectiveness device that is used to position the patient,
(RBE). It is used, among other things, to and an X-ray image converter (X-ray
subdivide the health hazard posed by the film, detector, …).
various types of radiation. In this con- 2. While overexposure, i.e. too much radia-
text, the effects that can be observed with tion, does not harm the quality of the
different types of radiation when the image, an underexposed shot results in an
same dose is administered in grays are image that shows much less detail. This
put in relation to each other. phenomenon is also called image noise.
5. Stochastic radiation effect: With regard 3. V = B/G = b/g. In X-ray imaging, the dis-
to the effect of ionizing radiation, each tance g is called the focus-­object distance
individual X-ray quantum can cause an and the distance b is called the focus-film
undesirable, damaging event in the distance (FFA). The distance B–G is
organism. The probability of this event called object-film distance (OFA). The
depends on how many radiation quanta variable V indicates the magnification of
strike the organism. Thus, the highest the image.
commandment of radiation protection is 4. Shielding: When an X-ray is taken, the
derived from the stochastic radiation patient must of course be exposed to the
effect: “As Low As Reasonably X-rays. However, if possible, all parts of
Achievable” (ALARA principle)—one the body that are not being examined
may only administer as little radiation as should be shielded from the radiation.
absolutely necessary, since there is no Most aids for this purpose are made of
threshold dose for a certain radiation lead or lead compounds (“lead rubber”).
damage. Deterministic Radiation Effect: Depending on the organ being examined,
This term means something like “delin- the patient can be protected in various
eation” or “determination”. In the con- ways. In particular, the organs that are
text of radiation exposure, it is therefore sensitive to radiation should be protected.
possible to determine the resulting dam- First of all, these are the gonads, i.e. the
age to a tissue. It is known, for example, ovaries in women and the testes in men.
after how much radiation the healthy However, the small intestine and the
skin reacts with a skin reaction (burn). hematopoietic tissue are also particularly
 378 M. Wenker et al.

sensitive to radiation. Ideally, the patient z Chapter 3

should always wear a lead apron or a lead 1. The Heel effect refers to the anode-side
coat when the extremities are imaged. dose drop.
Infants can also be completely wrapped in 2. Due to the compression of the breast, the
so-called radiation protection wraps. For tissue is distributed homogeneously both
images of the chest area, a half apron thoracic and mammillary and can thus
(gonadal protection apron) or a radiation be assessed more precisely.
protection skirt must always be worn to 3. In magnification mammography, the dis-
protect the lower half of the body from tance between the breast and the image
radiation. When taking images of the pel- receiver is increased. Due to the imaging
vis or hip, it is not possible to put on a laws, this achieves an enlargement of the
half apron, as this would cover the bone. structures, e.g. in order to better recog-
There are special lead covers for these nize the shape of microcalcifications,
shots, depending on gender. Blending in: even if the geometric blurring becomes
One of the most effective methods of somewhat greater. In addition, the grid
27 minimizing X-ray radiation is to blend in can be dispensed with for the magnifica-
the radiation field. Thus, by blending in, tion image, since the scattered radiation
you not only protect the patient, but you is already too far attenuated and no lon-
also get a better quality x-ray. Additional ger reaches the image receiver.
filters/compensating filters: Filters were
mentioned at the beginning of this chap- z Chapter 5
ter. These also contribute to the radiation 1. Answers:
protection of the patient. The filters in the (a) Setting fractures,
depth diaphragm harden the rays so that (b) Examinations of the gastrointestinal
the radiation that does not contribute to tract and other body cavities (e.g. the
the image formation does not reach the gall bladder) using contrast media,
patient in the first place. Radiation qual- (c) Examinations of vessels also with
ity: The dose to the patient can also be contrast media,
minimized by changing the radiation (d) Placement of probes or drains in the
quality. Whereas a few years ago, for body,
example, the fingers were x-rayed with a (e) Consideration of real-time processes
voltage of 44 kV, the Medical Association in the study of the swallowing act
now prescribes a voltage of at least and valvular activity.
50 kV. This makes it easier for the rays to 2. By the function “Last-­Image-­Hold (LIH)”
pass through the bones and the current the last image remains on the monitor,
intensity can be reduced. With the intro- can be stored digitally and thus replace an
duction of digital imaging techniques, the additional X-ray.
lower contrast that results from the higher 3. The image receiver and the X-ray tube
voltage can be increased again by suitable are connected by a semicircular rail,
image processing. which is anchored to the rest of the sys-
5. A digital image consists of many indi- tem by means of a holding module. This
vidual pixels. These are arranged in rows holding module can rotate and can also
and columns, this arrangement is then be moved so that the tube can move side-
called a pixel matrix or matrix for short. ways along the patient (= images in all
Depending on the system, an X-ray spatial directions are possible).
image consists of between 1024 × 1024 4. Digital subtraction angiography (DSA) is
and 4096 × 4096 pixels. One speaks of a an application used primarily for the visu-
1024 matrix or a 4096 matrix. alisation of vessels using contrast media.
Solutions
379 27
5. These are used in the seldinger technique. 3. E.g. intracranial aneurysm clips, pacemak-
With them (especially balloons and ers/ICDs, neurostimulators, insulin pumps,
stents), the wire is only guided through a bladder catheters with temperature probes
second lumen of the catheter for the first (there are also MR-­compatible materials
20–30 cm, after which it runs freely par- among the implants mentioned—their
allel to the catheter. In addition to the suitability must be checked in advance).
shorter wires, this also allows a faster But also shrapnel or claustrophobia (if
catheter change, but the guidance of the there is no alternative examination possi-
catheter is somewhat worse, since the bility, sedation of the patient may be nec-
wire reinforcement is only given at the essary).
catheter tip. 4. It depends on the region of examination.
Smaller arterial vessels (e.g. intracranial)
z Chapter 6 can be imaged with TOF angiography.
1. Motion artifact, pulsation artifact, metal Slow-flow vessels (e.g. sinus veins) can be
artifact, partial volume effect, hardening imaged with phase-contrast angiography.
artifact, measurement field overrun, 5. In addition to the immediate life-­saving
photon starvation artifact, ring artifact, measures such as emergency call and
line artifact. CPR, you must now also pay attention to
2. In sequential CT examinations, one slice the safety of patients and staff: The
is acquired per rotation, after which the patient must be out of the exam room as
table is advanced before the next exami- soon as possible, and if possible, a per-
nation section is acquired. In spiral CT, son should stand guard outside the door
the table is moved continuously, the raw for as long as possible. The resuscitation
data is acquired as a helix and an axial team or paramedics may not appreciate
image is calculated from this. the dangers of the device. If they instinc-
3. Adaptive Array Detector and Fixed Array tively run to the patient immediately,
Detector. In the “Adaptive Array Detector” emergency cases and oxygen cylinders
the detector chambers become wider and brought into the examination room
wider towards the periphery. This leads to become life-threatening projectiles.
the possibility of interconnecting individ-
ual elements and rows with the option of z Chapter 8
different layer thicknesses. With the “Fixed 1. The piezo effect is caused by the contrac-
Array Detector” there are fixed sizes of tion and elongation—i.e. compression
detector elements per detector row. By and expansion—of the crystal during
selecting certain detector rows, the layer ultrasound. An applied external electri-
thickness can be determined. cal voltage causes the emission of vibra-
tions, i.e. sound waves (=sound wave
z Chapter 7 emission). If the sound waves encounter
1. With a targeted look at a sure aqueous- an impedance jump (wave resistance) on
filled structure in the image (e.g., CSF or their way, e.g. at the border between fatty
bladder). If the fluid is brightly imaged, tissue and water, they are reflected and
the image is T2-weighted. If the fluid is received as an echo or resonance on the
dark, the image is T1-weighted. quartz crystal. The resulting sound pres-
2. A T2 weighting with fat saturation—here sure deforms the crystal and the electri-
fluid—i.e. also an oedema is mapped cal charge is shifted. This piezo effect
hyperintensely. The fat saturation helps to creates a measurable electrical voltage,
distinguish the edema from the fat, which which is recorded by the connected elec-
is also hyperintense in T2 weighting. tronics and displayed as an image.
 380 M. Wenker et al.

2. A-mode: The A-mode is the oldest method. (c) The accumulation of gadolinium in
“A” stands for amplitude modulation. a tissue depends on the general con-
Today, the method is still used for distance dition of the patient (fever), the
determination in ENT, ophthalmology waiting time after the injection and
and neurology. In the early days, before the the dose (“much helps much”). The
development of computer tomography, contrast medium may “behave dif-
this method was used, for example, to ferently” in a patient with fever than
detect a midline shift in a brain tumor. in patients without fever. This can
M-mode: With the M-mode (from English play a role in the findings.
“motion”) the temporal behavior of a tis- 2. Double contrast is the performance of
sue can be imaged. It is used in particular fluoroscopy with a positive CM (usually
in cardiology. A typical example is the barium) and a negative CM (e.g. cellu-
imaging of the movement of a heart valve lose, water, CO2).
or the myocardium. B-mode: The B-mode 3. Response:
(English “brightness”) is the most fre- (a) Absolute contraindications
27 quently used procedure. In the 2D image, 55 Severe kidney dysfunction not
the various image points are recorded with previously requiring dialysis
different brightness grey dots, depending 55 Manifest hyperthyroidism
on the strength of the reflected signal. 55 Sensitivity to iodine-­ containing
3. Blood flow toward the transducer is KM
coded red; blood flowing away from the 55 Certain thyroid carcinomas
transducer is coded blue. Faster blood (b) Relative contraindications
flow is shown lighter than slower flow. In 55 Heart failure
the image on the right, a corresponding 55 Severe hepatic dysfunction
coding is shown with an indication of the 55 Hematological diseases (Walden-
measured flow velocity. ström’s disease)
4. A special form is the so-­called pocket 4. 1% CM is found in the mother’s milk.
Doppler, in which the ultrasound probe That this amount has a harmful effect on
looks like a thick pen. It is mainly used in the infant has not yet been proven. The
vascular diagnostics to measure occlu- current recommendation does not call
sion pressure. for any special measures. Nevertheless, a
5. Ultrasound diagnostics is the primary 24-hour breastfeeding break can be con-
diagnostic imaging for abdominal com- sidered.
plaints, vascular diseases and for the
diagnosis of cardiac function. z Chapter 10
1. IMRT: IMRT (Intensity Modulated
z Chapter 9 Radiotherapy) is a further developed
1. X-ray contrast agents are divided into method of conformal irradiation.
two major groups: During irradiation, the multileaf lamel-
(a) Substances with lower density than lae move across the irradiation field. This
the environment to be imaged = neg- is done either in sliding-window tech-
ative contrast media (gases, water, nique, the irradiation runs while the
methyl cellulose, sorbitol) MLC move, or in step-and-shoot tech-
(b) Substances with a higher density nique, the irradiation is interrupted dur-
than the environment to be ing the movement of the MLC. This
depicted = positive contrast media allows the dose to be varied from point
(differentiation into water-soluble, to point. In this way, tumors can be irra-
water-insoluble and oil-containing) diated with a high dose and sensitive
Solutions
381 27
organs that are in close proximity can be ventional X-ray therapy, and for which sur-
spared more effectively because the gery is not an option because the risk of
reduced dose can be shaped more pre- anesthesia is too high or functional impair-
cisely to the organ contour. The disad- ment, e.g. blindness, is to be expected.
vantage of this method is the dose load 4. The boost is applied to a macroscopic
for healthy tissue. VMAT: Volumetric tumor or to an area where there is an
Modulated Arc Therapy (VMAT) is a increased risk of recurrence, e.g. at the site
further development of the IMRT tech- where surgery could only just be resected
nique: The number of small dose-modu- or not in healthy tissue. Percutaneously, it
lated fields increases, which are irradiated is applied in several sessions; with intersti-
in many different gantry positions. For tial or intracavitary brachytherapy, it is
this purpose, the gantry no longer occasionally applied as a single applica-
remains stationary at the individual posi- tion. It is possible to perform the boost
tions, but moves in a circle or semicircle. sequentially, i.e. following the radiation
This significantly shortens the irradia- series, or during the radiation series either
tion time. concomitantly or as a simultaneously
2. This refers to radiotherapy that is applied integrated boost (SIB).
in a spatially targeted and highly precise 5. Tumor volume (GTV = Gross Tumor
manner. The method was developed for Volume): GTV includes the macroscopic
brain tumors, but is now also used in the tumor, be it the primary tumor, be it
rest of the body as body stereotaxy, e.g. lymph node metastases or distant metas-
for primary tumors and metastases in the tases. Clinical Tumor Volume (CTV):
lungs and liver, as long as the tumor The CTV encompasses the area of mac-
diameter is not larger than 3 cm. roscopic tumor (GTV) and the region
3. Intracavitary: The classic indication for where tumor cells may still be scattered.
intracavitary brachytherapy is vaginal Planning Target Volume (PTV): The
application for irradiation of the vaginal planning target volume (PTV) includes
stump in corpus carcinoma. However, it is the CTV and is expanded with respect to
also possible for small superficial carcino- changes that may occur during radia-
mas in the esophagus or other cavities. tion. These include: Positioning inaccu-
Interstitial: The radionuclide is introduced racies by the MTRA, patient restlessness,
into the tissue either temporarily or perma- organ movements due to breathing, peri-
nently. The procedure always involves sur- stalsis (wave movement of the intestine),
gery and anesthesia. Under ultrasound different filling states of the bladder and
control, the radiation sources made of rectum, but also weight gain or loss.
125iodine (= seeds) are introduced via a hol-

low needle and remain in the tissue, e.g. in z Chapter 11

the prostate in the case of carcinoma detec- 1. Distance, stay, activity, shielding, avoid
tion. Depending on the size of the prostate, recording.
their number is between 80 and >100, their 2. Keep radiation effect on persons as low
dose rate is low (Low Dose Rate, LDR, as possible by decontamination, avoid
<1 Gy/h), the half-life is 60 days. Contact further spreading.
therapy: Contact therapy is rarely per- 3. Collimator, NaJ crystal, photomultiplier,
formed because the area to be irradiated electronic data processing.
must be small and superficial. In addition, 4. Radioiodine therapy with 131NaI. Benign
this very special method is only used to diseases: Thyroid enlargement, autonomy,
treat tumors that cannot be irradiated in Graves’ disease. Malignant disease: papil-
any other way, e.g. with electrons or con- lary and follicular thyroid carcinoma.
 382 M. Wenker et al.

5. Radiology uses ­transmission radiation, about the risks of the planned treatment,
nuclear medicine emission radiation. but also about the risks that may arise if
6. Alpha radiation therapy (e.g. bone the measure is not carried out. The actual
metastases), beta-minus radiation ther- treatment information includes the con-
apy, beta-plus radiation diagnostics crete treatment (e.g. computer tomogra-
(PET), gamma radiation diagnostics. phy) with possible risks (e.g. contrast
7. Coincidence refers to the nearly simulta- medium incident with anaphylactic shock).
neous impingement of annihilation In the end, it is not the frequency of risks
beams in the PET ring system. that is important, but the consequences.
8. Single photon emission computed tomog- For example, possible lethal complications
raphy (SPECT): Creation of a three- must be mentioned, even if their probabil-
dimensional image based on images ity of occurrence is very rare but possible.
taken at different angles and suitable Information must also be provided on pos-
back projection. sible alternatives to the proposed proce-
dure, especially if there are in fact two
27 z Chapter 12 approximately equivalent procedures.
1. Intolerance reaction to the KM. 2. The X-ray Ordinance regulates areas
2. To a thyrotoxic crisis. with X-ray radiation with a limit energy
3. In patients at risk, perchlorate (irenate) is of more than 5 keV and less than
used prophylactically before and 1 MeV. The handling of radioactive sub-
1–2 weeks after the examination with a stances and ionizing radiation not cov-
thyrostatic. Perchlorate decreases iodine ered by the X-ray Ordinance is regulated
uptake into the thyroid gland. by the Radiation Protection Ordinance.
4. Cardiac massage: find a hard surface if 3. Examinations may only be performed if
not already available → pressure point in a competent physician has provided the
the middle of the chest (lower half of the “justifying indication” according to § 23
sternum) → compression depth approx. RöV or § 80 StrlSchV. It must be assessed
4–5 cm → 100 compressions; ventilation: whether the benefit of the planned exam-
after the first 30 compressions (frequency ination outweighs the risk of radiation
100–120/min) → first ventilation cycle of exposure and whether the question can-
approx. 1 s with ventilation twice; con- not be answered by another examination
tinue as above in the ratio 30 (cardiac with lower radiation exposure.
compressions):2 (ventilations). 4. No, working in the controlled area is
5. If a tonic-clonic seizure lasts longer than possible under certain conditions.
5 min or if an entire series of seizures
occurs without the patient regaining con- z Chapter 14
sciousness in the meantime, this is referred 1. An epidural hemorrhage is located under
to as status epilepticus. The danger here is the dura and is limited biconvex. In addi-
an undersupply of oxygen (hypoxia) and tion, the cranial sutures are respected. A
dangerous cardiovascular stress. subdural hemorrhage spreads along the
dura, which includes the falx cerebri, and
z Chapter 13 can be delineated concavely. Subdural
1. The patient should be informed about the hemorrhages may cross the cranial sutures.
planned measures in such a way that he/she 2. Bleeding in the basal ganglia and in the
can decide for him/herself whether the pons is considered typical and is usually
planned procedure makes sense for him/ due to hypertension. In other hemor-
her (self-­determination information). To rhage localizations, one must search for a
this end, the patient must be informed cause for the hemorrhage.
Solutions
383 27
3. Tumor edema spreads finger-­like into the 2. To an inflammatory breast carcinoma.
gyri, the cortex is usually preserved, Clinically and mammographically, mas-
whereas ischemic edema involves the titis and inflammatory breast carcinoma
cortex in most cases. look very similar: in addition to a thick-
4. In the case of a space-­occupying lesion in ened cutis, a diffusely condensed breast
the cerebellopontine angle, one has to think parenchyma can be seen.
of a meningioma, an acoustic neuroma 3. One possible form of therapy is the
(=wannoma) and/or an epidermoid tumor. embolisation of fibroids. This involves
probing the feeding artery with a cathe-
z Chapter 15 ter and then closing it off with the help
1. DD mucocele shadowing vs tumor shad- of small particles. The fibroid dies from
owing of the NNH: thinning of the wall the lack of oxygen and hopefully no lon-
without destruction in mucocele. ger stands in the way of the patient.
2. An anechoic lumen, a smooth wall struc- 4. You think of an inflammatory process
ture and a distal sound amplification are with accompanying edema. Your suspi-
shown. cion is adnexitis.
3. Midface fractures are classified accord- 5. The indications are: positive lymph node
ing to LeFort into: involvement, tumor size: over 4 cm, from
(a) LeFort I = basal detachment of the FIGO III primary radiochemotherapy is
maxilla usually performed as combined tele- and
(b) LeFort II = pyramidal detachment brachytherapy, adenocarcinoma, R1/2
of the maxilla including the bony or narrow tumor-­free resection margin.
nose
(c) LeFort III = high avulsion of the z Chapter 17
entire midfacial skeleton including 1. <10 U = transudate, >10 U = exudate.
the bony nose 2. The X-ray shows the following charac-
4. In the case of an orbital fracture, if the teristics:
force is exerted directly on the eye, a so- (a) Kerley B/C line = interstitial edema
called blow-out fracture can occur, in in the interlobular septa in the form
which the orbital floor fractures and of a reticular pattern.
orbital content can enter the maxillary (b) “Frosted glass phenomenon” due to
sinus, which then becomes visible as a so-­ intralobular edema.
called “hanging drop”. (c) Peribronchial cuffing = oedema for-
In sialography, which can also be mation in the peribronchial intersti-
used to visualize salivary stones, the ori- tium.
fice of the salivary glands is probed with (d) “Washed out” Hilus.
a fine cannula and filled with CM to (e) Subpleural edema.
enable better visualization in conven- 3. p = pinhead, q = ­micronodular, r = nod-
tional X-rays, CT or MRI. This also ular.
allows tumors to be visualized. 4. Initial phase = Up to 1 h; interstitial pul-
monary edema with patchy indistinct
z Chapter 16 condensations develops; early
1. A breast carcinoma can be delineated on phase = 1–24 h; alveolar pulmonary
sonography as an echo-poor, blurred edema with microthrombi and rapid
round focus, possibly with dorsal sound fusion to homogeneous condensations;
extinction and above all with interrup- intermediate phase = 1–7 days; microat-
tion of the longitudinal connective tissue electasis, fibroblast proliferation and
structures (Cooper’s ligaments). regression to patchy shadows; late
 384 M. Wenker et al.

phase => 7 days; pulmonary fibrosis z Chapter 19

with regression of patchy shadows, 1. First, order a urinalysis, especially with
reticular pattern (= irreversible fibrosis). the question of hematuria, and a sonog-
5. In pulmonary embolism. Conventional raphy of the abdomen. If the diagnosis
X-rays show a regional reduction in of urolithiasis remains suspected, per-
blood flow, which reduces the diameter form a low-dose CT of the urinary tract.
of the vessel and results in a secondary 2. Bland renal cysts are hydrous in all imag-
increase in transparency (so-called ing techniques, i.e. anechoic with dorsal
Westermark sign). Furthermore, there is acoustic enhancement, in CT with den-
a so-called knuckle sign, an enlargement sity values around 0 HU and in MRI
with a jump in calibre, which results from fluid isointense in all sequences.
the ballooning of the central artery and a Complicated renal cysts may be hemor-
resulting clear difference in size to the con- rhaged or septated with corresponding
tinuing vessels. changes such as anechoic contents of the
cyst or hyperdense appearance on
27 z Chapter 18 CT. Contrast enhancement cannot be
1. Primary sclerosing cholangitis is a scle- detected in cysts; should you detect this,
rosing chronic inflammation and destruc- it can no longer be assumed to be a cyst.
tion of the intra- and extrahepatic bile 3. The benign prostatic hypertrophy affects
ducts and is manifested on ERCP (gold the central zone around the urethra and
standard) or MRCP by a pearl cord-­like has an inhomogeneous structure, the
duct irregularity. prostatic carcinoma is located in the
2. Response: peripheral zone and there mainly dorsal.
(a) Zenker diverticulum: 70% of all diver- In MRI the carcinoma is T2w hypoin-
ticula, cervical pulsatile diverticulum. tense with signal enhancement in diffu-
Preferred in men of older age. Large sion due to cytotoxic edema.
pseudodiverticulum localized dor- 4. Depending on the tumor stage, primary
sally at the upper esophageal jugular surgery, radiotherapy alone or hormone
predominantly on the left side. ablative therapy or a combination of
(b) Bifurcation diverticulum: True diver- hormone ablative therapy and radiother-
ticulum due to scarring, e.g. after apy.
TBC. 5. Calcifications of the vasa deferens of the
(c) Epiphrenic pulsatile diverticulum: seminal vesicles or the interdigital arter-
Pseudodiverticulum above the hia- ies are almost pathognomonic for the
tus, often combined with hiatal her- presence of diabetes mellitus.
nia or achalasia.
3. Krukenberg tumor is a drip metastasis of z Chapter 20
gastric carcinoma in the ovaries or in the 1. Definite fracture signs: Axial malalign-
Douglas space. ment, open fractures with bone fragments
4. Appendicitis presents as a cocard >7 mm. protruding from the wound, steps or gaps
The wall is thickened to >3 mm. Often in the course of the bone, crepitation.
an appendicolith is detectable. Uncertain fracture signs: pain, swelling,
5. During the sigmavolvulus, i.e. the rotation redness, hyperthermia, restricted mobility
of the sigmoid colon around its mesen- (functio lesa). X-rays should always be
teric axis, the coffee bean sign appears. taken in two planes.
Solutions
385 27
2. Type of lesion, bordering of the lesion, 4. Acute occlusion: lysis, thrombectomy.
cortical changes, periosteal reaction, Chronic occlusion: PTA, stent implanta-
assessment of the matrix, growth rate as tion.
an expression of aggressiveness, localiza-
tion. z Chapter 22
3. Protrusion: Bulging disc in which the 1. Autonomous adenomas.
diameter of the protrusion is greatest at 2. On CT, adenomas show hypodense and
the base. Extrusion: Bulging disc in take up contrast.
which the diameter of the protrusion is 3. The MRI.
greater peripherally than at the base 4. An examination with iodine-­containing
(hourglass shape). Bulging: broad-based contrast media (6–8 weeks before diag-
disc protrusion beyond the vertebral nostics) as well as contamination with
body, where the protrusion occupies iodine-containing food represent a con-
more than 180 ° of the disc circumfer- traindication of thyroid scintigraphy,
ence. Sequester: extrusion in which at because otherwise the applied 99mTc can-
least part of the herniated disc tissue no not be transported into the thyroid tissue
longer has a connection to the residual due to saturation. An undesired medici-
disc). nal TSH suppression of the patient
4. Tumor embolisation: angiographic should be avoided.
embolisation of osseous metastases, e.g. 5. To detect catecholamine-­ producing
renal cell carcinoma. Pain therapy: PRT pheochromocytomas, 123J- or 131J-labeled
for the treatment of herniated discs. MIBG is administered.
CT-guided treatment of bone tumors: 6. The most important benign indications
thermoablation for osteoid osteoma. for radioiodine therapy are functional
autonomies, Graves’ disease and euthyroid
z Chapter 21 strumen. A corresponding indication for
1. DeBakey: Type I (ascending aorta the therapy of malignant tumors is the
affected downstream of the supraaortic still existing functional similarity to the
vessels), Type II (ascending aorta thyroid tissue. This is the case with papil-
affected upstream of the supraaortic ves- lary (approx. 70% of malignant thyroid
sels), Type III (aorta affected distal to tumors) as well as follicular (approx. 20%
the supraaortic vessels). Stanford: Type of malignant thyroid tumors), the so-­
A: Ascending aorta is involved. Type B: called differentiated thyroid carcinomas.
Aorta distal to the supra-aortic vascular
branches is affected). z Chapter 23
2. First determine pretest probability 1. As with sonography, computed tomog-
(according to Wells), not high: D-dimer raphy can detect the fatty hilus as a fatty
determination, if negative no treatment, isodense central zone in the lymph node
high probability: direct compression even in relatively large lymph nodes in
ultrasound, if negative no treatment, if the groin. This is indicative of benignity
positive treatment, in case of inconclu- of the lymph node. An absent fatty hilus
sive findings supplementary phlebogra- is a sign of pathologic change, such as
phy or control ultrasound in four to malignancy or inflammation. The shape
seven days. also plays an important role in the evalu-
3. CT and MRI are equivalent in principle, ation of the lymph node as in sonogra-
but since there is often an emergency sit- phy. A further indication of malignancy
uation, CT is given priority for rapid or benignity results from the localization
clarification. of the lymph node.
 386 M. Wenker et al.

2. For an echinococcus cyst. catheter is used to measure pO2 in venti-

3. Thymomas and thymic carcinomas usu- lated premature infants. The appropriate
ally present as a well circumscribed soft position should be above the diaphragm,
tissue mass in the upper anterior medias- at a safe distance from the outlet of the
tinum. Vascular infiltration or sheathing renal arteries.
as well as pleural metastases are indica- 2. Respiratory distress syndrome (ANS)
tive of malignancy. Magnetic resonance can occur in premature infants <28th
imaging (MRI) of the thorax may be week of gestation due to lung immatu-
helpful in rare cases to assess vascular rity, in shock situations and, for example,
infiltration. in infants of diabetic mothers. Stage IV
corresponds to white lung on X-ray.
z Chapter 24 3. Your tentative diagnosis is intussuscep-
1. The single-flush catheter is placed over a tion. This is an invagination of a part of
suitable vein under sterile conditions and the intestine into the following caudal
should be positioned in front of the right part of the intestine. This leads to stran-
27 atrium. The beginning of the catheter gulation of the mesenteric vessels with
should always be imaged as well, since the edema, stasis hemorrhage, intestinal
catheter may have already coiled up at the necrosis due to ischemia.
beginning. The umbilical vein catheter is 4. For imaging, an MRI of the entire cra-
placed via the umbilical vein through the niospinal axis must be performed. In the
ductus venosus Arantii into the inferior T2 image, the solid part of the tumor is
vena cava and is used, among other things, predominantly hyper- to isointense to
for the possibility of an exchange transfu- the cerebellar cortex and shows a hetero-
sion or for measuring the central venous geneous appearance. The T1-weighted
pressure. The catheter should end 1 cm image shows a predominantly hypo- to
above the diaphragm. The umbilical artery isointense, heterogeneous tumor.