Basic Radiological Techniques

2007
Basic Radiological
Techniques
………………………………………………………..
………………………………………………....
……………………………………………..
By Abdelrahman Abdelhalim
Basic Radiological Techniques... By Abdelrahman Abdelhalim
1/1/2007
INTRODUCTION
&
GENERAL SCHEME
Basic Radiological Techniques... By Abdelrahman Abdelhalim 2

PREFACE
These papers are laid during my preparation for the 1st parts of FEB and Master
examinations, initially my intention is to collect and organize easy trusted papers
for my own personal use. Accordingly, none of the material in these papers is of my
own writing. I hope that these papers are useful and I ask God for knowledge which
is beneficial and sustenance which is good, and deeds which are acceptable.
Abdel-rahman Abdel-halim
Cairo - 2007
Abdoabdoo@gmail.com
Abdofiles@gmail.com
GENERAL SCHEME
The following is the topics that should be discussed in the majority of the radiological techniques:
Methods:
Indications:
Contraindications:
A. Due to radiation: e.g. pregnancy.
B. Due to the contrast medium: see chapter 2
C. Due to the technique: Skin sepsis at the needle puncture site.
Contrast medium:
Equipment:
Patient preparation:
• Explain the procedure, obtain consent when necessary.
• Previous films and notes should be obtained.
• Bowel preparation ….
• Premedication ….
• For female patients: apply 10 day rule, Care must be taken all times to maintain privacy and dignity &
Chaperone is usually necessary.
Preliminary film:
• The purpose of this film is:
1. To make any final adjustment in exposure factors, positioning of the patient, centering…
2. To exclude prohibitive factors such as residual barium from previous examination or excessive fecal
loading.
3. To demonstrate, identify and localize opacities which may be obscured by CM e.g. renal calculi.
Technique:
Aftercare:
Complications: may be subdivided into
D. Due to the anesthetic: …..
E. Due to the contrast medium: ….
F. Due to the technique: ….

CHAPTER ONE
CONTRAST MEDIA

CONTRAST MEDIA
DEFINITION:
Contrast media are substances that enhance the inherent contrast between soft tissues, in
radiological investigations.
CLASSIFICATION:
Summarized in the diagram below…
CONTRAST MEDIA
Radiographic MRI Ultrasonography

CM CM CM
Positive Negative
(Radio- (Radio-lucent)
opaque) e.g. Air- Co2 - O2
Iodine Barium Bromine

Contrast Media
preparations preparations
(ICM)
Water Oily
Soluble ICM ICM
RADIOGRAPHIC CONTRAST MEDIA

Radiographic CM, according to their atomic weight and their ability to absorb X-ray, are of 2 types:
1- Positive (Radio-opaque):
• These are elements with high atomic weight, so high ability to absorb X-ray (high radio-density).
• Include: Iodine, Barium, and Bromine preparations.
2- Negative (radio-lucent):
• These are elements of low atomic weight, so little (if no) ability to absorb X-ray and introduced
into cavities, or organs to delineate them by virtue of their radiolucency, compared to the
surrounding tissues e.g. encephalography. Also they are used in GIT examination e.g. barium
meal and enema to give better visualization of mucosal detail.
• Include: air, CO2 and O2.

WATER SOLUBLE IODINATED CONTRAST MEDIA
CLASSIFICATION:
A. According to the number of benzene rings and ionicity:
1. Monomeric Ionic (HOCM): one (mono) benzene ring & dissociate into ions in solutions.
o Agents used in uro- and angiography e.g. Urografin, Angiografin
o Agents used in oral cholecystography e.g. Tele-paque.
2. Monomeric Non-ionic (LOCM): one benzene ring & not dissociate into ions in solutions.
o E.g. Omnipaque, Ultravist.
3. Dimeric Ionic (LOCM): 2 (di) benzene rings & dissociate into ions in solutions.
o Agents used in uro- and angiography e.g. Hexabrix.
o Agents used in intravenous cholangiography e.g. Biligrafin.
4. Dimeric Non-ionic (LOCM) e.g. Iotrolan (Isovist) that used for myelography as it has neural tolerance.
These agents are iso-osmolar with plasma. They are also highly viscous and, thus, have limited clinical
usefulness.
B. According to osmolarity (commonly used):
1. High Osmolar Contrast Media (HOCM):
o The osmolarity of ionic CM (1200-2000 mOsmol/kg = 4-7 osmolarity of blood) depends
on the concentration, which typically ranges from 30%- 75%.
o The major ionic agents on the market are: Urografin & Conray.
2. Low Osmolar Contrast Media (LOCM):
o Non-Ionic LOCM:
§ They have lower incidence of adverse reactions while being equally effective as imaging
agents.
§ The common agents in the market, differing in the R-group are: Ultravist (Iopromide) &
Omnipaque (Iohexol).
o Ionic LOCM: There is only one on the market Hexabrix (Ioxaglate).
C. According to system to be examined: e.g.
1. Urographic and angiographic agents: e.g. Urografin, Ultravist, Angiografin..
2. Myelographic agents: isovist, Iotrolan.
INDICATIONS:
Water soluble ICM are used in a wide variety of radiological investigations, the following are such examples
of common ones:
A. Urinary tract investigations e.g. excretion urography, cystourethrography, urethrography.
B. Angiographic investigations e.g. aortography, peripheral arteriography, venography.
C. Biliary tract investigations e.g. cholecystography, cholangiography.
CONTRAINDICATIONS:
The following are high risk conditions that with the iodinated CM may cause severe adverse reactions.
1. A previous severe adverse reaction to contrast medium: with HOCM this carries a 20% risk of a
similar reaction on a subsequent occasion; the risk is decreased to 5% with LOCM.
2. Significant allergic history e.g. asthma.
3. Proven hypersensitivity to iodine.
4. Moderate to severe impairment of renal function.
5. Hepatic failure.
6. Decompensated cardiac failure.
7. Sickle cell anemia.
8. Myelomatosis.
9. Dehydration.

ADVERSE REACTIONS:
• Pathogenesis: The pathogenesis of such adverse reactions probably involves direct cellular
effects; enzyme inhibition; and activation of the complement, histamine release.
• Adverse reactions to ICM are classified as idiosyncratic and non-idiosyncratic:
A. Idiosyncratic or anaphylactic reactions:
o Mild symptoms: include scattered urticaria, pruritus; rhinorrhea; conjunctivitis, nausea
and/or vomiting; coughing; and dizziness.
o Moderate symptoms: include persistent vomiting; diffuse urticaria; facial edema;
laryngeal edema; mild bronchospasm; palpitations, tachycardia, or bradycardia and
hypertension.
o Severe symptoms: include life-threatening arrhythmias , hypotension, laryngeal
edema, pulmonary edema, seizures and syncope.
B. Non-idiosyncratic reactions:
1. Nephropathy:
• The incidence of contrast-induced nephrotoxicity is approximately 5%. For the majority, the
renal impairment is temporary.
• The predisposing factors:
a. Pre-existing impairment of renal function.
b. Diabetes mellitus: especially those under metformin treatment.
c. Dehydration.
d. Drugs: Nephrotoxic drugs such as aminoglycoside antibiotics & NSAIDs.
e. Extremities of age.
f. Multiple myeloma.
• The mechanisms of CM induced nephropathy:
a. Hemodynamic changes: resulting from reduced renal blood flow, increased blood
viscosity, platelet aggregation and thrombus formation.
b. Intra-tubular obstruction: direct toxic effect of CM on the lining of tubules, the
dead cells get in the lumen and obstructing it.
c. Tubular cell damage: acute tubular and medullary necrosis.
d. Immunogenic mechanisms: proliferative glomerulonephritis, antibody formation
and complement activation may be included.
2. Vascular toxicity:
• Venous effects: include pain at the injection site, may extend to the whole arm and
thrombophlebitis as a result of the toxic effect on endothelium.
• Arterial effects: CM may lead to endothelial damage and vasodilatation, leading to sensation of
heat or pain.
3. Soft tissue toxicity:
• Pain, swelling, erythema and sloughing of skin may occur from extravasated CM. the risk is
increased when pumps are used to inject large volumes of CM during CT examinations.
4. Cardiac toxicity:
• Intracoronary injection of CM may cause ventricular fibrillation, ventricular tachycardia, asystole,
sinus bradycardia, heart block.
5. Hematological changes:
• Hemolysis and haemoglobinuria have been reported following angiocardiography with
diatrizoate and acute renal failure may supervene.
• CM may impair blood clotting and platelet aggregation.
• CM may provoke sickle cell crisis especially with HOCM.

6. Neurotoxicity:
• Intravenous CM may provoke convulsions in patients with epilepsy or cerebral tumors.
• Very rarely a transient cortical blindness, due to a direct effect of CM on the visual cortex, may
occur after vertebral angiography.
7. Thyroid effects:
• Thyrotoxicosis may occur in patients with non-toxic goiters, or be exacerbated in those with pre-
existing thyrotoxic symptoms.
• CM may interfere with thyroid function tests.
• Prophylaxis for adverse CM effects:
A. Pre-testing: involves applying contrast medium to the cornea or injecting a 1 ml test dose IV a few minutes
prior to the full IV injection.
B. Pre-treatment with steroids: a suggested regime is methyl-prednisolone 32 mg orally 12 and 2 hours prior to
injection of CM. however; the reduction in the incidence of adverse reactions using oral steroids is not as great
as that achieved by the use of LOCM.
C. Change of CM to a LOCM: This is the most important factor in the reduction of CM adverse reactions.
D. Reduction of patient anxiety and apprehension.
NOTE: Pre-treatment with antihistaminics: prophylactic chlorpheniramine is of no benefit and when
given is associated with a threefold increase in the incidence of flushing.
Ø Indications for LOCM

o If it were not for their expense, there would have been a complete switch to LOCM many
years ago.
o The following should receive LOCM in preference to HOCM:
1. Extremities of age (Infants and small children and the elderly).
2. Those with renal and/or cardiac failure.
3. Poorly hydrated patients.
4. Patients with diabetes, myelomatosis or sickle cell anemia.
5. Patients who have had a previous severe contrast medium reaction or those with a
strong allergic history.
• Treatment of adverse reactions:

Ø Management lines:
§ Check ABC: Airway patency, Breathing & Circulation.
§ Call for Help.
A. Treatment of allergic reactions:
1. Antihistaminics e.g. Avil I.V.
2. Adrenaline 1:1000 (0.5 cc subcutaneous or I.M.).
3. Corticosteroids e.g. Hydrocortisone (100 mg), Dexamethasone 4 mg or Prednisolone 20 mg I.V., if
the above measures failed to control symptoms.
B. Treatment of Respiratory symptoms:
1. Oxygen mask.
2. Adrenaline 1:1000 (0.5 cc subcutaneous or I.M.): repeat after 10 min.
3. Aminophyline (0.5mg) slowly I.V.
4. Corticosteroids e.g. Hydrocortisone (100 mg), or Prednisolone 20 mg I.V., if the above measures
failed to control symptoms.
C. Treatment of circulatory collapse:
1. Call for the cardiac team immediately.
2. Lower the head of the couch and raise the patient’s legs
3. Start cardiac massage.
4. Defibrillation.
CONTRAST AGENTS IN MRI
MECHANISM OF ACTION:
• To enhance the inherent contrast between tissues, MRI contrast agents must alter the rate of
relaxation of the protons within the tissues.
• The changes in relaxation must vary for different tissues in order to produce differential
enhancement of the signal.
CLASSIFICATION:
Agents with unpaired electron spins are therefore potential contrast agents in MRI. These may be classified into 3
groups:
1- Ferromagnetic: these have magnetic moments which align with the scanner’s applied field. They will
maintain their alignment even when the applied field is removed. This retained magnetism may cause
particle aggregation and interfere with cell function, making them unsafe as MR contrast agents.
2- Paramagnetic (e.g. gadolinium): these have magnetic moments which align to the applied field, but
once the gradient field is turned off, thermal energy within the tissue is enough to overcome the
alignment. They may be made soluble by chelation and can therefore be injected intravenously. Their
maximum effect is on protons in the water molecule, shortening the T1 relaxation time and hence
producing increased signal intensity (white) on T1 images.
3- Super-paramagnetic (e.g. ferrite): these are aggregates of paramagnetic ions in a crystalline lattice. They
cause reduction in the T2 relaxation time, and hence producing decreased signal intensity (black) on T2
images. They are less soluble than paramagnetic agents. Due to their chemical structure and so are
available only as a colloidal suspension.
GADOLINIUM (GD)
Chemistry:
• Gadolinium is a metallic rare-earth element, atomic number 64; atomic weight 157, has 7 single
electrons on the outer shell, characterized by strong paramagnetic properties and it influences the
relaxation time T1. It is toxic as free ion, so administrated as a complex e.g. with DTPA (Magnevist).
• These are a number of gadolinium chelates: e.g. Gd-DTPA (Magnevist), Gd-DOTA (Dotarem).
Indications:
1. CNS tumors.
2. Demyelinating diseases – for differentiating acute from chronic plaques.
3. Accurate delineation of tumour margins from oedema.
4. Discrimination of tumour recurrence from post-therapy fibrosis.
5. Discrimination of recurrent intervertebral disc prolapse from postoperative fibrosis.
6. Cardiac/aortic imaging.
Contraindications: No absolute contraindications known.
Dose: 0.1 Up to 0.2 m mol/kg (according to the magnetic field strength).
Side effects: Include: Warmth, local pain, strange taste, nausea, vomiting, Headache, dizziness.
MRI GIT CONTRAST AGENTS
§ These are used to distinguish bowel from adjacent soft tissue masses. As with CT, all bowel contrast agents
need to mix readily with the bowel contents to ensure even distribution. They must also be palatable.
§ They can be divided into 2 groups:
Positive agents: e.g. fatty oils and gadolinium
• Act by T1-shortening and appear white on T1 images.
Negative agents: e.g. ferrite and barium sulphate (60-70 % w/w).
• Act by T2-shortening and appear black on T2 images.

CONTRAST AGENTS IN ULTRASONOGRAPHY
MECHANISM OF ACTION:
• All ultrasound CM depend on the interaction between encapsulated gas microbubbles and
the US waves, i.e. diffraction of ultrasound waves on gas microbubbles.
EXAMPLES:
1- Echovist: bubbles in a Galactose solution.
2- Levovist: the most widely used US CM, microbubbles of air enclosed by a thin layer of palmitic
acid in a Galactose solution. Stable in blood for 1-4 min.
INDICATIONS:
• Right sided heart diseases e.g. Septal defects: after IV injection , the CM travels with blood
to the right side of the heart, then through the pulmonary artery to the lungs where CM
loses its echogenic characteristics. Passage into the left ventricle is only possible in cases of
cardiac septal defects.
• To asses patency of the Fallopian tubes.
• Imaging of vascular structures which cannot be evaluated even with Doppler techniques.

CHAPTER TWO
URINARY TRACT

EXCRETION UROGRAPHY
Also called: intravenous urography (IVU)/ intravenous pyelogram (IVP).
Indications:
• Suspected urinary tract pathologies e.g. haematuria, renal calculi, renal tumours
Contraindications:
1. Due to radiation: pregnancy.
2. Due to the contrast medium: AS GENERAL
§ A previous severe adverse reaction to contrast medium: with HOCM this carries a 20% risk of a
similar reaction on a subsequent occasion; the risk is decreased to 5% with LOCM.
§ Significant allergic history e.g. asthma
§ Proven hypersensitivity to iodine.
§ Moderate to severe impairment of renal function.
§ Hepatic failure.
§ Decompensated cardiac failure.
§ Sickle cell anemia, Myelomatosis.
Contrast media:
• HOCM: e.g. Urografin (Na & Meglumine Diatriazoate) 60% and 76%.
o Concentration: 370 mgI/ml
o Dose: 1 ml/kg.
o A usual amount given to adult patients is 50 – 100 ml .
• LOCM: e.g. Ultravist, are better tolerated than the HOCM and are recommended for patients at risk (see
chapter two).
Equipment:
• Fluoroscopy unit with tilting table is preferred.
Patient Preparation:
• Bowel preparation is an important consideration; preparation is a combination of a dietary restrictions and
laxatives.
1. No food for 6 hours prior to the examination.
2. The patient should (if possible) be ambulant for 2 hours prior to the examination to reduce bowel
gases.
3. Dehydration (controversial) should be avoided in cases of renal failure, Myelomatosis.
• Prednisolone 32 mg orally 12 and 2 hours prior to injection of CM.
• The patient should void immediately prior to the examination.
Preliminary films:
• Supine, full-length AP of the abdomen.
o 35 × 43 cm cassette is placed longitudinally.
o The vertical central ray is directed to the level of the lower costal margin.
o Benefits: demonstrate possible calcifications, calculi or other abnormalities in the
abdomen, and to check the technique factors.
Patient Position:
• The patient lies supine on the scanner table.
Technique:
1. CM is injected (through a 19-G needle) as a bolus in a suitable vein e.g. the median antecubital vein.
2. Pain in the upper arm or shoulder due to stasis of CM in vein is relieved by arm abduction.

Films:
1. Immediate film:
• AP of the renal areas.
• Film exposed 10-14 sec after injection (arm to kidney time).
• Shows the nephrogram i.e. renal parenchyma opacified by CM in the renal tubules.
2. 5-min film:
• Determine if excretion is symmetrical.
• Determine if there is a need to a further injection of CM (if there is poor initial opacification).
ð NOW a compression band applied around the patient’s abdomen to produce better pelvicalyceal distention.
ð Compression is not done in: Recent abdominal surgery – renal trauma – large abdominal mass – when the 5-
min film already shows distended calyces.
3. 15-min film:
• Usually there is adequate distention of the pelvicalyceal systems with opaque urine by this time.
ð Compression is released after satisfactory demonstration of
pelvicalyceal systems.
4. Release film:
• Supine AP abdomen.
• Shows the whole urinary tract.
5. After micturation film:
• Full-length abdominal film or a coned view of the bladder
with the tube angled 15° caudal and centered 5 cm above
the Symphysis pubis.
• Value:
Assess bladder emptying.
Diagnosis of bladder tumors.
Demonstrate a return to normal of dilated
upper tracts with relief of bladder pressure.
Confirm ureterovesical junction calculi.
Demonstrate urethral diverticulum in females.
6. Additional films:
• Delayed films (may be necessary up to 24 hrs) in case of
obstructive uropathy.
• Prone Abdomen : for better visualization of the ureters.
• Oblique films for the kidneys and the ureters.
• Oblique films for the bladder and prostate (in suspected cases of prostatic enlargement)
• Tomography if there is confusing overlying shadows.
Aftercare: as general
Complications: as general

INFUSION UROGRAPHY
Indications:
• As alternative to excretion urography in cases of:
1. Renal failure.
2. Hepatic failure.
3. Trauma (emergency urography).
Contraindications:
• General contraindication ….
• Children.
Disadvantages:
Does not estimate renal function.
Contrast media:
• As excretion urography (better LOCM)
Equipment:
As before
As before
Preliminary films:
As before
Patient Position:
• The patient lies supine on the scanner table.
Technique:
• 100 ml CM (in 100 ml saline) is infused over 30 minutes.
Films:
Spot films to the abdomen are taken at 5 min, 15 min and the end of infusion.
Aftercare: as general
Complications: as general

PERCUTANEUOS NEPHROSTOMY
This is a radiological technique used to demonstrate the renal calyces and pelvis by introduction of a
drainage catheter into the collecting system of the kidney.
Indications:
1. Obstructive uropathy.
2. Before percutaneous nephrolithotomy.
3. Ureteric Fistulae; external drainage may allow closure.
Contraindications:
Uncontrolled bleeding diathesis.
Contrast media:
As for excretion urography.
Equipment:
1. Fluoroscopy unit with tilting table or real timeultrasound unit.
2. Puncture needle (18-G).
3. Guide-wires
1. Fasting for 6 hrs.
2. Premedication e.g. sedation using Diazepam.
3. Prophylactic antibiotics.
4. Surgical backup for possible complications.
5. The patient should void immediately prior to the examination.
Patient Position:
The patient lies prone on the fluoroscopic table with a foam pad under abdomen, so fix kidneys in posterior
position.
Technique:
Identifying the collecting system:
• Excretion urography; if adequate residual function.
• Antegrade Pyelography.
• Real-time U/S used to:
1. Identify the renal pelvis for antegrade pyelography.
2. Determine the plane of puncture of the collecting system.
3. Guide puncturing needle into the collecting system with a biopsy
needle attachment.
Site/Plane of puncture:
• The point is on the posterior axillary line below the 12th rib.
• Identification of the mid/lower pole calyces by U/S or contrast determine the plane of
puncture.
• The puncture will be via the soft tissues and renal parenchyma.
• The drainage catheter is also more comfortable for the patient and less likely to be
kinked when the patient is supine.

Technique of puncture and catheterization:
1. The skin and soft tissue is infiltrated by local anesthesia using spinal needle.
2. The puncturing needle is introduced gently and the stillete is removed.
3. The guide wire is inserted through the needle.
4. The needle is removed.
5. The catheter is then threaded over the guide wire.
6. The guide wire is removed and the catheter is fixed to the skin.
7. Drainage is commenced.
(a) A markedly hydronephrotic right pelvicalyceal system from malignant ureteric obstruction.
(b) Under ultrasound and fluoroscopic guidance, a 19 G sheathed needle is inserted into the
lower pole calyx and this is followed by guidewire insertion.
(c) An 8.5 F Locking-Loop Pigtail nephrostomy catheter is inserted
Aftercare:
1. Bed rest for 12 hrs.
2. Measure blood pressure & temperature every ½ hr for 6 hrs.
3. Urine culture and sensitivity.
Complications:
1. Unsuccessful drainage.
2. Hemorrhage.
3. Perforation of the collecting system.
4. Septicemia.

RETROGRADE (ASCENDING) PYELOURETEROGRAPHY
This is a radiological technique used to demonstrate the renal calyces and renal pelvis with a suitable organic
iodine CM by mechanical filling through a catheter.
Indications:
1. Demonstrations of the site, length, lower limit & nature of the obstructive lesion.
2. Demonstration of the pelvicalyceal system after an unsatisfactory excretion urogram.
Contraindications: Acute urinary tract infection

Contrast media:
• HOCM or LOCM
o Concentration: 150 – 200 mgI/ml i.e. not too dense to obscure small lesions.
o Dose: 10-20 ml.
Equipment: Fluoroscopy unit
Patient preparation: Preparation for surgery

Preliminary film: Full-length supine AP abdomen
Technique:
In the operating theater:
• The surgeon catheterizes the ureter via a cystoscope and advances catheter to desired level.
• CM is injected under fluoroscopic control and spot films are taken.
In the X-ray department: With ureteric catheter in situ:
• Under fluoroscopic control, urine is aspirated and CM “3 – 5 ml” is slowly injected.
• Films: using the undercouch tube
1. supine PA of the kidney
2. Both 35° anterior obliques of the kidney.
• The catheter may be left in the ureters to drain a pelviureteric obstruction, so withdrawal
ureterograms are not possible.
Aftercare:
1. Post-Anaesthetic observation.
2. Prophylactic antibiotics.
Complications:
Due to the Anaesthetics:
• Complications of general anesthesia.
Due to CM:
• Absorption of CM from the intact renal pelvis leads to CM adverse effects. (However still less
than IVP).
• Chemical pyelitis ( if there is stasis of CM)
• Extravasation due to over distension of the pelvis (usually asymptomatic but may cause pain,
fever & rigors).
Due to Technique:
• Infection.
• Mucosal damage of the ureters.
• Ureter or pelvis perforation.

ASCENDING URETHROGRAPHY IN THE MALE
Indications:
1. Stricture.
2. Urethral tears.
3. Congenital abnormalities.
4. Periurethral or prostatic abscess.
5. Fistula or false passage.
Contraindications:
1. Acute UT infection.
2. Recent instrumentation.
Contrast media:
• HOCM or LOCM
o Concentration: 200-300 mgI/ml i.e. not too dense to obscure small lesions.
o Volume: 10-20 ml
Equipment:
1. Fluoroscopy unit with tilting table and spot film device.
2. Foley catheter.
Patient preparation: None.
Preliminary film:
Supine AP view of the bladder base and urethra, 18×24 cm cassette is placed longitudinally in the
cassette tray; the central ray is directed 15˚ caudally & centered 5 cm above the Symphysis pubis.
Patient Position:
The patient lies supine on the fluoroscopic table.
Technique:
1. Using aseptic technique the tip of the Foley’s catheter is inserted so that the balloon lies in the
fossa navicularis and its balloon is inflated with 1-2 cm water.
2. CM, using 20 ml syringe, is injected under fluoroscopic control.
3. Films are taken in the following positions:
a. 30° LAO, with the right leg abducted and knee flexed.
b. 30° RAO, with the left leg abducted and knee flexed.
c. Supine PA.
4. Ascending urethrogram should be followed by micturating cystourethrography or excretory
micturating cystourethrography to demonstrate the proximal urethra.
5. Occasionally a urethral fistula or a periurethral abscess is only seen in the voiding examination,
Also reflux of the CM into dilated prostatic duct is better seen during micturation.
Aftercare: None.
Complications:
Due to CM:
Adverse reactions are rare.
Due to Technique:
2. Urethral trauma.
3. Intravasation of CM, especially if excessive pressure is used to overcome a stricture.

MICTURATING CYSTOURETHROGRAPHY
Indications:
1. Vesicoureteric reflux.
2. Study of Urethra during micturation.
3. Bladder abnormalities.
4. Stress incontinence.
Contraindications: Acute UT infection.

Contrast media:
• HOCM or LOCM
o Concentration: 150 – 200 mgI/ml i.e. not too dense to obscure small lesions.
o Volume: 250-300ml.
Equipment:
1. Fluoroscopic unit with spot film device and tilting table.
2. Video recorder.
3. Foley catheter; in small infants use a fine feeding tube ( 5-7 F).
The patient should void immediately prior to the examination.
Preliminary films:
• Coned view of the bladder.
Patient Position:
The patient lies supine on the fluoroscopic table.
Technique:
To demonstrate Vesicoureteric reflux:
1. Under aseptic technique, introduce the catheter into bladder.
2. The residual urine is drained.
3. CM is slowly dripped in and bladder filling is observed by intermittent fluoroscopy.
4. Spot films are taken and any reflux is recorded.
5. The catheter is not removed until the radiologist is convinced that the patient will micturate or
until no more CM could be dripped into bladder.
6. The examination is expedited if the catheter remains in situ until micturation commences and
then is quickly withdrawn.
7. Older children and adults are given a urine receiver (micturate while standing erect), but smaller
children should be allowed to micturate onto absorbent pads on which they can lie.
8. Infants and children with a neuropathic bladder, micturation should be accomplished by a
suprapubic pressure.
9. Spot films are taken during micturation and any reflux is recorded.
10. The lower ureter is best seen in the anterior oblique position on that side.
11. Boys should micturate in the LAO position, with the right hip and knee flexed, or in the RAO
position, with the left hip and knee flexed, so that spot films can be taken of the entire urethra.
12. Finally, a full length view of the abdomen is taken to demonstrate any reflux of CM that might
have occurred unnoticed in the kidneys and to record the post-micturation residue.

To demonstrate a Vesicovaginal or Rectovesical fistula:
As for Vesicoureteric reflux, but films are taken in the Lateral position.
To demonstrate Stress Incontinence:
1. As for Vesicoureteric reflux.
2. The catheter is left in situ until the patient is in the erect position.
3. Films (should include the sacrum & Symphysis pubis, as bony landmarks are used to assess
bladder neck descent):
a. Lateral bladder.
b. Lateral bladder, during straining.
c. The catheter removed and lateral bladder view is taken during micturation.
Aftercare:
• Warn the patient about possibility of dysuria and retention of urine as a result. Treat that by analgesics
and micturation in hot bath for children.
Complications:
Due to CM:
1. Adverse reaction due to absorption of CM by bladder mucosa. (however still less than IVP)
2. CM induced Cystitis.
Due to Technique:
2. Catheter trauma leading to dysuria, frequency, haematuria and urinary retention.
3. Bladder perforation due to over distension (treated by using non retaining catheter e.g. Jaques).
4. Catheterization of vagina or an ectopic urethral orifice.
5. Retention of a Foley catheter.

CHAPTER THREE
GASTROINTESTINAL
TRACT

CONTRAST SWALLOW
Methods:
• Both single and double contrast techniques are employed in the examination of the oesophagus.
• Double contrast offers better visualization of fine mucosal detail.
Indications:
1. Dysphagia - The most common condition requirung examinations by barium swallow.
Causes of dysphagia include: carcinoma, oesophageal strictures, cardiac achalasia..etc.
2. Oesophageal Perforation: only Water-soluble CM is used.
3. Oesophageal Varices & Ulceration.
4. Tracheo-Oesophygeal Fistula.
5. Hiatus hernia & reflux.
6. To assess the effect of any mediastinal masses on the esophagus .
Contraindications:
Oesophageal perforation contraindicates the initial use of a barium compound as it resulting in leakage into
mediastinal, pleural or peritoneal cavities. In such cases it is normal to commence the examination using a
water-soluble contrast agent.
Contrast media:
Barium is used unless there are specific contraindications.
1. Barium :
• Volume: 75 – 100 ml
• Concentration: 250% weight/volume (w/v)
• Advantages:
o Gives excellent coating allowing demonstration of normal and abnormal mucosal
patterns.
o Cheap compared to Water soluble CM.
• Disadvantages:
o High morbidity associated with barium in the peritoneal cavity.
o Subsequent abdominal CT and US are rendered difficult (if not impossible) to
interpret.
2. Gastrographin: in cases of suspected perforation.
3. LOCM: if aspiration is a possibility.
Equipment:
1. Fluoroscopic unit with a spot film device (high-kV technique 90-110 kv).
2. Videotape recording is useful especially in the diagnosis of motility disorders.
• No special patient preparation is required unless the examination is likely to include a barium
examination of the stomach.
• In cases of lower oesophageal obstruction, e.g. achalasia with retained food residues in the dilated
oesophagus above the site of obstruction, insert a Ryle tube and wash with saline or sodium
bicarbonate till the oesophagus is clean, and then give the barium to visualize the site of obstruction
in the lower end.
Preliminary Films:
A control film is advised prior to a water-soluble study if perforation is suspected.
o AP
o Lateral for neck & soft tissue exposure.
Technique:
In practice, precise patient positioning is achieved under fluoroscopic control. The position of the patient as
described here should be seen as a guide.
1. The fluoroscopy table is placed in the vertical position.
2. The patient stands facing the X-ray tube with his back against table.
3. The patient is asked to rotate into RAO (this will clear the esophagus away of the spine).
4. The patient is asked to swallow a mouthful of Barium and spot films of the upper and lower oesophagus
are taken.
Modified Technique:
For Tracheo-Oesophygeal Fistula in infants:
1. A nasogastric tube is introduced to the level of the mid-esophagus
NB: as we prevent aspiration by the nasogastric tube, so the only source of contrast in the bronchi is a Fistula.
2. CM (Barium or LOCM) is syringed in to distend the oesophagus.
For Oesophageal varices
1. Thick paste is used.
2. The oesophagus is filled with barium.
3. The patient is asked to perform Valsalva`s maneuver to enhance visualization of varices.
Aftercare: None.
Complications:
1. Barium leakage from unsuspected perforation.
2. Aspiration.

CONTRAST MEAL
Methods:
• Double Contrast (method of choice): show mucosal pattern for early detection of Carcinoma &
Ulceration.
• Single Contrast: in Children (mucosal pattern not necessary) - ill adults (gross pathology).
Indications:
1. Dyspepsia.
2. Suspected gastric & duodenal ulcers.
3. Assessment of site of perforation (Gastrographin or LOCM is essentially used)
4. Unexplained weight loss.
5. Pyloric stenosis.
6. GIT Haemorrhage.
7. Partial obstruction.
8. Carcinoma; Mass in upper abdomen
Contraindications:
1. Complete large bowel obstruction.
2. Suspected perforation (non-ionic water-soluble CM could be used).
Equipment:
AS CONTRAST SWALLOW >>>
Contrast media:
1. Barium :
o Volume: 75 – 150ml
o Concentration: 250% w/v (low-viscous/high density)
2. Carbex granules for double contrast techniques.
1. Nil orally for 6 hours before exam.
2. No smoking, as smoking increases gastric motility.
3. Ensure that there are no contraindications to the procedure or pharmacological agents used.
Preliminary films: None.
Technique: the Double contrast method
1. The fluoroscopy table is placed in the horizontal position.
2. The patient lies on his left side and asked to drink barium (this position prevents barium
reaching the duodenum quickly).
3. Then the patient turns supine and to the right side, to bring the barium against the gastro-
oesophageal junction (to check for presence of gastro-oesophageal reflux).
4. Intravenous Buscopan, 20 mg, is given (to overcome peristalsis & spasm).
5. The patient is then rolls over in a complete circle to finish in an RAO position.

Films:
There is a great variation in views recommended, In practice, precise patient positioning is achieved under
fluoroscopic control. The position of the patient as described here should be seen as a guide.
Position Demonstrates
Supine RAO Antrum and greater curve
Supine Antrum and body
Supine LAO Lesser curve
Supine Left Lateral Fundus
Prone Duodenal loop
Prone, RAO, Supine, LAO Duodenal Cap series
Erect RAO, LAO
Erect Fundus
Aftercare:
1. Patient should be warned that their bowel motions will be white for a few days after the examination.
2. The patient should be advised to drink adequate volumes of fluids to avoid barium impaction.
3. Examine the patient for any side effects of drugs used.
Complications:
1. Barium leakage from unsuspected perforation.
2. Aspiration of barium mixture.
3. Barium impaction.
4. Barium appendicitis.
5. Side effects of drugs used.

BARIUM FOLLOW-THROUGH
Methods:
1. Single contrast.
2. Enhanced with Effervescent agent.
3. Enhanced with Pneumocolon technique.
Indications:
1. Pain.
2. Diarrhea.
3. Anemia/ GIT bleeding.
4. Partial obstruction.
5. Malabsorption.
6. Abdominal mass.
7. Failed small bowel enema.
Contraindications: as barium meal
1. Complete large bowel obstruction.
2. Suspected perforation … use water-soluble CM.
Contrast media:
Barium is used unless there are specific contraindications.
1. Barium :
• Volume: 300 ml
• Concentration: 100% weight/volume (w/v)
• Advantages: as before
• Disadvantages: as before
2. Gastrographin: 10 ml may be added to Barium to reduce the transit time through the small
bowel.
Equipment:
AS CONTRAST SWALLOW >>>
1. Metoclopramide 20 mg orally 20 min before examination.
2. Nil orally for 6 hours before exam.
Preliminary film:
Plain abdominal film.
Technique:
§ Barium follow-through may accompany a barium meal or done alone.
§ The aim is to deliver a single column of barium into the small bowel.
1. The fluoroscopy table is placed in the horizontal position.
2. The patient is asked to swallow the Barium.
3. The patient is asked to lie on his right side.
4. If the transit time through the small intestine is found to be slow , a dry meal may help to speed
it up.
5. If a follow-through examination is combined with a barium-meal, glucagon is used for the
duodenal cap views rather than Buscopan because it has a short length of action and does not
interfere with the small bowel transit time.

Films:
1. A prone PA film (this position separates the loops of small bowel by pressure) of the abdomen is taken
every 20 min during 1st hour, then1 film every 30 min till barium reaches the colon.
2. Spot films of the terminal ileum are taken supine. A compression pad is used to displace any
overlying loops of small bowel that may obscure the terminal ileum.
§ Cassette: 35 x 45 cm longitudinal to include diaphragm.
§ Central ray: vertical – midline at level of lower costal margin.
Additional films:
To separate small bowel loops:
1. Oblique films.
2. With Tube angled into pelvis.
3. With the patient tilted head down.
To demonstrate diverticulae:
1. Erect to reveal any fluid levels caused by CM retained within the diverticulae.
Aftercare: As barium meal.

Complications: As barium meal.

SMALL BOWEL ENEMA
This test is similar to a barium follow through. However, instead of drinking the barium liquid, a thin tube
is passed down in the oesophagus, through the stomach and into the small intestine. Barium liquid is
then poured down the tube. This test is not commonly done, but can give some different information
about the small intestine than the above tests.
Advantage:
It gives better visualization of the small bowel than achieved by a barium follow-through because rapid
infusion of a large, continuous column of CM directly into jejunum.
Disadvantage:
1. Intubation may be unpleasant for the patient.
2. Time consuming.
3. Higher radiation dose.
Indications: As Barium follow-through.
NB: In some departments it is only performed in the case of an equivocal follow-through.
Contraindications:
As Barium follow-through.
Contrast Media:
Barium Sulphate:
• Volume: 1500 ml
• Concentration: 70% weight/volume (w/v) (low-viscousisty produces better mucosal
coating / reduced density permits the visualization of bowel loops)
• Advantages: as before
• Disadvantages: as before
Equipment:
1. AS BEFORE >>>
2. A Duodenal catheter "Bilbao-Dotter tube" OR "Silk tube” or a Nasogastric tube
1. A low-residue diet for 2 days prior to the examination.
2. Stop any antispasmodic drugs 1 day prior to the examination.
3. Nil orally 12 hours before.
4. Anaesthetize the pharynx with lignocaine spray immediately before exam.
Preliminary film:
Plain abdominal film.
Technique:
1. The patient sits on the edge of X-ray table.
2. Anesthetize the pharynx thoroughly with lignocaine spray.
3. The tube is passed through the nose or the mouth, ask the patient to swallow while tube passing
in the pharynx, advance tube to the gastric antrum.
4. The patient then lies down & the tube is passed down into the duodenum using one or
combination of the following maneuvers (this may be helped by Metoclopramide 20 mg IV).
5. The tube is then passed into the Duodeno-jejunal flexure to diminish the risk of aspiration due to
reflux of barium into the stomach.

6. Barium is then infused quickly (1000ml for single contrast) until the barium has reached the
colon. Double contrast method may also be used.
7. Fluoroscopy is performed during infusion and spot films are taken of the barium column at the
regions of interest, until the colon is reached.
8. The tube is then withdrawn; aspirate any residual fluid in the stomach to reduce the risk of
aspiration.
Aftercare:
1. Nil orally 5 hours after the examination.
2. The patient is warned that diarrhea may occur as a result of the large amount of fluids taken.
Complications:
1. Aspiration.
2. Perforation of the bowel due to manipulation of the guide wire.

BARIUM ENEMA
Methods:
1. Double Contrast: is the method of choice.
2. Single Contrast – Uses:
¬ Children – not necessary to show mucosal pattern.
¬ Reduction of intussusception.
Indications:
1. Change of Bowel habits.
2. Lower abdominal Pain.
3. Mass.
4. Rectal bleeding & Melaena.
5. Obstruction.
Contraindications:
Absolute:
1. Toxic megacolon.
2. Pseudo membranous colitis.
3. Rectal biopsy within the previous 3 days if performed with rigid sigmoidoscopy (better to wait for 7
days).
Relative:
1. Incomplete bowel preparation.
2. Recent barium meal.
3. Suspected bowel perforation or fistula : use non-ionic water-soluble CM.
Contrast Media:
• Barium Sulphate:
o Volume: 500 ml
o Concentration: 125 % weight/volume (w/v) (high-density /low viscosity).
• Air (as a negative contrast medium for double contrast).
Equipment:
1. Fluoroscopic unit with spot film device.
2. Tilting table.
3. Barium enema administration kit “Polythene barium container, Connecting tubing, Control
valve & Rectal catheter “Miller disposable enema tube”.
A good bowel preparation is a must.
The following is a suggested regime for bowel preparation:
A. For 3 days prior to examination: low residue diet.
B. On the day prior to examination: fluids only – laxatives (e.g. Picolax).
C. On the day of the examination:
1. Colonic washout with 2 liters of taped tap water.
2. Fluid restriction (this improves coating because the mucosa will be drier).
3. Prophylactic Systemic antibiotics (Amoxicillin 1 g – Gentamicin 120 mg IV 15 min prior to the
examination) for patients with prosthetic heart valves.
Preliminary film:
Not necessary, except if toxic megacolon is suspected.

Technique:
Double Contrast Barium enema
1. The patient lies on one side, and the catheter is inserted into the rectum.
2. Connections are made to the barium reservoir.
3. Smooth muscle relaxant (e.g. Buscopan 20 mg or Glucagon 1 mg) is given IV.
4. Barium is infused, intermittent screening is required to check the progress of the Barium and the infusion is terminated
when the Barium reaches the hepatic flexure.
5. Air is gently pumped into the bowel, forcing the column of Barium round towards the caecum, and producing the double
contrast effect.
6. The patient rolls onto his left side and ends in the RAO position so that the barium coats the bowel mucosa.
Films:
There is a great variation in views recommended, In practice, precise patient positioning is achieved under
fluoroscopic control. The position of the patient as described here should be seen as a guide.
• Spot films of the rectum and sigmoid colon (lying):
a. RAO
b. LPO
c. Prone
d. Left lateral of the rectum
• Spot films of the hepatic flexure, splenic flexure and rectum (erect):
a. RAO to open out the hepatic flexure.
b. LAO to open out the splenic flexure.
c. Right lateral of the rectum.
• Spot film of the caecum (lying):
The patient lies supine, slightly on the right side as this position usually gives a double contrast effect
in the caecum.
• Over couch films to demonstrate the entire large bowel (lying):
a. Supine.
b. Prone.
c. Left lateral decubitus.
d. Right lateral decubitus.
e. Prone, with the tube angled 45 cauded and centred 5cm above the posterior superior iliac
spines. This view separates loops of sigmoid colon.
Aftercare: As barium meal
Complications:
1. Perforation of the intestine especially in cases of intestinal ulceration, neoplasms and patients on
steroid therapy.
2. Barium intravasation.
3. Intramural barium.
4. Transient bacteraemia.
5. Cardiac arrhythmias due to rectal distension.
6. Side effects of the pharmacological agents used.

INSTANT BARIUM ENEMA
Indications:
1- To identify the level of suspected large bowel obstruction.
2- To show the extent and severity of mucosal lesions in active ulcerative colitis.
Contraindications:
1- Toxic megacolon.
2- Rectal biopsy within the previous 3 days.
3- Long standing ulcerative colitis → make a barium enema 1st to exclude carcinoma.
Preliminary film:
Plain abdominal film to exclude: Toxic megacolon and perforation.
Technique:
As normal barium enema.
Films: films are obtained as required e.g.
1- Prone
2- Left lateral decubitus.
3- Erect.

CHAPTER FOUR
BILIARY TRACT
IMAGIMG

ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY (ERCP)
Indications:
Suspected biliary or pancreatic disease e.g. obstructive jaundice in post-cholecystectomy patients.
Contraindications:
1- Oseophageal stricture or obstruction.
2- Pyloric stenosis.
3- Acute pancreatitis.
4- Recent gastric surgery.
Contrast Media:
LOCM : should be diluted to 50% strength with normal saline to ensure that calculi will not be obscured.
Equipment:
1- Fluoroscopic unit with a spot film device .
2- Side-viewing endoscope.
3- Polythene catheters.
1- Nil orally for 4-6 h prior to the examination.
2- Local anaesthetic lozenges may be given 30 min before the exam.
3- Sedation may be essential in special cases.
Preliminary Films:
Prone AP of the upper abdomen (check for opaque gallstones and/or pancreatic stones)
Technique:
1- The patient lies on his left side.
2- The endoscope is introduced - via the mouth - gently until the ampulla of Vater is identified.
3- The patient then is turned prone to assist the selective cannulation of the biliary duct.
4- A catheter filed with contrast medium is introduced via the endoscope.
5- Contrast is injected slowly under fluoroscopic control and a series of spot films are taken as
required when duct filling is complete.
Films:
Pancreas (using fine focal spot): Prone, RPO & LPO.
Bile ducts:
1- 1-early filling films to show calculi:
a- Prone –straight and posterior obliques.
b- Supine – straight, both oblique.
2- Films following removal of the endoscope, which may obscure the duct.
3- Delayed films to assess the gallbladder and emptying of the common bile duct.
Aftercare:
1- Nil by mouth until the anaesthetic has worn off.
2- Blood pressure and pulse are recorded every 30 min for 6 hours.
Complications:
1. Due to contrast media: allergic reactions – acute pancreatitis.
2. Due to the technique: damage by the endoscope e.g. rupture of the oesophagus,
damage to the ampulla – bacteraemia – septicemia.

PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY
(PTC)
Indications:
1. Cholestatic jaundice, to confirm or exclude extrahepatic bile duct obstruction.
2. Preoperatively on patients with obstructive jaundice to asses the site and extent of the lesion.
Contraindications:
Bleeding tendency (platelets < 100,000 - prothrombin time 2 seconds greater than control).
Contrast Media: LOCM : 20-60 ml
Equipment:
1- Fluoroscopic unit with a spot film device .
2- Chiba needle.
1- Coagulation studies: prothrombin time and platelet count are checked.
2- Prophylactic antibiotic cover is given 1 day prior to the study and continued 3 days afterwards,.
3- Nil orally for 4-6 h prior to the examination.
4- Sedation may be essential in special cases.
Preliminary Films:
Supine AP of the upper abdomen.
Technique:
1- The patient lies supine.
2- The injection site is identified under fluoroscopic control and marked on the skin surface.
3- Under strict aseptic conditions, local anaesthetic is administered at the injection site.
4- During suspended respiration the Chiba needle is inserted into the liver, but once it is within the
liver parenchyma the patient is allowed shallow respirations.
5- The trocar/stylet is withdrawn, and the needle connected to a syringe.
6- Contrast medium is injected under fluoroscopic control.
7- Images are acquired as the biliary tree is opacified.
8- Contrast and bile are aspirated at the end of the examination to reduce intrabiliary pressure and
the needle is removed.
9- Finally a sterile dressing is applied over the injection site.
Films:
Pancreas (using fine focal spot): Prone, RPO & LPO.
Bile ducts:
4- 1-early filling films to show calculi:
c- Prone –straight and posterior obliques.
d- Supine – straight, both oblique.
5- Films following removal of the endoscope, which may obscure the duct.
6- Delayed films to assess the gallbladder and emptying of the common bile duct.
Aftercare:
Blood pressure and pulse are recorded every 30 min for 6 hours.
Complications:
1. Due to contrast media: allergic reactions – acute pancreatitis.
2. Due to the technique: damage by the endoscope e.g. rupture of the oesophagus, damage to the
ampulla – bacteraemia – septicemia.

CHAPTER SEVEN
FEMALE
REPRODUCTIVE
SYSTEM

HYSTEROSALPINGOGRAPHY
Indications:
1. Primary & Secondary Infertility.
2. Recurrent abortions.
3. Assessment of tubal surgery.
4. Intervention: tubal canalization.
Contraindications:
1. Pregnancy.
2. Pelvic infection (A purulent discharge on inspection of the vulva or cervix).
3. Recent dilatation & curettage.
4. Recent abortion.
Contrast Media:
• HOCM e.g. Gastrographin or LOCM e.g. Ultravist, Iotrolan.
• Concentration: 300 mgI/ml
• Volume: 10 – 20 ml.
• Notes:
o LOCM has no advantages as regards the image quality or side-effects.
o Oily CM is no longer recommended.
Equipment:
Vaginal speculum
1. Fluoroscopy unit with spot film device. Vulsellum

2. Vaginal speculum.
forceps
3. Vulsellum forceps.
4. Uterine cannula or 8F pediatric Foley catheter.
• The examination is undertaken between 4th & 10th day of the cycle. (because during this
peroid the endometrium is restored –but not so thick- and the uterine cavity is free from clots & debris)
• No intercourse between booking the appointment & the time
of the examination.
HSG position
• The bladder & the rectum are evacuated.
• Premedication for apprehensive Patients.
• Paracetamol - 1 gm 1 hour before exam.
• Antibiotics: if there is positive history of PID and SBE.
Preliminary film:
Coned PA view of the pelvic cavity.
Speculum in position
Technique:
1. The patient is placed supine in the lithotomy position.
2. A lubricated speculum is introduced to dilate the vagina.
3. The anterior lip of the cervix is steadied with the Vulsellum
forceps.
4. The cannula is inserted into the cervical canal.
5. CM is slowly injected under fluoroscopic control.

NOTES:
o The procedure is done under complete aseptic conditions.

o Care must be taken to expel all air bubbles from the syringe and cannula, as these
would otherwise cause confusion in interpretation.
o Spasm of the uterine cornu may be relieved by IV glucagon.
Films: using the under-couch tube..

1. First film: as the tube begins to fill, demonstrating the uterine cavity & tubal filling.
2. Second film: when peritoneal spill has occurred & with all instruments removed.
Aftercare:
• Ensure that the patient has no serious discomfort or bleeding.
• The patient advised that she may have bleeding per vagina for 1 – 2 days & pain
may persist for up to 2 weeks.
Complications:
• Due to CM:
Allergic reaction – especially if CM is forced into the circulation.
• Due to Technique:
1. Abortion: the operator must be sure that the patient is not pregnant.
2. Bleeding: from trauma to the vagina, the cervix or the uterus.
3. Pain:
may occur during using the Vulsellum forceps, insertion of the cannula, with tubal
distension proximal to a block ,or with peritoneal irritation during the following day &
up to 2 weeks.
4. Nausea, vomiting & headache: usually transient.

5. Infection.
6. Intravasation of CM: into the venous system of uterus, intravasation is of little significance
when water-soluble CM is used.
Factors that predispose to intravasation:
§ Direct trauma to the endometrium.

§ Timing of the procedure near to the menstruation.
§ Timing of the procedure within few days after curettage.
§ Tubal occlusion due to high pressure generated within the uterine cavity.
§ Uterine abnormalities e.g. tuberculosis, carcinoma or fibroids.
Essential Charateristics of a Normal HSG:
o UTERINE CAVITY
§ The cavity is triangular in shape
§ Walls are regular and concave
§ Fundus may be convex
§ Length and intercorn. distance are about 35mm
o FALLOPIAN TUBE:
§ Length 7-14 cm .
§ Devided into: Interstitial, Isthmic, Ampullary,Infundibular& Fimbrial.

CHAPTER EIGHT
MAGNETIC RESONANCE
IMAGING
(MRI)
TECHNIQUES

MRI GENERAL POINTS
1. A surface coil gives a better signal-to-noise (S/N) ratio and improved resolution, without an
increase in scan time, than the body coil.
2. The smaller the field of view (FOV), the better resolution.
3. Intravenous gadolinium contrast agents are used for imaging:
a. Infections – to delineate fluid-filled or drainable collections.
b. Tumours – to characterize the lesion, determine the amount of necrosis and the extent
of surrounding oedema.
c. Vascular lesions e.g. AV malformations & aneurysms.
d. Synovial disease, e.g. rheumatoid arthritis.
e. Avascular necrosis, e.g. Perthe’s disease.
4. Artefacts in MRI
a. Chemical shift artefact:
• This is the most noticeable of the artefacts.
• Protons in fat and water have different resonant frequencies. Signal arising from
protons in fat will be interpreted as arriving from a different point along the
frequency encoded read-out axis relative to signal from water. This difference will
depend on the strength of the main magnetic field and will be more apparent at
higher field strengths.
• It is most noticeable around the bladder, kidneys and vertebral endplates (regions
with fat/water interfaces).
b. Motion artifact (ghosting):
• Biological motions e.g. cardiac, CSF pulsation, GIT, Respiratory and arterial pulsations
causes artefacts.
• This increases noise, edge blurring and streaking.
• Blood flow produces signal loss as protons in arterial or venous blood moving and
phase mismatches occur.
c. Ferromagnetic artefact:
• Ferromagnetic objects alter the T1 and T2 decay characteristics of the local magnetic
environment and usually result in a signal void around the object.
d. Radiofrequency artefact:
• RF noise degrades MR images. Patient generated noise can occur due to eddy
currents from thermal movement of ions. System-generated noise from coils or
amplifiers may produce specific patterns such as herring artefact. Extrinsic RF may
produce linear streaking and can arise from any malfunctioning electrical device, e.g.
light bulb or leaking RF door seals.
e. Aliasing artefact:
• If the field of view is smaller than the area of tissue excites, structures that are
peripheral to the field of view will wrap around the image and be seen on the
opposite edge.
f. Partial volume averaging:
• This is analogous to similar artefacts occurring in CT. the signal intensity of any
particular voxel is determined by the average signal intensity within it. Artefact due
to partial volume averaging increases with the section thickness.

MRI GENERAL SCHEME
Indications:
1. tumours.
2. Congenital anomalies.
3. infection.
4. Others ….
Contraindications:
1. Patients with cardiac pace maker and cochlear implant.
2. Patients with surgical aneurysmal clips.
3. Pregnancy: although there are currently no recognized adverse biological effects associated with
magnets up to 1.5 T, it is generally accepted that scanning in the first trimester of pregnancy is
contraindicated.
Contrast media:
• Gadolinium DTPA (Magnevist)
o Dose: 0.1 ml/kg – 0.2 ml/kg body weight.
o Route: intravenous (hand injection)
o Indications:
1. ….
Equipment:
• MRI unit: closed or open (for claustrophobic patients).
• ……
• Explain the procedure.
• Ensure that there no contraindication to the MRI or CM.
• All metallic objects worn by the patient should be removed.
• General anaesthesia or sedation may be necessary in some patients and children.
Patient Position:
• The patient lies supine on the scanner table, ……
Technique:
Techniques in use vary widely, and continue to change with the development of new imaging
sequences, the techniques described below are therefore only a guide to basic methods in use.
• Planes: Sagittal – Axial – Coronal ….
• Sequences: T1 (pre and post- contrast) – T2 – FLAIR – Proton density …..
• Typical parameters for spin echo (SE) pulse sequences:
o For T1 weighting (both TR and TE are short)
§ TR 300–500 ms
§ TE 10–30 ms
o For T2 weighting (both TR and TE are long)
§ TR ≥ 2000 ms
§ TE 280 ms
o For Proton weighting (TR is long and TE is short)
§ TR ≥ 2000 ms
§ TE 120 ms

MRI BRAIN
Indications:
1. Intracranial tumors.
2. Congenital CNS anomalies.
3. Intracranial infection.
4. Raised intracranial tension.
5. In cases of stroke, both ischemic and hemorrhagic.
6. In cases of seizures, migraine, demyelination, dementia and psychosis.
7. In cases of MS (multiple sclerosis): it is the only effective way of diagnosing multiple sclerosis.
Contraindications: general contraindications
Contrast media:
o Indications:
2. CNS tumors (Accurate delineation of tumour margins from oedema).
3. Demyelinating diseases – for differentiating acute from chronic plaques.
Equipment:
• Head coil.
Patient Preparation: General preparations
Patient Position:
• The patient lies supine on the scanner table, head resting in the head support of the head coil.
Technique:
Techniques in use vary widely, and continue to change with the development of new imaging
sequences, the techniques described below are therefore only a guide to basic methods in use.
• Initial midline sagittal localizer scans are obtained.
• Suggested Protocol:
§ Sagittal scan: T1 weighted sequence.
§ Axial scan: T1 (pre- and post- Contrast), T2, FLAIR sequences
§ Coronal scan: T1 or T2 sequences.
NOTES:
o T1-weighted (short TR sequences) sections are anatomically rich, but as a broad generalization
they less helpful for disease detection except in conjunction with intravenous gadolinium
contrast enhancement while FLAIR sequences (Fluid Attenuated Inversion Recovery): provide
great sensitivity in the detection of demyelination and infarction.

MRI ORBIT
Indications:
1. Exophthalmos.
2. Orbital tumors.
3. Vascular anomalies.
Contraindications: >>>>>
Contrast media: >>>>>
o Indications:
1. Orbital tumors e.g. optic neurofibroma, optic glioma, meningioma.
Equipment: >>>>>
• Head coil or surface coil (in case of globe lesion): it increases the signal-to-noise (S/N) ratio,
leading to increased spatial resolution without increase in scan time.
Patient Preparation: >>>>>
Patient Position: >>>>>
Technique:
Techniques in use vary widely, ……..
• Initial sagittal localizer scans are obtained.
§ Sagittal scan: Spin-echo T1 weighted sequences.
§ Axial scan:
• Spin-echo T1 weighted (before and after Contrast).
• Fast spin-echoT2 weighted.
§ Coronal scan:
• STIR (Short Time Inversion Recovery) sequence with fat saturation.
§ Oblique planes: may be required to show the optic nerve
NOTES: T1-weighted (short TR sequences) sections are anatomically rich, but as a broad generalization they less
helpful for disease detection except in conjunction with intravenous gadolinium contrast enhancement, while STIR
(Short Time Inversion Recovery) sequence suppressing the signal from retro-orbital fat.

MRI SHOULDER
Indications:
1. Diagnosis and evaluation of rotator cuff injury, impingment and instability.
2. Useful in frozen shoulder syndrome.
3. Synovial inflammation and tumours.
4. Diagnosis of marrow infiltrative lesions (some cases) localized to the shoulder joint.
Contraindications:
• As Before >>>>>
Contrast media:
• Routinely not used, but diluted Gd DTPA (0.4 ml in 100 cm saline) may be injected into the joint
prior to examination. It increases contrast between the labrum and the joint cavity.
Equipment:
• Shoulder coil or surface coil: it increases the signal-to-noise (S/N) ratio, leading to increased
spatial resolution without increase in scan time.
• Immobilization foam pads.
• As Before >>>>>
Patient Position:
• As Before >>>>>
Technique:
Techniques in use vary widely, ….
• Initial axial localizer scans are obtained.
§ Sagittal scan: Spin-echo T1 weighted sequences, slices are presented from the
glenoid cavity medially to the bicipital groove laterally.
§ Axial scan:
§ Coronal oblique scan: parallel to the supraspinatus muscle
• Spin-echo T1 weighted .
• PD (Proton Density Weighted).

MRI HIP
Indications:
1. Evaluation of unexplained hip pain suspecting avascular necrosis of femoral head.
2. Diagnosis of labral tears.
3. Inflammatory conditions e.g. Septic , TB.
4. Synovial tumours.
5. Slipped capital femoral epiphysis (subtle cases).
Contraindications:
• As before >>>>> + patients with metal prosthesis.
Contrast media:
o Route: intravenous (hand injection).
o Indications: in cases of tumours and post-operative evaluation.
Equipment:
• Body coil.
• As Before >>>>>
Patient Position:
• The patient lies supine on the scanner table; the legs straight and parallel to each other (the
patient feet towards the tube).
• The limbs are immobilized by foam pads and straps.
Technique:
Techniques in use vary widely…
• Initial Spin-echo T1 weighted axial localizer scans are obtained.
§ Sagittal scan:
• Spin-Echo T1 weighted sequences.
• Fast Spin-Echo T2 weighted sequences.
• Fast Spin-Echo Proton Density (PD) weighted sequences.
§ Axial scan: both hip joints are included
• Spin-echo T1 weighted (pre- and post-Contrast).
§ Coronal scan: slices may be angled so that they are parallel to each femoral neck.
• Spin-echo T1 weighted.
• Concepts of technique:
o Small FOV should be used to maximize resolution.
o Additional sequences may be used e.g. that including fat suppression techniques.

MRI KNEE
Indications:
1. Diagnosis and evaluation of meniscal tears.
2. Diagnosis and evaluation of cruciate ligaments tears.
3. Diagnosis of marrow infiltrative lesions (some cases) localized to the knee joint.
4. Bone tumours (e.g. osteosarcoma): MRI helps in detection the extent of the tumour to the
surrounding soft tissue.
Contraindications:
• As before >>>>> + patients with metal prosthesis.
Contrast media:
o Route: intravenous (hand injection).
o Indications: in cases of tumours and post-operative evaluation.
Equipment:
• Quadrate knee coil: it increases the signal-to-noise (S/N) ratio, leading to increased spatial resolution
without increase in scan time.
• As Before >>>>>
Patient Position:
• The patient lies supine on the scanner table; the knee in question is positioned in quadrate knee coil.
• The limb may be externally rotated 15 - 20° to bring the lateral femoral condyle parallel to the sagittal
plane facilitating visualization of ACL on sagittal images.
Technique:
Techniques in use vary widely…
• Initial Spin-echo T1 weighted axial localizer scans are obtained.
§ Sagittal scan:
• Spin-Echo T1 weighted sequences.
• Fast Spin-Echo T2 weighted sequences.
• Fast Spin-Echo Proton Density (PD) weighted sequences.
§ Axial scan:
• Spin-echo T1 weighted (pre- and post-Contrast).
§ Coronal scan:
• Spin-echo T1 weighted.
• Concepts of technique:
o Small FOV should be used to maximize resolution.
o Menisci & cruciate ligaments are best evaluated in sagittal images while the collateral
ligaments are best evaluated in coronal images.
o Meniscal tears are best imaged with MR sequences that are neither purely T1 nor T2
weighted.

MRI LUMBAR SPINE
Indications:
1. Disc prolapse (to detect cord or nerve root compression).
2. Spinal dysraphism (to detect cord termination).
3. Post operative spine.
4. Inflammatory conditions e.g. Discitis, Pott’s disease.
5. Evaluation of conus in patients with suggestive symptoms.
6. Tumours: e.g. ependymoma, astrocytoma, neuroma and secondary metastasis.
7. Trauma to the spine.
Contraindications:
• As Before >>>>>
Contrast media:
o Indications:
1. Tumours e.g. astrocytoma, ependymoma, meningioma.
Equipment:
• Phased array spinal coil: it increases the signal-to-noise (S/N) ratio, leading to increased spatial
resolution without increase in scan time.
• Immobilization foam pads to elevate the knees.
• As Before >>>>>
Patient Position:
• The patient lies supine on the scanner table, with the median sagittal plane perpendicular to the table
and the knees elevated on foam bad for comfort and to flatten the lumbar curve and thus the spine lies
nearer to the coil.
• The coil should extend from the xiphisternal joint to the bottom of the sacrum.
Technique:
Techniques in use vary widely …
• Initial coronal localizer (from the posterior aspect of the spinous processes to the
anterior border of the vertebral bodies) scans are obtained.
§ Sagittal scans:
• Spin-echo T1 weighted sequence (pre- & post- contrast); Fast Spin-echo T2
weighted.
§ Axial scan:
• Spin-echo T1 weighted (pre and post-Contrast) & Fast Spin-echo T2 weighted.
• Slices are taken parallel to each disc space and extend from the lamina above to
the disc.
§ Coronal scan (not routine):
• Spin-echo T1 weighted
MRI CERVICAL SPINE

Indications:
As lumbar.
Contraindications:
As lumbar.
Contrast media:
As lumbar.
Equipment:
• As Before >>>>>
Patient Position:
• The patient lies supine, head first, on the scanner table, with the median sagittal plane
perpendicular to the table and the spine positioned centrally over the phased array surface.
• The head and neck are positioned over the surface coil and a band is placed across the forehead
to minimize patient movement.
Technique:
As lumbar.
MRI DORSAL (THORACIC) SPINE
Indications:
As lumbar.
Contraindications:
As lumbar.
Contrast media:
As lumbar.
Equipment:
• As Before >>>>>
Patient Position:
• To identify the thoracic vertebrae accurately, it is necessary to position the patient and perform
the necessary localizer scans for lumbar imaging.
• The patient lies supine, head first, on the scanner table, with the median sagittal plane
perpendicular to the table and the spine positioned centrally over the phased array surface.
Technique:
As lumbar.

COMPUTED
TOMOGRAPHY
( CT )
TECHNIQUES

CT GENERAL SCHEME
Indications:
Trauma.
Mass.
Tumours.
+ Specific indications
Contraindications:
A. Due to radiation:
e.g. pregnancy.
B. Due to the contrast medium:
… see general notes
C. Due to the technique:
Skin sepsis at the needle puncture site.
Contrast media:
• HOCM e.g. Urografin. Or LOCM e.g. Ultravist (in high risk groups... etc).
o Indications: …..
o Route: IV.
o Dose: ….
o Flow rate: ….
• Gastrografin: in cases of abdomenal and pelvic examinations
o Indications: …..
o Route: Oral , rectally.
o Dose: ….
Equipment:
• CT unit: conventional, spiral or multi-slice...
• Contrast injector: ….
• Stabilizing foam pads.
• As Before >>>>>
Patient Position:
• The patient lies supine, (head or feet) first, on the scanner table, with the median sagittal plane
perpendicular to the table
Technique: 6 points
• Scout: .
• Slice thickness:
• Field of view (FOV): .
• Matrix:
• Radiation factors: kV: …. & mAmp: …..
• Window – level: brain – bone –lung ….. etc
Aftercare: examine the patient for any side effects of drugs used.
Complications: ..

CT BRAIN
Indications:
1. Following head injury with neurological deficit.
2. In cases of stroke, both ischaemic and haemorrhagic.
3. Suspected intracranial haemorrhage.
4. Suspected intracranial neoplasms e.g. meningioma, gliomas.
5. Vascular lesions e.g. aneurysms, AV malformation.
6. Inflammatory lesions e.g. brain abscess.
7. Congenital malformation e.g. brain atrophy.
8. Neurological symptoms e.g. convulsions, headache, dizziness...
9. Symptoms of increased intracranial tension e.g. projectile vomiting, blurring of vision...
Contraindications:
A. Due to radiation: e.g. pregnancy.
B. Due to the contrast medium: … see general notes
C. Due to the technique: Skin sepsis at the needle puncture site.
Contrast media:
• HOCM e.g. Urografin
o Indications: neoplastic, inflammatory lesions, vascular malformations.
o Not in: emergency conditions e.g. head trauma, haemorrhage.
o Dose & Route: 50-100 ml – IV. (1-2 ml/kg)
o Concentration: 300-370 mgI/ml.
o Flow rate: hand injection.
• LOCM e.g. Ultravist (in high risk groups... etc).
Equipment:
• CT unit: conventional, spiral or multi-slice...
• Stabilizing foam pads.
• Ensure that there no contraindication to the CT or CM.
• General anaesthesia or sedation may be necessary in some patients and children.
Patient Position:
• The patient lies supine, head resting in the head support and is secured in position with the aid of straps.
• Head first, on the scanner table, with the median sagittal plane perpendicular to the table.
Technique:
• Scout: lateral scan projection radiograph is obtained.
• Slice thickness: 5-mm contiguous sections, parallel to the cantho-meatal line, from the foramen magnum
to superior border of the petrous bone, with 10-mm sections to the vertex.
• Field of view (FOV): 22 cm in adults – 18 cm in children.
• Matrix: 512 × 512
• Radiation factors: kV: 120-140 & mAmp: 200
• Window – level: brain window 150-40 & bone window 1500-250 (in cases of trauma or suspected bone lesion)
Aftercare:….. Complications:….

CT ORBIT
Indications:
1. Orbit Trauma- location of foreign bodies.
2. Exophthalmos.
3. Tumours e.g. rtinpoblastoma, optic gliomas...
4. Vascular anomalies.
5. Bony anomalies.
Contraindications:
As before…
Contrast media:
As before…
Equipment:
As before…
As before…
Technique:
CT sections may be obtained in either the coronal or axial planes.
Axial plane imaging:
• Patient Position: The patient lies supine, head resting in the trans-axial head support.
• Scout: PA projection radiograph is obtained.
• Localizer: from the inferior orbital margin to superior orbital margin.
Coronal plane imaging:
• Patient Position:
o Method 1: the patient lies prone, the neck extended and the chin rests on the head support.
o Method 2: the patient lies supine, the neck extended, the gantry angled to establish the scan plane.
• Scout: Lateral projection radiograph is obtained.
• Localizer: from the inferior orbital margin to superior orbital margin.
NOTE: if spiral scanning options are available, the coronal images may be acquired with a volume
acquisition, using a 3 mm slice thickness and 3 mm table increments, but with a 2 mm reconstruction
index to give overlapping sections.
In Both Axial and coronal planes:
• Slice thickness: 3-mm contiguous sections.
• Field of view (FOV): 15 cm.
• Matrix: 512 × 512
• Window – level: soft tissue window 250-50 & bone window 1500-250 (in cases of trauma or
suspected bone lesion).
Aftercare:
Examine the patient for any side effects of drugs used.
Complications:
Due to CM …. Due to radiation….

CT SELLA TURCICA
Indications:
1. Pituitary gland tumours e.g. micro- and macro- adenoma.
2. Acromegaly.
3. Hyperprolactinemia.
4. Visual field defect.
5. Cavernous sinus syndrome.
6. Wide sella by X-ray.
Contraindications:
As before…
Contrast media:
As before…
Equipment:
As before…
As before…
Technique:
• Patient Position: The patient lies supine, head resting in the trans-axial head support,
positioning is aided by external alignment lights.
• Scout: lateral radiograph is obtained.
• Localizer: from the floor of the sella turcica to 10 cm above the anterior clinoid process of the
sphenoid bone.
• Localizer: starting immediately behind the posterior clinoid process and ending just in front of
the anterior clinoid process.
• Slice thickness: 1-2 mm contiguous sections.
• Matrix: 512 × 512
• Window – level: soft tissue window 250-50 & bone window 1500-250 (in cases of trauma or suspected
bone lesion).
Aftercare:
Complications:

CT PETROUS BONE
Indications:
1. Cholesteatoma.
2. Acoustic neuroma.
3. Glomus jugulare.
4. Tinnitus, vertigo…
Contraindications:
As before…
Contrast media:
As before…
Equipment:
As before…
As before…
Technique:
• Localizer: starting immediately above the petrous bone and ending just below of the petrous
bone.
• Localizer: starting immediately behind the petrous bone and ending just in front of the petrous
bone.
NOTE: if spiral scanning options are available, the coronal images may be acquired with a volume acquisition,
using a 3 mm slice thickness and 3 mm table increments, but with a 2 mm reconstruction index to give
overlapping sections.
• Slice thickness: 1-2 mm contiguous sections.
• Matrix: 512 × 512
• Window – level: soft tissue window 250-50 & bone window 1500-250 (in cases of trauma or suspected
bone lesion).
Aftercare:
Complications:

CT PARA-NASAL SINUSES
Indications:
1. Sinusitis.
2. Tumours.
3. Polypi.
4. Post-operative.
Contraindications:
As before…
Contrast media:
As before…
Equipment:
As before…
As before…
Technique:
• Localizer: starting immediately above the frontal sinuses and ending just below of the floor of
the maxillary.
• Localizer: starting immediately in front of the frontal sinus and ending just behind the sphenoid
sinus.
• Slice thickness: 5 mm sections and 2 mm sections in the region of osteo-meatal complex.
• Matrix: 512 × 512
• Window – level: bone window 1500-250 & soft tissue window 250-50.
Aftercare:
Complications:

CT NECK
Indications:
1. Tumours of pharynx, larynx.
2. Swellings e.g. lymph node, goiter, salivary glands…
Technique:
• Patient Position: The patient lies supine, neck extended, positioning is aided by external
alignment lights.
• Localizer: starting at the skull base (C1) and ending at upper chest.
• Slice thickness: 5 mm sections.
• Matrix: 256
• Window –level: soft tissue window 250-50 & bone window 1500-250 (if bone lesion is
suspected).
CT PAROTID
Indications:
1. Tumours.
2. Swellings …
3. Parotitis.
Technique:
• Patient Position: The patient lies supine, neck extended, positioning is aided by external
alignment lights.
• Localizer: starting at the EAM and ending at the lowe border of the mandible.
• Slice thickness: 3 mm sections.
• Matrix: 256
• Window –level: soft tissue window 250-50 & bone window 1500-250 (if bone lesion is
suspected).

CT CERVICAL SPINE
Indications:
As MRI
Contraindications:
As before…
Contrast media:
As before…
Equipment:
As before…
As before…
Technique:
• Patient Position: The patient lies supine, head resting in the trans-axial head support, positioning is
aided by external alignment lights.
• Localizer: starting from the base of the skull to C7
• Slice thickness: 3 mm sections parallel to disc space.
• Matrix: 256
CT LUMBO-SACRAL SPINE
Indications:
As MRI
Contraindications:
As before…
Contrast media:
As before…
Equipment:
As before
As before
Technique:
• Patient Position: The patient lies supine, head resting in the trans-axial head support, positioning is
aided by external alignment lights.
• Localizer: starting from L1 to S1
• Slice thickness: 3 mm sections parallel to disc space.
• Matrix: 256

CT CHEST
STANDARD PROTOCOL
Indications:
1. Plain chest X-ray revealed
2. Assessment of tumours of pleura, lung and mediastinum.
3. Assessment of fluid collection.
4. Detect metastatic deposits.
Contraindications:
As before…
Contrast media:
•
HOCM e.g. Urografin
o Dose & Route: 100 ml – IV just before examination.
o Flow rate: as a bolus - hand injection.
Equipment: As before…
Patient Preparation: As before..
Patient Position:
• The patient lies supine; the arms are raised and placed behind the patient’s head, out of the
scan plane.
• Head first on the scanner table, with the median sagittal plane perpendicular to the table.
Technique:
The patient is scanned during arrested inspiration, to reduce the motion artifact.
• Scout: PA scan projection radiograph is obtained.
• Localizer: starting just above the lung apices and ending just below the costophrenic angles.
• Slice thickness: 10 mm contiguous sections.
• Matrix: 256
• Window – level: lung window 1200-600 – mediastinum window 300-30 & bone window 1500-
250 (in suspected rib fractures or bone lesions)
Aftercare:
Complications:
o NOTES: In suspected bronchial carcinoma, scanning continues through the adrenal glands to check for
metastatic spread.
HIGH RESOLUTION PROTOCOL = HRCT
Indications:
This technique provide high resolution images of the lung parenchyma so used in assessment of
diffuse lung disease, arterial assessment (pulmonary emboli, aortic dissection).
Technique:
• 1-mm slices at 15-mm intervals in full inspiration.
• Image reconstruction using “bone” algorithm, i.e. high-resolution algorithm.
• Maximize spatial resolution using smallest field of view (FOV) possible.

CT ABDOMEN
Indications:
1. Abdominal mass e.g. liver, GB, GIT, spleen, pancreas,..
2. GIT bleeding e.g. hematemesis, melena, bleeding per rectum.
3. Tumour staging, detection of lymphadenopathy.
4. Bowel tumours.
5. Following abdominal trauma.
Contraindications:
As before…
Contrast media:
Oral and IV contrast media are usually employed.
IV contrast media:
• HOCM e.g. Urografin
o Dose & Route: 100 ml – IV just before examination.
o Flow rate: as a bolus - hand injection.
Oral contrast media:
• Urographin 38%: (10 ml diluted by 200 ml water) taken by the patient prior to the examination,
at intervals, to opacify GI tract.
Equipment:
As before…
As before..
Fasting 6 hours prior to examination is necessary.
The oral CM is taken by the patient –at intervals (1 cup every ½ hour) prior to- the examination
Patient Position:
• The patient lies supine; the arms are raised and placed behind the patient’s head, out of the scan plane.
• Feet first on the scanner table, with the median sagittal plane perpendicular to the table.
Technique:
The patient is scanned in arrested respiration, to reduce the motion artifact.
• Scout: AP scan projection radiograph is obtained.
• Localizer: starting just above the higher dome of diaphragm (the right) to the iliac crest.
• Slice thickness: 10 mm contiguous sections, 3 mm when examining small organs (pancreas, adrenal glands.
• Matrix: 256
• Window – level: soft tissue window 250-50 – liver window 160-60
Aftercare:
Complications:
NOTES:
o Almost all patients examined by CT for abdominal or pelvic lesions are indicated for IV contrast injection
except some limited circumstances e.g. acute abdominal trauma.
o The amount of oral contrast media and the intervals of intake are subject to great variation.

CT LIVER
SINGLE-PHASE CONTRAST ENHANCED
“Scanning the liver one time with a single contrast bolus”
80% of hepatic parenchymal blood flow is supplied by portal vein.
Lesions are detected in the portal phase of enhancement (60 sec after bolus injection)
DUAL-PHASE CONTRAST ENHANCED = TRI-PHASIC

“Scanning the liver twice with a single contrast bolus”
A. Scan at arterial phase: During the first 20 sec, opacification the hepatic arteries
B. Scan at venous phase: 60 sec after contrast injection, opacification of portal veins.
C. Delayed phase: 180 sec after contrast injection.
This examination needs to be performed in very short time, so conventional CT units are not suitable for it, and
the contrast should be injected by pump injector.
CT PELVIS
Indications:
1. Enlarged prostate.
2. Pelvic tumous e.g. prostate, rectum, colon , uterus, vagina, ovaries…
3. Tumour staging, detection of lymphadenopathy.
4. Following pelvic trauma.
Contraindications:
As before…
Contrast media:
Oral and IV contrast media are usually employed.
IV contrast media:
• As before…
Oral (or rectal) contrast media:
• Urographin 38%: (10 ml diluted by 200 ml water) taken by the patient prior to the examination, at
intervals, to opacify GI tract.
• It may be rectally to opacify the rectum.
Equipment:
As before…
As before..
Fasting 6 hours prior to examination is necessary.
The oral CM is taken by the patient –at intervals (1 cup every ½ hour) prior to- the examination
Patient Position:
• As abdomen…
Technique:
• Scout: AP scan projection radiograph is obtained.
• Localizer: starting just above the iliac crest to the lower border of the symphesis pubis.
• Slice thickness: 10 mm contiguous sections, 3 mm when examining small organs (urinary bladder and prostate)
• Matrix: 256
• Window – level: soft tissue window 250-50 – bone window 1500-250 (in cases of trauma or bone lesions)
Aftercare:
Complications:

ULTRASOUND AND
DOPLLER
TECHNIQUES

ULTRASOUND GENERAL SCHEME
Indications:
Contraindications:
Coupling gel:
It is essential for ensuring optimum image quality. This is applied to the examined surface to
ensure an air-free contact between the patient and the transducer face.
Equipment:
• Ultrasound unit: the majority of ultrasound machines give 2D cross-sectional images of tissue (B
mode) and usually have the facility to display echo depth in one direction against time (M
mode), while the more complex systems have the facility to display the Doppler spectrum or
colour flow images of moving blood.
• Transducers (probes): there is a variety of transducers available for use; the type of probe
selected depends on the examination requirements.
Patient Position:
Technique:
Aftercare: in cases of invasive e.g. biopsy taking procedures.
Complications:

ULTRASOUND OF THE LIVER
Indications:
1. Focal or diffuse liver lesion.
2. Hepatomegaly.
3. Jaundice.
4. Abnormal liver function tests e.g. elevated liver enzymes ALT, AST & Alfa fetoprotein.
5. Portal hypertension.
6. Fever of unknown origin.
7. Hepatic trauma.
8. Guided percutaneuos procedures.
Contraindications: None
Equipment:
• Real time ultrasound unit.
• Curved linear array 3-5 MHz
• 7.5 MHz transducer could be used in children.
• Fasting for 6-12 hours prior to the study to ensure that the gall bladder is full, and to reduce
bowel gases.
Patient Position:
• The patient lies supine, head resting in the head support.
• This position may be uncomfortable for elderly or very ill patients, so raise the patient’s head as
much as necessary; a comfortable patient is much easier to scan.
Technique:
1. Coupling gel is applied to the skin of the right hypochondrium.
2. Time-gain compensation (TGC) is set to give uniform reflectivity throughout the right lobe of
the liver.
3. A combination of sub- and intercostals scanning is used.
4. Scanning is done -at least- in 2 planes e.g. longitudinal and transverse.
5. Different angles of isonation can reveal pathology and eliminate artifact.
6. Deep inspiration is useful in a proportion of patients, but not all.
7. Upright or left lateral decubitus positions may be necessary if visualization of the whole liver
is still incomplete.
8. Because the size, shape and position of the gall bladder are infinitely variable, so are the
techniques required to scan it:
o The higher frequency probe is used e.g. 5 MHz or higher especially for anterior gall
bladders.
o A high line density is used to pick up tiny stones or polyps.
o The time gain compensation (TGC) is altered to eliminate or reduce anterior artefacts
and reverberation echoes inside the GB.
o Scanning the GB in at least 2 planes and 2 patient positions is usually necessary to not
miss pathology.

Normal appearance:
• The Liver:
o Homogenous parenchyma, same (or slightly increased) echogenicity when compared to the
right kidney.
o The smooth parenchyma is interrupted by vessels and ligaments.
o Normal liver contour should be smooth with no focal bulges.
o The inferior margin coming to a point anteriorly.
• Portal vein:
o The normal diameter usually does not exceed 14 mm.
o Walls are of increased reflectivity (HYPERECHOIC) in comparison to normal parenchyma.
o The blood flow is towards the liver (hepatopetal).
o The normal waveform on Doppler is mono-phasic with gentle undulations (due to respiratory
modulations).
• Hepatic veins:
o Unlike portal veins, their walls do not have a fibrous sheath and therefore their walls are less
reflective.
o The normal waveform on Doppler is tri-phasic reflecting right atrial pressures.
o The three main hepatic veins (left, middle and right) can be traced into the IVC at the superior
margin of the liver.
• The gall bladder:
o The size, shape and position of the gall bladder are infinitely variable.
o The normal GB wall is never more than 3-mm thick.
o After fasting for around 6 hours, it should be distended with bile into an elongated pear-
shaped sac.
o Normally it should have a hyperechoic, thin wall and contain anechoic bile.
• Bile ducts:
o The internal diameter of the common bile duct does not exceed 6 mm (in longitudinal
section), intrahepatically the duct diameter decreases.
o The right and left hepatic ducts are just visible, but more peripheral branches are usually too
small to see.
o The main, right and left hepatic ducts tend to lie anterior to the portal vein branches.
NOTE: Assessment of gallbladder function:

• Fasting GB volume may be assessed by measuring longitudinal, transverse and AP
diameters.
• Normal GB contraction reduces the volume by more than 25%, 30 min after a fatty meal.

ULTRASOUND OF THE PANCREAS
Indications:
1. Suspected pancreatic tumour.
2. Pancreatitis, for detection the cause and/or complications.
3. Epigastric mass.
4. Epigastric pain.
5. Jaundice.
6. Guided percutaneuos procedures e.g. biopsy.
Equipment:
• Curved linear array 3-5 MHz
• Fasting for 6-12 hours prior to the study, preferably overnight.
Patient Position:
• This position may be uncomfortable for elderly or very ill patients, so raise the patient’s head as
much as necessary; a comfortable patient is much easier to scan.
Technique:
1. Coupling gel is applied to the skin of the epigastium.
2. Time-gain compensation (TGC) is set to give uniform reflectivity.
3. Start by scanning the epigastium in transverse plane:
• Using the left lobe of the liver as an acoustic window.
• Using the splenic vein as an anatomical marker, the body of the pancreas can be
identified anterior to this.
4. Scanning is done -at least- in 2 planes e.g. longitudinal and transverse.
6. The transducer is angled transversely and obliquely to visualize the head and tail.
7. The tail may be demonstrated from a left intercostals view using the spleen as an acoustic
window.
8. Left and right oblique decubitus scans may be needed as gastric or colonic gas may prevent
complete visualization.
9. Water may be drunk to improve the window through the stomach and the scans repeated in
all positions.
Normal appearance:
o Its texture is rather coarser than that the liver, in adults the pancreas is hyperechoic
compared to normal liver.
o It has not a capsule and its margins can appear ill-defined.
o The main pancreatic duct can usually be visualized in the body of the pancreas; the normal
diameter should not measure more than 3 mm in the head or 2 mm in the body.

ULTRASOUND OF THE URINARY TRACT
Indications:
1. Renal mass e.g. tumours, cystic disease.
2. Suspected renal parenchymal disease.
3. Haematuria.
4. Possible renal obstruction e.g. due to stone, or tumour.
5. Urinary bladder mass or calculi.
6. Prostate evaluation.
7. Guided percutaneuos procedures e.g. biopsy, needle placement
Equipment:
• Curved linear array 3-5 MHz, 7.5 MHz transducer could be used in children.
• Preferably fasting for 6-12 hours prior to the study, preferably overnight.
• Full bladder is required for urinary bladder examination.
Patient Position:
Technique:
1. Coupling gel is applied to the skin.
3. The right kidney may be scanned through the liver and posteriorly in the right loin (lateral
decubitus).
4. The left kidney is harder to visualize anteriorly unless the spleen is large, but can be
visualized from the left loin, so turn the patient to the lateral decubitus.
5. Scanning is done -at least- in 2 planes e.g. longitudinal and transverse plans; this usually
requires a combination of subcostal and intercostal scanning.
7. The bladder is scanned suprapubically in transverse and; longitudinal planes; measurements
taken of 3 diameters before and after micturation enable an approximate volume to be
calculated.
8. The bladder volume can be estimated by taking the product of 3 perpendicular
measurements and multiplying by 0.56:
Volume (ml) = length × width × anteroposterior diameter (depth) × 0.56
Normal appearance:
• The kidneys:
o The cortex of the normal kidney is slightly hypo-echoic when compared to the normal liver.
o The renal sinus containing the PCS is hyperechoic due to sinus fat
o The normal adult kidney measures 9-12 cm in length.
• The urinary bladder:
o When the UB is distended with water, the walls are thin, regular and hyperechoic.
o The ureteric orifices can be demonstrated in a transverse section at the bladder base.

ULTRASOUND OF THE SPLEEN
Indications:
1. Splenomegaly e.g. due to portal hypertension, malignancy (leukaemia, lymphoma),
systemic infection, immunological diseases.
2. Splenic trauma.
Equipment:
• Curved linear array 3-5 MHz.
• Preferably fasting for 6-12 hours prior to the study, preferably overnight.
Patient Position:
Technique:
1. Coupling gel is applied to the skin.
3. The spleen is scanned in the left lateral aspect.
4. Gentle inspiration is frequently helpful.
5. Scanning is done -at least- in 2 planes e.g. longitudinal and transverse plans; this usually
requires a combination of subcostal and intercostal scanning.
Normal appearance:
o The normal spleen has a fine, homogenous texture, with smooth margins and a pointed
inferior edge.
o It has similar echogenicity (or slightly hypoechoic) to the liver, and more echogenicity than the
adjacent kidney.
o The main splenic artery and vein and their branches may be demonstrated at the splenic
hilum.
o The splenic length should not exceed 12 cm.

ULTRASOUND OF THE THYROID GLAND
Indications:
1. Neck mass: to assess the site of origin and characteristics.
2. Hyper- or hypo- thyroidism.
3. Guided percutaneuos procedures e.g. biopsy.
Equipment:
• Linear array 7.5 MHz or higher frequency may be used.
Patient Position:
• The patient lies supine and the head is slightly extended.
• A pillow is placed under the shoulders.
Technique:
1. Coupling gel is applied to the neck.
3. Each lobe and the isthmus are scanned separately.
4. The neck vessels (the carotid arteries and the jugular veins) are examined.
5. Scanning is done -at least- in 2 planes e.g. longitudinal and transverse plans.
7. Colour Doppler may be useful in assessing blood flow to masses demonstrated within the
gland.
Normal appearance:
o The thyroid consists of right and left lobes connected by a narrow bridge of tissue anterior to
the trachea called the isthmus.
o The normal thyroid gland has a homogenous echotexture of medium homogenicity.
o The common carotid artery and the internal jugular vein are important landmarks (anechoic
structures) that lie posterior and lateral to the thyroid and define its lateral margins.
o The sternomastoid, sternohyoid and sternothyroid muscles can be imaged anterior and lateral
to the thyroid gland.

ULTRASOUND OF THE BREAST
Indications:
1. It is used in preference to mammography in examining young breasts due to the amount of
glandular or tissue within them.
2. As a follow up to mammography to determine whether a lesion is a cyst.
3. Ultrasound gives different tissue information from that obtained by X-ray making this a useful
supplementary tool.
4. Interventional indications:
To facilitate the accurate placement of needles for: renal biopsy, antegrade pyelography,
percutaneuos nephrostomy, cyst aspiration and drainage of perinephric collections.
Contraindications: None.
Equipment:
• High frequency 5 - 10 MHZ linear array transducer.
1. Care must be taken all times to maintain privacy and dignity.
2. Chaperone is usually necessary.
Technique:
1. Patient lies supine with her arms are elevated above head.
2. Coupling gel is applied to the examined breast.
3. Each breast is examined in a systematic clockwise fashion, with the nipple as the centre of
the clock.
4. Each of the 4 quadrants of the breast and the axillary tail are examined using a combination
of longitudinal and transverse planes.
ULTRASOUND OF THE FEMALE PELVIS

Indications:
1. To identify the nature of pelvic masses.
2. Pregnancy – normal & suspected ectopic.
3. Abortions – complete &incomplete.
4. Location of IUCD.
5. Assessment of tubal patency.
6. Infertility procedures.
Equipment:
• 2 or 3 dimensional real-time ultrasound unit.
• 3.5 Or 5 MHz transducer (for TAS) or 7.5 MHz (for TVS).
• Colour Doppler is useful in assessment of tubal patency, vascularity of a mass or fetal
circulation.
• Full explanation of the technique is given to the patient.
• Patient consent.
• Chaperone is usually necessary.

• Full bladder is necessary for transabdominal scanning "it provides a good acoustic window for
visualization of pelvic organs"
• Empty bladder is necessary for transvaginal scanning.
Technique:
Transabdominal scanning (TAS):
1. The patient lies supine.
2. Coupling gel is applied to the lower abdomen.
3. Scanning is done -at least- in 2 planes e.g. longitudinal and transverse plans.
Transvaginal scanning (TVS):
1. The patient is placed supine in the lithotomy position.
2. Coupling gel is applied to the probe which is then covered with a condom.
3. The labia are separated and the probe is gently maneuvered to visualize the
anatomical structures.
4. The transducer probe should be disinfected after the procedure to prevent
cross-contamination.
CONTRAST MEDIUM
Galactose monosaccharide microparticles (Echovist) is a specific contrast agent employed in the
assessment of tubal patency; spillage of the microparticles into the peritoneal cavity infers patency.
Normal appearance:
Essential Characteristics of a Normal Uterus:
o Midline oval (in TS) or piriform (in LS) -shaped organ.
o Endometrium:
§ Menstrual phase: hypoechoic.
§ After menstruation: thin echogenic line.
§ Ovulation: endometrium separated from the myometrium.
§ After ovulation: thickened & more echogenic.
o Size = 5 – 8 cm length & 1.5 – 3 cm width.
Essential Characteristics of a Normal Ovary:
o Hypoechoic ovoid structure.
o Size = length × width × hight × 0.5 - Normally = 5.5 -10.5 cm.
o Follicles: follicular phase (small hypoechoic follicles 15- 28 mm) - ovulation (follicles disappear
with collapsed wall with fluid in Douglas pouch) - Post-ovulation (small follicles appear again).

ULTRASOUND OF THE PROSTATE GLAND
Indications:
1. Detection of prostatic tumors esp. carcinoma.
2. Elevated PSA.
3. Assessment of the size of the gland &the amount of residual urine in BPH.
4. Ultrasound guided biopsy.
Equipment:
• Real-time ultrasound unit.
• 3.5 or 5 MHz transducer (for TAS) or 6.5-7.5 MHz (for TRS).
• Color Doppler is useful in assessment of vascularity of a mass.
• Full explanation of the technique is given to the patient.
• Full bladder is necessary for transabdominal scanning "it provides a good acoustic window for
visualization of pelvic organs"
• Empty bladder is necessary for transvaginal scanning.
• Antibiotics (e.g. 80mg Gentamicin) given 3 days prior to the procedure if a biopsy is intended.
• Local anaesthesia prior to the biopsy.
Technique:
Transabdominal scanning (TAS):
2. Coupling gel is applied to the lower abdomen.
3. Sagittal, transverse and oblique images are taken as required.
Transrectal scanning (TRS): method of choice, as it is clearly demonstrating zonal anatomy.

1. The patient lies on the left side, arms resting on the pillow & knees flexed.
2. Coupling gel is applied to the probe which is then covered with a condom.
3. The probe is gently maneuvered to visualize the anatomical structures.
4. The transducer probe should be disinfected after the procedure to prevent
cross-contamination.
Transperineal scanning:
In this method the risk of infection is reduced during biopsy taking.
Normal appearance:
Essential Characteristics of a Normal Prostate:
o Clearly defined pear-shaped organ at the base of the UB.
o Anatomically subdivided into peripheral gland (peripheral & central zones) and central gland
(transitional & periuretheral zones).
o The volume of the prostate = length × width × hight × 0.5. Normally < 22 ml.
Essential Characteristics of Normal Seminal Vesicles:
o By TAS: 2 areas of low reflectivity on either side of midline.

o As echogenic as prostate.
o Symmetrical appearance.
o Normal AP diameter < 10 mm.
ULTRASOUND VENOGRAPHY
Indications:
1. Suspected deep vein thrombosis (DVT).
2. Follow up of unknown DVT.
3. To guide access for interventional venous procedures.
Equipment:
• Real-time ultrasound unit.
• 5 – 7.5 MHz transducer.
• Color Doppler is useful.
Patient preparation: None.

Technique:
1. The patient lies supine with foot-down tilt. The popliteal and calf veins can be easily
examined with the patient sitting with legs dependent or lying on a tilted couch with flexed
knees and externally rotated hips. The femoral veins and external iliac veins are examined
supine and the popliteal veins may be examined with the patient prone.
2. Longitudinal and transverse scans for external iliac, femoral and popliteal veins.
3. Each vein may be identified by real-time scanning and colour Doppler. If any doubt it may be
confirmed as a vein by the spectral Doppler tracing. A normally patient vein can be
completely occluded on real time scanning by transducer pressure.
4. The normal venous signal is phasic and in the larger veins varies with respiration. Flow can
be stopped by a Valsalva maneuver and is augmented by distal compression of the foot or
calf.
5. Acute thrombus may be non-echogenic but the vein should not fill with colour Doppler and
should not be compressible. The thrombus tends to become echogenic after a few days.
Note: although this technique is less well established for the exclusion of thrombus in the calf
vessels, it has been shown to have a sensitivity and specificity close to that of Venography.

BREAST
Imaging modalities include:

1- Mammography.
2- Ultrasound and Doppler.
3- Ductography.
4- CT.
5- MRI.
6- Radio-isotope scanning.
7- Thermography.
8- Diaphography.

MAMMOGRAPHY
Indications:
1. Breast mass.
2. Pain.
3. Nipple discharge.
4. As a part of screening for breast cancer..
Contraindications:
1. Pregnancy.
2. Lactation.
3. During menstruation.
Limitations:
1. Not done during pregnancy and lactation.
2. Young patients as dense breast tissue may hide mass.
3. Need special apparatus and technique.
4. Does not differentiate between solid and cystic masses.
Equipment and exposure factors:

1. The kVp output is between 25 – 35 kVp.
2. The tube current is kept as high as possible to minimize exposure times.
3. Total filtration: 0.03 mm molybdenum.
4. Exposure time should be < 2 seconds.
5. The focal spot < 0.6 mm.
6. The film/screen combination must be high resolution film/screen combination.
7. The focus to film distance (FFD) must be 60 cm or more.
Projections:
1- Cranio-caudal view: patient is standing, facing the machine- both the breast table and the tube
are horizontal – markers are placed on the axillary side – the breast is compressed firmly.
2- Medio-lateral view: patient is standing, facing the machine- both the breast table and the tube
are vertical – markers are placed outside – the breast is compressed firmly.
3- Others: Latero-medial , Oblique view & Axillary view: to visualize the axillary tail and lymph
nodes.
NormaL mammography appearance:

1. Skin thickness < 2mm.
2. Subcutaneous tisssue is radiolucent.
3. Nipple is protruded.
4. Glandular and fatty elements vary with age and physiology.

VENOUS SYSTEM
Methods of imaging:
1- Venography.
2- Ultrasound.
3- Computed tomography (CT): can show IVC involvement and
renal vein involvement in renal cell carcinoma and Wilms’
tumour.
4- MRI: will show the presence r absence of flowing blood. The
ability of MR to image in the plane of the vessel makes it well
suited to assessing in the venous system. Flow artifact can
cause problems in interpretation but the use of bolus
gadolinium enhancement techniques, combined with volume
gradient echo imaging can produce excellent visualization of
the venous system. In addition, MRI can be used to age
thrombus and differentiate acute from chronic clot.
5- Radioisotopes: the patency of blood vessels may be examined
using 99m Tc-colloid or 99m Tc-macro aggregated albumin (MAA)
injecting into a supplying vessel with fast-frame dynamic
imaging. Thrombus may be imaged with 111 In- or 99m Tc-invitro
labelled platelets.

LOWER LIMB VENOGRAPHY
Indications:
1. Deep Venous Thrombosis (DVT).
2. Oedema of unknown cause.
3. Demonstration of incompetent perforating veins.
4. Congenital malformations involving the venous system.
Contraindications: Local sepsis.
CM: LOCM 240 (Niopam)
Equipment:
2. Tilting table.
1. Fasting for 6 hours.
2. Elevation of the examined leg overnight before examination, if oedema is
severe.
Preliminary films: using undercouch tube
1. PA Knee
2. PA ankle.
Technique:
1. The patient lies supine with the head raised on a shallow pillow to delay the
transit time of the contrast medium.
2. A tourniquet is applied above the ankle to occlude the superficial veins.
3. A Butterfly needle is inserted into a distal vein on the dorsum of the foot.
4. 40 ml of CM is injected and the first spot films (PA calf and PA knee) are
taken.
5. A further 20 ml of CM is injected quickly whilst the patient performs a
Valsalva maneuver to delay the transit time of the contrast medium in the
proximal and pelvic veins.
6. At the end the Butterfly needle is flushed with saline to avoid the risk of
phlebitis due to stasis of CM.
Films:
1. AP and Obliques (external and internal rotation) of the calf.
2. AP of the popliteal, common femoral and iliac veins.
Aftercare: Limb exercise.

Complications:
a. Due to CM:
1. General complications of I.V. CM.
2. Thrombophlebitis.
3. Tissue necrosis due to extravasation of CM.
4. Cardiac arrhythmia.
b. Due to Technique:
1. Haematoma.
2. Pulmonary embolus.
UPPER LIMB VENOGRAPHY

Indications:
1. Oedema of the upper limb.
2. Demonstration of the site of a venous obstruction.
3. SVC obstruction.
CM: LOCM 300 (Niopam).
Equipment: Fluoroscopic unit with spot film device.
Patient preparation: fasting for 6 hrs.
Preliminary films: using undercouch tube

• PA Shoulder
Technique:
2. A Butterfly needle is introduced into the median cubital vein.
3. 30 ml of CM is injected and the spot films are taken.
4. At the end the Butterfly needle is flushed with saline to avoid the risk of
phlebitis due to stasis of CM.
Aftercare: None
Complications: ….

SUPERIOR VENA CAVOGRAPHY
Indications:
1. Demonstration of the site of a venous obstruction.
2. Congenital abnormalities of venous system.
CM: LOCM 370 (Niopam), 60 ml.
Equipment: Rapid serial radiography unit.
Preliminary films: PA upper chest & lower neck.
Technique:
2. 2 Butterfly needles are introduced into the median antecubital veins of
both arms.
3. 30 ml of CM per side is injected (simultaneously and rapidly by 2 operators).
4. The injection is recorded by rapid serial radiography.
Films:
Rapid serial radiography is performed: 1 film/sec for 10 seconds.
Aftercare: None
Complications: ….

INFERIOR VENA CAVOGRAPHY
Indications: as SVC
CM: as SVC
Equipment:
1. Rapid serial radiography unit.
2. Catheter.
3. Pump injector.
Preliminary films: Centered to region of interest.
Technique:
2. The catheter is inserted into the femoral vein using Seldinger technique.
3. 40 ml CM is injected by pump injector (in 2 sec).
4. The injection is recorded by rapid serial radiography.
Films:
Rapid serial radiography is performed: 1 film/sec for 10 seconds.
Aftercare:
1. Pressure at the puncture site.
2. Observation for 2 hours.
Complications:…
PORTAL VENOGRAPHY
Indications:
1. Demonstration of the anatomy of the portal system prior to operations in
patients with portal hypertension.
2. To check the patency of a porto-systemic anastomosis.
Methods:
1. Trans-splenic approach.
2. Trans-hepatic approach.
3. Late phase superior mesenteric angiography.
4. Para-umbilical vein catheterization.
CM: LOCM 370 (Niopam), 50 ml.
Equipment:
1. Rapid serial radiography.
2. Arterial catheter (SMA approach).
3. 10-cm needle (20-G) with stiletto and outer plastic sheath.

1. Admission to hospital.
2. Check clotting factors.
3. Ascites is drained.
4. Nil orally for 6 hours prior to the procedure.
5. Sedation using Diazepam 10 mg orally.
Technique: (Trans-splenic approach)
2. The position of the spleen is detected using ultrasound or by percussion.
3. The access point is as low as possible in the midaxillary line, usually at the
level of the tenth or eleventh space.
4. The region is anaesthetized using a sterile procedure.
5. The patient is asked to hold his breath in mid-inspiration, and the needle
introduced inwards and upwards into the spleen.
6. The needle and stiletto are then withdrawn, leaving the plastic cannula in
situ. Blood will flow back easily if is correctly sited.
7. The patient is asked to breathe as slowly as possible to avoid trauma to the
spleen from excessive movement of the cannula.
8. A test injection of small volume of CM under screening control. If cannula
outside spleen, complete repuncture is necessary.
9. When cannula in proper position, Measure the splenic pulp pressure by a
sterile manometer (normally 10 – 15 mmH2O).
10. Hand injection of 50 ml CM in 5 sec and recorded by rapid serial
radiography.
11. The cannula should be removed as soon as possible to minimize trauma to
the spleen.
Films: by rapid serial radiography 1 film/sec for 10 seconds.
Complications:
a. General complications of CM.
1. Haemorrhage.
2. Subcapsular injection.
3. Trauma to of adjacent structures e.g. pleura, colon.
4. Splenic rupture.
5. Infection.
6. Pain especially with an extra capsular injection.

DESCENDING (RETROGRADE) VENOGRAPHY
Aim:
1. Evaluation of L.L. venous valvular function.
2. Degree of deep veins reflux.
Equipment:
2. Tilting table.
3. set of Needles, Catheters, guide-wire
Technique:
1. Patient lies supine.
2. Aseptic skin preparation for the groin region.
3. Local anaesthesia at a point 1 cm medial to femoral artery pulsations & 3 cm below
inguinal ligament.
4. 5 mm skin incision over femoral vein → facilitate needle introduction.
5. Introduce needle by Seldinger technique while pt performing valsalva → distend femoral
vein.
6. Remove trocar after puncture → withdraw needle slightly while gentle suction applied
to a saline-filled syringe.
7. When blood return, remove needle → insert guide-wire for few centimeters → remove
needle → insert a short catheter (6 French end-hole).
8. Test injection.
9. Place pt 60° semi-upright on tilting table → retrograde flow.
10. During quiet respiration, Inject 15 ml urografin 60% by hand injection slowely under
fluoroscopic control.
11. Spot films for: iliofemoral region, thigh, leg during injection. Valsalva may be done →
assist retrograde flow of CM.
12. Functional integrity of the venous valves is classified as follows:
a. Grade 0:Competent with no reflux CM.
b. Grade 1:Minimal incompetent, reflux beyond uppermost femoral valve but not
beyond midthight.
c. Grade 2: Mild incompetent, reflux into the femoral vein → knee level.
d. Grade 3: Moderate incompetent, reflux to a level just below knee.
e. Grade 4: Severe incompetent, reflux into Calf veins at level of the ankles.
Aftercare:
Limb exercise
Complications:
a. Due to CM:
1. General complications of I.V. CM.
2. Thrombophlebitis.
3. Tissue necrosis.
4. Cardiac arrythmia.
1. Pulmonary embolus.
2. Haematoma.

VERTEBRAL
COLUMN

METHODS OF IMAGING
1. Plain x-ray films: AP, Lateral and oblique are useful in a wide variety of spinal pathologies e.g.
suspected spinal injury, developmental malformations and spondylolisthesis.
2. Tomography: where both CT and MRI are unavailable.
3. Myelography: visualization of the spinal canal of the vertebral column by CM injection into the
subarachnoid space, nowadays it is of limited use as CT and MRI myelography have superior
diagnostic advantages.
4. Radiculography: performed by injecting CM into the lumbar thecal sac, indicated in suspected
lumbar root or cauda equine compression, spinal stenosis and conus medullaris lesions in
patients in whom CT is inconclusive and who are unable to undergo MRI.
5. Discography: performed by injecting non-ionic CM e.g. iopamidol or iohexol into an
intervertebral disc. Rarely indicated in degenerative diseases of thee spine, in degenerated
discs, discography shows a reduced disc height, and complex or multiple irregular fissures in the
annulus fibrosis, with or without contrast leakage through annular tears.
6. Facet joint arthrography: this is a technique for the verification of pain of facet joint origin.
7. Epidurography and epidural venography: are obsolete.
8. Arteriography: used for study of vascular malformations shown by other methods, usually MRI.
9. CT with CSF opacification by interathecal CM (NB: not IV): CT myelography.
10. Radionuclide imaging: commonly performed (highly sensitive)for detection of bone metastases.
11. MRI: with or without IV gadolinium enhancement is the preferred technique for most spinal
pathology; it is the only technique for diagnosing spinal multiple sclerosis, and the best
technique for the acute management of spinal compression.
MRI has revolutionized the imaging of spinal disease; advantages include non-invasiveness,
multiple imaging planes, high soft tissue contrast and lack of radiation exposure.
12. Ultrasound: very limited rule in neonates and intraoperatively.

CERVICAL MELOGRAPHY
Indications:
Suspected spinal cord pathology , if the patient unable or unwilling to undergo MRI.
• Degenerative diseases e.g. disc herniation with root compression, ankylosing spondylosis
• Tumors e.g. ependymoma, metastases.
• Spinal trauma.
Contraindications:
1. Acute inflammation or infection.
2. Suspected increased intracranial tension.
3. Recent lumbar puncture (within one week).
4. Due to radiation: pregnancy.
Contrast media:
• Water soluble CM: e.g. iohexol (Omnipaque®) and Iotrolan (Isovist®).
o Concentration: 200-300 mgI/ml
o Dose: 10-15 ml (max. dose is equivalent of 3 g iodine)
• Oily CM e.g. Lipidol and myodil are obsolete nowadays.
Equipment:
1. Fluoroscopy unit with tilting table is preferred.
2. 20-G or 22-G needles.
1. Mild sedation using oral diazepam may be necessary.
2. Explain the procedure and obtain consent.
3. The patient is asked to empty his bladder prior to the start of the procedure.
Preliminary films:
• AP view:
o 24×30 cm cassette is placed longitudinally.
o The vertical central ray is directed to a point 5 cm above the suprasternal notch.
• Lateral view:
o The centering point is 2.5 cm posterior to the mandible angle.
Patient Position:
• The patient lies prone on the scanner table with arms at the sides.
Technique:
1. Using lateral fluoroscopy the C1/2 space is identified.
2. Using aseptic technique, the skin and subcutaneous tissues are anaesthetized with 1% lignocaine.
3. A 20-G needle is introduced parallel to the long axis of the spine between the laminae of C1 and C2
(lateral fluoroscopy is used to adjust the direction of the needle).
NB: The patient is asked to remain absolutely still during the insertion of the needle.
4. The stilette is removed and a small amount of CSF is obtained as a sample.
5. Under fluoroscopy a small amount of CM is injected to verify correct needle tip placement (this will flow
away from the needle tip and gravitate anteriorly to layer behind the vertebral bodies).
6. Injection is continued slowly until the required dose has been delivered.
7. If the CM tends to flow into the head before filling the lower cervical canal, tilt the table feet down and
vice-versa if the contrast flowing into the thoracic region without filling the upper cervical canal.
NOTE: lumbar injection for cervical myelography is as effective as cervical injection when nothing
restricts the upward flow of CM.

Films:
AP, lateral and oblique views are taken as required.
Aftercare:
1. Headache may occur up to 12 hours after the procedure, so the patient is asked to sit upright
after the procedure for several hours and to sleep on raised pillows.
2. Observe the patient for any complications.
Complications:
1. Headache: the commonest complication (in 30-40% of patients).
2. Nausea and vomiting in about 5%.
3. Infection e.g. meningitis, arachnoiditis.
4. Injury to the spinal cord.
5. Bleeding and hemorrhage.
6. Hypotension.
LUMBAR MELOGRAPHY
(RADICULOGRAPHY)
As cervical myelography except in
Preliminary films:
• AP and lateral views of the region under study :
o The vertical central ray is directed to the lower costal margin (L3).
Patient Position:
• The patient in the lateral decubitus.
Technique:
1. Using lateral fluoroscopy the L2/3, L3/4
OR L4/5 space is identified.
2. Using aseptic technique, the skin and
subcutaneous tissues are anaesthetized
with 1% lignocaine.
3. A 22-G needle is introduced with a slight
cranial angulation between the laminae
of L2 and L3 (lateral fluoroscopy is used
to adjust the direction of the needle).
NB: The patient is asked to remain
absolutely still during the insertion of
the needle.
4. The stilette is removed and a small
amount of CSF is obtained as a sample.
5. Under fluoroscopy a small amount of CM
is injected to verify correct needle tip placement (this will flow away from the needle tip and gravitate
anteriorly to layer behind the vertebral bodies).
6. Injection is continued slowly until the required dose has been delivered.
7. After the injection of CM, the patient turns to lie prone, and a series of films is obtained. Before taking
films ensure that the relevant segment of the spinal canal is adequately filled with CM, this requires
some degree of feet down tilt of the table.

DOPPLER
TECHNIQUES

CAROTID STUDY
The neck vessels can be examined by means of ultrasound equipment which combines real-time B-mode imaging, pulsed
Doppler and colour Doppler. Using this combination, vessel anatomy is demonstrated and blood flow qualified using
spectral analysis.
Indications:
Suspected vascular disease at the carotid bifurcation, which is a common site of atherosclerotic lesions,
associated with transient ischaemic attacks (TIAs).
Equipment:
1. Real-time ultrasound unit.
2. 7.5 MHz transducer (for B-mode), 5 MHz (for Doppler).
Patient Preparation: None
Patient Position:
• The patient lies supine, with extended neck & the head is turned away from the side being examined.
Technique:
1. A transverse scan is performed to locate the position of the carotid bifurcation and to orient the vessels.
2. Each of the ECA and ICA has characteristic Doppler waveform in Pulsed Doppler; the ICA has no branches
extra-cranially.
3. A Longitudinal scan is carried from the clavicle to the angle of the jaw using anterior and posterior
oblique approaches.
4. Areas of abnormalities are noted and percentage of area stenosis is estimated.
5. The dynamics of blood flow can also be demonstrated using colour flow mapping.
6. In order to encode the arterial colour signals in the transverse scanning, the transducer is angled 30
degree to the vertical plane, while in the longitudinal scan; the colour window is angled 30 degrees from
the vertical.
B-mode imaging of the carotid lesions:
1. Measurement of the intima-media thickness.
2. Detection of atherosclerotic plaque characters:
a. Echogenicity: homogenous or heterogenous “suspects intra-plaque hemorrhage”.
b. Surface: smooth, irregular, or ulcerating.
c. Calcification: partially or totally.
3. Diagnosis of dissection.
4. Measurement of percent diameter reduction in stenotic lesion by comparing the residual lumen to the
true lumen at the same site of the lesion or to the lumen in a normal distal segment.
Colour Doppler flow imaging:
1. It shows the course of the artery.
2. The normal carotid bifurcation shows a zone of flow separation near the origin of the ICA and another
smaller zone at the origin of the ECA, this zone is absent in the presence of atherosclerotic lesions.
3. Diagnosis of occluded vessel by complete absence of color Doppler flow (i.e. can differentiate total
occlusion from more than 95% stenosis).
4. Measurement of percent diameter reduction in stenotic lesion by similar way in the B-mode imaging.
Pulsed Doppler:
1. The normal ICA has a high pitch frequency with a high diastolic flow.
2. The normal ECA has a strong multiphasic signal with a high peak systolic frequency.
3. The CCA has a waveform that half-way between the ICA and ECA.
4. Turbulent blood flow can be induced by atheromatous causes and by non-atheromatous causes such as
carotid bulb, branching vessel, tortuous or kinked vessel.

RENAL STUDY
Indications:
1- Detection of hemodynamically significant renal artery stenosis.
2- Evaluation of renal parenchyma (in systemic diseases and conditions such as
acute tubular necrosis).
3- Diagnosis of renal artery or renal vein occlusion.
4- Diagnosis of arteriovenous fistulae and malformations.
5- Intraoperative monitoring of the renal artery reconstruction.
Equipment:
1. Real-time ultrasound unit.
2. 2.5 - 3.5 MHz transducer.
Patient Preparation: overnight fasting.
Technique: two approaches
Trans-abdominal approach:
2. The probe is placed 2 or 3 cm caudal to the xiphoid process along the midline of the abdomen.
3. Initially, the long axis of the abdominal aorta is displayed with a parallel segment of the
superior mesenteric artery viewed anteriorly.
4. The probe is rotated 90 degree at this position and moved cranially and caudally until a cross
section of the abdominal aorta and a long axis view of one or both of the renal arteries are
imaged.
5. With the renal artery visualized the sample volume is positioned on the vessels and the
Doppler signals obtained after adjustment of the angle cursor.
Trans-lumbar approach:
1. The patient lies prone.
2. The probe placed 5-6 cm lateral to the spinous process at the 12th rib or 3 cm below the 12th
rib.
3. The long axis of the kidney is seen and subsequently the probe is shifted medially until the
renal hilum is imaged.
4. The sample volumes are positioned on these vessels.
The renal spectral waveform:
• The spectral waveform of the renal arteries is characteristic of arteries supplying low resistance vascular
beds such as the internal carotid and hepatic arteries.
• These arteries are characterized by:
1. A forward flow during systole and diastole.
2. No diastolic flow reversal.
3. A sharp systolic peak with gradual systolic deceleration.
4. A high end-diastolic flow.
• The estimated Doppler parameters:
1. The peak systolic velocity (PSV).
2. The end diastolic velocity (EDV).
3. The resistivity index (RI) = (PSV-EDV) / PSV
4. The pulsatility index (PI) = (PSV-EDV) / mean velocity.

Basic Radiological Techniques

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2007

Basic Radiological Techniques... By Abdelrahman Abdelhalim 2

Basic Radiological Techniques... By Abdelrahman Abdelhalim 3

Basic Radiological Techniques... By Abdelrahman Abdelhalim 4

Radiographic MRI Ultrasonography

Iodine Barium Bromine

RADIOGRAPHIC CONTRAST MEDIA

Basic Radiological Techniques... By Abdelrahman Abdelhalim 5

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Ø Indications for LOCM

• Treatment of adverse reactions:

Basic Radiological Techniques... By Abdelrahman Abdelhalim 9

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Basic Radiological Techniques... By Abdelrahman Abdelhalim 12

Basic Radiological Techniques... By Abdelrahman Abdelhalim 13

Basic Radiological Techniques... By Abdelrahman Abdelhalim 14

Basic Radiological Techniques... By Abdelrahman Abdelhalim 15

Basic Radiological Techniques... By Abdelrahman Abdelhalim 16

Contraindications: Acute urinary tract infection

Equipment: Fluoroscopy unit

Patient preparation: Preparation for surgery

Basic Radiological Techniques... By Abdelrahman Abdelhalim 17

Basic Radiological Techniques... By Abdelrahman Abdelhalim 18

Contraindications: Acute UT infection.

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Basic Radiological Techniques... By Abdelrahman Abdelhalim 23

Basic Radiological Techniques... By Abdelrahman Abdelhalim 24

Basic Radiological Techniques... By Abdelrahman Abdelhalim 25

Basic Radiological Techniques... By Abdelrahman Abdelhalim 26

Aftercare: As barium meal.

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Basic Radiological Techniques... By Abdelrahman Abdelhalim 30

Basic Radiological Techniques... By Abdelrahman Abdelhalim 31

Basic Radiological Techniques... By Abdelrahman Abdelhalim 32

Basic Radiological Techniques... By Abdelrahman Abdelhalim 33

Basic Radiological Techniques... By Abdelrahman Abdelhalim 34

Basic Radiological Techniques... By Abdelrahman Abdelhalim 35

Basic Radiological Techniques... By Abdelrahman Abdelhalim 36

1. Fluoroscopy unit with spot film device. Vulsellum

Basic Radiological Techniques... By Abdelrahman Abdelhalim 37

o The procedure is done under complete aseptic conditions.

Films: using the under-couch tube..

4. Nausea, vomiting & headache: usually transient.

Factors that predispose to intravasation:

§ Direct trauma to the endometrium.

Essential Charateristics of a Normal HSG:

Basic Radiological Techniques... By Abdelrahman Abdelhalim 38

Basic Radiological Techniques... By Abdelrahman Abdelhalim 39

Basic Radiological Techniques... By Abdelrahman Abdelhalim 40

Basic Radiological Techniques... By Abdelrahman Abdelhalim 41

Basic Radiological Techniques... By Abdelrahman Abdelhalim 42

Basic Radiological Techniques... By Abdelrahman Abdelhalim 43

Basic Radiological Techniques... By Abdelrahman Abdelhalim 44

Basic Radiological Techniques... By Abdelrahman Abdelhalim 45

Basic Radiological Techniques... By Abdelrahman Abdelhalim 46

MRI CERVICAL SPINE

Basic Radiological Techniques... By Abdelrahman Abdelhalim 48