Table Of Content

CONTENTS ���������� ��� ��������� ����� ������� SEVENTH EDITION EDITED BY DAVID SUTTON MD, FRCP, FRCR, DMRD, FCan.AR (Hon) Consulting Radiologist St Mary's Hospital and Medical School, London Director, Radiological Department (1963-1984) Consulting Radiologist, The National Hospital for Neurology and Neurosurgery, London, UK. ASSOCIAtE EDITORS Nuclear Medicine PHILIP J.A. ROBINSON FRCP, FRCR MRI JEREMY P.R. JENKINS FRCP DMRD, FRCR CT RICHARD W. WHITEHOUSE BSc, MB ChB, MD, FRCR Ultrasound PAUL L. ALLAN MSc, MBBS, DMRD, FRCR, FRCP(Ed) Cardiac Radiology PETER WILDE BSc, MRCP, FRCR Neuroradiology JOHN M. STEVENS MBBS, DRACR, FRCR I CHURCHILL LIVINGSTONE TEXTBOOK OF RADIOLOGY AND IMAGING VOLUME 1 Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� CHURCHILL LIVINGSTONE An imprint of Elsevier Science Limited 2003, Elsevier Science Ltd. All rights reserved. The right of David Sutton to be identified as editor of this work has been asserted by him in accordance with the Copyright, Designs and Patent Act 1988. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without either the prior permission of the publishers (Elsevier Science Limited, Robert Stevenson House, 1-3 Baxter's Place, Leith Walk, Edinburgh EH 13AF) or a licence permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London W I T 4LP. First Edition 1969 Second Edition 1975 Third Edition 1980 Fourth Edition 1987 Fifth Edition 1993 Sixth Edition 1998 ISBN 0 443 071098 International Student Edition ISBN 0 443 07108X British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record from this book is available from the Library of Congress Note Medical knowledge is constantly changing. As new information becomes available, changes in treatment, procedures, equipment and the use of drugs become necessary. The editors, contributors and the publishers have, as far as it is possible, taken care to ensure that the information given in this text is accurate and up to date. However, readers are strongly advised to confirm that the information, especially with regard to drug usage, complies with the latest legislation and standards of practice. The Publishers have made every effort to trace the copyright holders for borrowed material. If they have inadvertently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity. The publisher's policy is to use paper manufactured from sustainable forests Commissioning Editor: Michael J. Houston Project Development Manager: Martin Mellor Project Manager: Nora Naughton (Aoibhe O'Shea) Designer: Sarah Russell Printed in China by RDC Group Limited Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� Cover illustrations: Vol 1: Front: Figs. 2.09; 1.60; 1.61A,B; 15.1 39B Back: Figs. 25.144; 2.8; 15.144; 26.43C Vol 2: Front: Fias. 59.26A; 59.39; 58.94A-D; 59.37 Back: Figs . 33.7113; 55.43C; 58.43C CONTENTS SECTION 2 Cardiovascular system 10 The normal heart: anatomy and techniques of examination 265 Peter Wilde, Mark Callaway 11 Acquired heart disease I: the chest radiograph 283 Mark Callaway, Peter Wilde 12 Acquired heart disease II: non-invasive imaging 317 Mark Callaway, Peter Wilde 13 I nvasive imaging and interventional techniques 347 Peter Wilde, Mark Callaway 14 Congenital heart disease 363 Peter Wilde, Anne Boothroyd 15 Arteriography and interventional angiography 411 David Sutton, Roger H. S. Gregson, Paul L. Allan, Jeremy P. R. Jenkins 16 Phlebography 483 David Sutton, Roger H. S. Gregson, Paul L. Allan, Jeremy P. R. Jenkins 17 The lymphatic system 509 Graham R. Cherryman, Bruno Morgan SECTION 1 Respiratory system 1 The normal chest: methods of investigation and differential diagnosis 1 Janet Murfitt, Philip J. A. Robinson, Richard W. Whitehouse, Andrew R. Wright, Jeremy P R. Jenkins 2 The mediastinum 57 Roger H. S. Gregson, Richard W. Whitehouse, Andrew R. Wright, Jeremy P. R. Jenkins 3 The pleura 87 Michael B. Rubens, Simon P G. Padley 4 Tumours of the lung 107 Michael B. Rubens, Simon P. G. Padley, Jeremy P. R. Jenkins 5 Pulmonary infections 131 Simon P. G. Padley, Michael B. Rubens 6 Diseases of the airways: collapse and consolidation 1 61 Michael B. Rubens, Simon PG. Padley 7 Diffuse lung disease 187 Simon P G. Padley, Michael B. Rubens 8 Miscellaneous chest conditions 217 Simon P G. Padley, Michael B. Rubens 9 The paediatric chest 247 Catherine M. Owens, Karen E. Thomas CONTENTS Previous Page Next Page Next Page CONTENTS ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� TEXTBOOK OF RADIOLOGY AND IMAGING 32 The urethra and male genital tract 1017 Julian Kabala, Philip J. A. Robinson, Raj Persad, Robert Jones 33 Obstetric ultrasound 1 039 Roger Chisholm, Jeremy P R. Jenkins 34 Gynaecological imaging 1 069 Mary Crofton, Jeremy P R. Jenkins SECTION 5 Skeletal system: soft tissue 35 Congenital skeletal anomalies: skeletal dysplasias, chromosomal disorders 1107 Peter Renton, Ruth Green 36 Periosteal reaction; bone and joint i nfections; sarcoid 1153 Peter Renton 37 Avascular necrosis; osteochondritis; miscellaneous bone lesions 1179 Peter Renton, Ruth Green 38 Disease of joints 1 201 Peter Renton, Ruth Green 39 Tumours and tumour-like conditions of bone (1) 1247 Mark Cobby, lain Watt 40 Tumours and tumour-like conditions of bone (2) 1287 Mark Cobby, lain Watt 41 Disorders of the lymphoreticular system and other haemopoietic disorders 1321 Mark Cobby, lain Watt 42 Metabolic and endocrine disorders affecting bone 1351 Jeremy W. R. Young, Leonie Gordon 43 Skeletal trauma: general considerations 1371 Jeremy W R. Young 44 Skeletal trauma: regional 1389 Jeremy W R. Young 45 The soft tissues 1 417 Jeremy P R. Jenkins, Janet Murfitt, Fritz Starer , Richard W Whitehouse, W Gedroyc 46 The breast 1451 Michael J. Michell, Chris Lawinksi, Will Teh, Sarah Vinnicombe SECTION 3 Abdomen and gastrointestinal tract 18 The salivary glands, pharynx and oesophagus 533 A. H. A. Chapman, John A. Spencer, J. Ashley Guthrie, Philip J. A. Robinson 19 The stomach and the duodenum 575 A. H. A. Chapman, J. Ashley Guthrie, Philip J. A. Robinson 20 The small bowel and peritoneal cavity 615 Steve Halligan 21 The large bowel 635 Steve Halligan, Philip]. A. Robinson 22 The acute abdomen 663 Stuart Field, lain Morrison 23 The abdomen and major trauma 691 Otto Chan, loannis Vlahos 24 The biliary tract 711 John Karani 25 The liver and spleen 737 Robert Dick, Anthony Watkinson, Julie F. C. Olliff, Philip J. A. Robinson, Richard W. Whitehouse 26 The pancreas 787 Janet Murfitt, Richard W. Whitehouse, Philip J. A. Robinson, Richard Mason, Paul A. Dubbins, Andrew R. Wright 27 The adrenal glands 825 David Sutton, Philip J. A. Robinson 28 The paediatric abdomen 849 Karen E. Thomas, Catherine M. Owens SECTIONS Genito-urinary tract 29 The urogenital tract: anatomy and investigations 885 Julian Kabala, Tim Whittlestone, David Grier, Philip]. A. Robinson 30 The kidneys and ureters 929 Julian Kabala, Carl Roobottom 31 The bladder and prostate 989 Julian Kabala, Gary N. Sibley, Jeremy P R. Jenkins, Paul Hulse SECTION 4 Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� CONTENTS 7 SECTION 6 55 Angiography in neuroradiology 1673 David Sutton, John M. Stevens, Katherine Mizkiel 56 Interventional neuroradiology 1 707 Rolf Jager , Stefan Brew 57 Intracranial lesions (1) 1 723 David Sutton, John M. Stevens, Katherine Mizkiel 58 I ntracranial lesions (2) 1 767 David Sutton, John M. Stevens, Katherine Mizkiel, Philip J. A. Robinson, Keith Dewbury 59 Recent technical advances 1 819 Richard W Whitehouse, Philip l. A. Robinson, Jeremy P. R. Jenkins, Paul L. Allan, Nicola H. Strickland, Philip Gishen, Andrew R. Wright, Andrew P Jones Useful appendices 1 847 A. Centres of ossification 1 847 B. Glossary of CT terms 1850 C. Glossary of MR terms 1852 D. Radiopharmaceuticals for imaging 1 855 I ndex to volumes 1 and 2 47 The pharynx and larynx: the neck 1489 Peter D. Phelps, Philip J. A. Robinson, Richard W Whitehouse, Andrew R. Wright, Julie F. C. Olliff 48 The sinuses 1519 Swarupsinh V Chavda, Julie F. C. Olliff 49 Teeth and jaws 1531 Peter Renton 50 Ultrasound of the eye and orbit 1551 John A. Fielding 51 The orbit 1 573 Michael 1. Rothman, Gregg H. Zoarski 52 The petrous temporal bone 1597 Peter D. Phelps 53 The skull 1 617 David Sutton 54 Neuroradiology of the spine 1 643 John M. Stevens, Brian E. Kendall Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� CONTRIBUTORS Paul L. Allan MSc, MBBS, DMRD, FRCR, FRCP (Ed) Mark Cobby MBChB, MRCP, FRCR Honorary Consultant Radiologist Consultant Radiologist Royal Infirmary Frenchay Hospital Edinburgh, UK Bristol, UK Stefan Brew MB, ChB, MHB (Hons), MSc, FRANZCR, FRCR Keith Dewbury BSc, DMRD, FRCR Consultant Radiologist Consultant Radiologist National Hospital for Neurology and Neurosurgery Southampton General Hospital London, UK Southampton, UK Anne Boothroyd MBChB, FRCR Robert Dick MB, BS(Syd), FRCAR, FRCR Consultant Radiologist Department of Radiology Royal Liverpool Children's Hospital Royal Free Hospital Liverpool, UK London, UK Mark Callaway BM, MRCP, FRCR Paul Dubbins BSc, FRCR Consultant Radiologist Consultant Radiologist Bristol Royal Infirmary Imaging Directorate Bristol, UK Derriford Hospital Plymouth, UK Otto Chan FRCS, FRCR Ply Consultant Radiologist Stuart Field MA, MBBChir, DMRD, FRCR The Royal London Hospital Consultant Radiologist London, UK Kent and Canterbury Hospital Canterbury, UK Anthony H. A. Chapman FRCP, FRCR Head of Clinical Radiology John A. Fielding MD, FRCP(Edin), FRCR Leeds NHS Trust Consultant Radiologist Consultant Radiologist Royal Shrewsbury Hospital St James's University Hospital Shrewsbwy, UK Leeds, UK W. Gedroyc MRCP, FRCR Swarupsinh V. Chavda MBChB, DMRD, FRCR Consultant Radiologist Consultant Radiologist St Mary's Hospital St James's University Hospital London, UK Leeds, UK Philip Gishen MB, BCh, DMRD, FRCR Graham R. Cherryman M[3013, FRCR Consultant Radiologist and Director of Imaging Professor of Radiology Hammersmith Hospital London, of Leicester UK Honorary Consultant Radiologist Roger H. S. Gregson MSc, MB, FRCR, DMRD UHL NHS Trust Consultant Radiologist and Head of Training Leicester, UK University of Nottingham Roger Chisholm MA, MBBChir, MRCP, FRCR Nottingham, UK Consultant Radiologist Ruth Green FRCR Hope Hospital Consultant Radiologist Salford, UK Royal National Orthopaedic Hospital Mary Crofton FRCR, FRCP Middlesex. UK Consultant Radiologist David Grier MBChB, MRCP, FRCR Department of Radiology Consultant Radiologist St Mary's Hospital Bristol Royal Hospital for Children London, UK Bristol, UK Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� CONTRIBUTORS 9 Leonie Gordon MD Michael J. Michell FRCR Professor of Radiology and Nuclear Medicine Consultant Radiologist Medical University of South Carolina King's College Hospital Charleston, London, UK South Carolina, USA Katherine Mizkiel BM(Hons), MRCP, FRCR J. Ashley Guthrie BA, MRCP, FRCR Consultant Neuroradiologist Consultant Radiologist National Hospital for Neurology and Neurosurgery St James's University Hospital London, UK Leeds, UK Bruno Morgan MA, MRCP, FRCR Steve Halligan MBBS, MD, MRCP, FRCR Senior Lecturer and Honorary Consultant Radiologist Consultant Radiologist University Hospitals Leicester St Mark's Hospital Leicester, UK London, UK Hulse MRCP FRCR lain Morrison MB BS, MRCP, FRCR Paul Consultant Radiologist Consultant Radiologist Kent and Canterbury Hospital Christie Hospital Canterbury, UK Manchester, UK Janet Murfitt MB BS, MRCP, FRCR H. Rolf Jager MD, FRCR Consultant Radiologist and Director of Diagnostic Imaging Consultant Radiologist St Bart's and The London NHS Trust National Hospital for Neurology and Neurosurgery London, UK London, UK Jeremy P. R. Jenkins FRCP, DMRD, FRCR Julie F.C. Olliff B Med Sci, BM BS, MRCP, FRCR Consultant Radiologist Consultant Radiologist Honorary Senior Clinical Lecturer Honorary Senior Clinical Lecturer University of Birmingham Manchester Royal Infirmary and University of Manchester Birmingham, UK Manchester, UK Andrew P. Jones MSc Catherine M. Owens BSc, MRCP, PFCR Clinical Director Consultant Paediatric Radiologist Consultant Clinical Scientist Department of Radiology Head of MR Physics Group Great Ormond Street Hospital for Children Christie Hospital London, UK Manchester, U K Robert Jones BmedSci, BMBS, FRCS(Ed) Simon PG. Padley MRCP, FRCR Consultant Radiologist Urology Research Fellow Chelsea and Westminster Hospital Bristol Royal Infirmary London, UK Bristol, UK John Karani MSc, MBBS, FRCR Raj Persad ChM, FRCS, FRCS(Urol), FEBU Consultant Radiologist Consultant Urologist Bristol Royal Infirmary King's College Hospital Bristol, UK London, U K Peter D. Phelps MD, FRCS, FRCR Julian Kabala MRCP, FRCR Former Consultant Radiologist Consultant Radiologist Royal National Orthopaedic Hospital and University Bristol Royal Infirmary College Hospital Bristol, UK Honorary Senior Lecturer Brian E. Kendall FRCR, FRCP, FRCS I nstitute of Orthopaedics Consulting Radiologist London, UK The National Hospital for Neurology and Neurosurgery Peter Renton FRCR, DMRD and the Middlesex Hospital Consultant Radiologist London, UK Honorary Senior Lecturer Chris Lawinksi BSc, MSc, MPhil Royal National Orthopaedic Hospital Consultant Physicist and University College London Hospitals King's College Hospital London, UK London, UK Philip J.A. Robinson FRCP, FRCR Richard Mason FRCS, MRCP, FRCR Professor of Clinical Radiology Consulting Radiologist University of Leeds Middlesex Hospital Consultant Radiologist University College of London Hospitals Leeds Teaching Hospitals London, UK Leeds, UK Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� 10 TEXTBOOK OF RADIOLOGY AND IMAGING M. I. Rothman MD Sarah Vinnicombe BSc, MRCP, FRCR Assistant Professor of Radiology, Neurosurgery and Consultant Radiologist Otolaryngology /Head and Neck Surgery, Department of Diagnostic Imaging Medical Director. Anna Gudelsky Magnetic Resonance Center St Bartholomew's Hospital Baltimore, London, UK Maryland, USA loannis Viahos MSc, MBBS, MRCP, FRCR Carl Roobottom MSc, MBChB(Hon), MRCP, FRCR Research Fellow Consultant Radiologist Department of Diagnostic Imaging Dcrriford Hospital St Bartholomew's Hospital Plymouth, UK London, UK Michael B. Rubens MB, DMRD, FRCR lain Watt FRCP, FRCR Consultant Radiologist and Director of Imaging Consultant Clinical Radiologist Royal Brompton Hospital Bristol Royal Infirmary London, UK Bristol, UK Gary N. Sibley FRCS Anthony Watkinson Bmet, MSc, MBBS, FRCS, FRCR Consultant Urologist Consultant and Senior Lecturer in Radiology Department of Urology Royal Free Hospital Bristol Royal Infirmary London, UK Bristol, UK Peter Wilde BSc, MRCP, FRCR John A. Spencer MA, MD, MRCP, FRCR Consultant Cardiac Radiologist Consultant Radiologist Directorate of Clinical Radiology St James's University Hospital Bristol Royal Infirmary Leeds, UK Bristol, UK John M. Stevens MBBS, DRACR, FRCR Richard W. Whitehouse BSc, MB ChB, MD, FRCR Consultant Radiologist Consultant Radiologist Department of Radiology Manchester Royal Infirmary National Hospital for Neurology and Neurosurgery Manchester, UK London. UK Tim Whittlestone MA, FRCS (Ebg), MD, FRCS(Urol) Nicola H. Strickland BM, BCh, MA(Hons)(Oxon), FRCP, FRCR Hunterian Professor of Surgery Consultant Radiologist Specialist Registrar in Urology Hammersmith Hospital NHS Trust Bristol Royal Infirmary London, UK Bristol, UK David Sutton MD, FRCP, FRCR, DMRD, FCan.AR (Hon) Andrew R. Wright MA, MBBS, MRCP, FRCR Consulting Radiologist Consultant Radiologist St Mary's Hospital and Medical School, London Honorary Senior Lecturer Director, Radiological Department (1963-1984) St Mary's Hospital Consulting Radiologist, The National Hospital for Neurology Imperial College and Neurosurgery London, UK London, UK Jeremy W. R. Young MA, BM, BCh, FRCR Will Teh MBChB, MRCP, FRCR Professor and Chairman of Radiology, Medical University Consultant Radiologist of South Carolina Northwick Park Hospital Charleston Middlesex, UK South Carolina, USA Karen E. Thomas MA, BM BCh, MRCP, FRCR Gregg Zoarski MD Consultant Paediatric Radiologist Department of Diagnostic Radiology Hospital for Sick Children University of Maryland Medical Center Toronto Baltimore Ontario, Canada Maryland, USA Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� PREFACE The First Edition of this Textbook was conceived in the 1960s syllabus for Specialist Radiologists, the change was highly and published in 1969. 1, like many of my contemporaries began successful from a purely practical point of view. Sales rose by my studies in Radiology at the end of the Second World War. 300°% (from 1000 to 4000 copies per annum). My first post as an ex military service registrar was in the The first edition of this popular text-hook was published in Radiology Department of the National Hospitals for Nervous 1 969 and this seventh edition in still growing strongly at the Disease at Queen Square. It was pure serendipity that I should mature age of thirty three years. Review of the last five editions thus become associated with James Bull, the only British cover a period of exponential growth in radiological facilities and radiologist trained in Scandinavian neuroradiological techniques, imaging. New fields were just beginning to open at the time of the including percutaneous angiography. and at that tine representing first edition and these included ultrasound and nuclear medicine. the most advanced aspects of radiology. Computer tomography began in the 1970s to he overtaken in the My training in percutaneous cerebral angiography laid the 1 980s by magnetic resonance. It was generally felt that CT would foundation for other percutaneous techniques which I was able to soon be out-moded, but the last few years have seen a remarkable apply when appointed to St. Mary's hospital in 1952. Here again comeback from CT in the form of multi-slice spiral CT. As a pioneer work had already begun exploiting the potential for new result the versatility, speed and scope of CT examinations has methods in vascular surgery. been transformed. As a result of this background we were able to publish in 1962 In general, we hope this book reflects British Teaching Hospital the first personal monograph based on an experience of more than Practice in the field of Imaging. The ISE edition remains very ten thousand cases. (See Ch. I5). popular with non British readers and the 6th Edition has also been X-Rays were discovered by Roentgen in 1895, and though the translated into two further languages, Greek and Portuguese. We importance of the discovery was immediately realised and widely believe that much of its success is due to the decision to discussed the impact on medical practice was surprisingly slow. concentrate on Clinical rather than Technical aspects of our The diagnosis and treatment of fractures and lesions of bones and rapidly expanding and evolving specialty. joints was the first area to be thoroughly studied and surveyed. At Whilst each new edition has emphasised clinical rather then the same tine, the dangers and potential hazards of the new rays technical progress, the student must also be aware of. and absorb. were becoming apparent for the first time, as was the therapeutic the technical advances. The new edition therefore includes a chapter use of X-Rays. devoted to explaining this area. Other features of this new edition In the Post war period, paining and experience of a specialist are the complete rewriting by mainly new authors of major sections radiologist was still a matter of considerable debate and concern. of the text. These include the Cardiac. GU. Paediatric, Small and Broadly speaking, there were those who favoured a technical Large bowel, Major Abdominal Trauma and Intcrventional approach and paining, usually pure scientists or physicists, and Neuroradiology chapters. Other chapters have been revised by others who preferred a largely clinical approach with a minimum deleting obsolete material or including new material. Recent clinical of technical training. Thus advanced paining in medicine or trends are also reflected in the revision. Thus imaging and Staging surgery was regarded by many as essential for high quality of malignant tumors has been revised and updated in many areas. radiology. The British Faculty of Radiologists was expanding and the opportunity has been taken to integrate the latest version of rapidly and soon became the Royal College of Radiologists. The the World Health Organisation (WHO) reclassification on a FRCR thus became the essential higher radiological qualification histopatholigical basis of primary cerebral tumoii s. The expansion on a par with the MRCP or FRCS, and the DMRD was of non invasive and minimally invasive angioaraphy is monitored, downgraded to a qualifying diploma. and discussed. However, this is to some extent balanced by the At the time of this controversy, I took the opportunity to broaden increasing use of interventional techniques. my experience and expertise with the MD thesis, Membership of Radiology is a graphic subject. and images and illustrations are the Royal College of Physicians, London and Fellowship of the its vital tool. This edition contains no less then 5600 illustrations. Faculty of Radiologists. This was undoubtedly the clinical, rather some 2000 of which are new. than technical approach to radiological expertise. As in previous editions, we would remind the student that large In 1955 1 was appointed Editor to the Faculty .Journal, and took textbooks. like large animals, have a longer period of gestation. It the opportunity to persuade the Editorial Board to change its is therefore important to keep up with the current literature and name to Clinical Radiology. Apart from showing where my own attend up to date seminars. interest lay in the continual medico-political controversy between pure scientists (mainly physicists) and clinicians which many felt David Sutton could adversely affect the future paining and examination '_002 Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� THE NORMAL CHEST: METHODS OF I NVESTIGATION AND DIFFERENTIAL DIAGNOSIS J anet Murfitt with contributions from Philip J. A. Robinson, Richard W. Whitehouse, Andrew R. Wright and Jeremy P. R. Jenkins graphy in these circumstances. In addition it is still used in some centres to assess a peripheral lung mass, the lung apices and the abnormal hilum. However, conventional CT scanning i s far superior for staging malignancy, detecting pulmonary metastases, and assessing chest wall and pleural lesions, the lung mass, the hilum and mediastinum. High-resolution CT scanning is of proven value in the diagnosis of diffuse lung disease, particularly in the early stages when the chest radiograph is normal, and for follow-up. In most centres high- resolution scanning is used for the detection of bronchicctasis, and surgery is undertaken without preoperative bronchography. Radionuclide scanning is used as the first-line investigation of suspected pulmonary embolus in the majority of cases, with a normal scan excluding the presence of an embolus. Pulmonary angiography remains the gold standard for the diag- nosis of pulmonary embolism. It is usually undertaken in those patients with massive embolism when embolectomy or thrombo- lysis is contemplated. However, spiral CT angiography is showing sensitivity and specificity rates approaching those of conventional angiography in the diagnosis of pulmonary embolism, and can reliably demonstrate vessels down to the subsegmental level. Ultrasound is of use for investigating chest wall and pleural lesions and lung lesions adjacent to the chest wall. It should be used for the localization of pleural fluid prior to a diagnostic tap or drainage to reduce the risk of a malpositioned catheter and pneumo- thorax. However, the acoustic mismatch between the chest wall and air-containing lung results in reflection of the ultrasound beam at the lung-pleura interface, so that normal lung cannot be demonstrated. Biopsy of pulmonary lesions using a fine needle for aspiration has a high diagnostic yield for malignancy, excluding lymphoma. with a low incidence of complications. A cutting needle is associ- ated with a higher complication rate but is more helpful in the diagnosis of lymphoma and benign lung conditions. 1 • Plain films: a PA, lateral b AP, decubitus, supine, oblique • Inspiratory-expiratory d Lordotic, apical, penetrated • Portable/mobile radiographs • Tomography • CT scanning • Radionuclide studies • Needle biopsy • Ultrasound • Fluoroscopy • Bronchography • Pulmonary angiography • Bronchial arteriography • MRI • Digital radiography • Lymphangiography. The plain postero-anterior (PA) chest film i s the most frequently requested radiological examination. Visualisation of the lungs is excellent because of the inherent contrast of the tissues of the thorax. Lateral films should not be undertaken routinely. Comparison of the current film with old films is valuable and should always be undertaken if the old films are available. A current film is mandatory before proceeding to more complex investigations. Simple linear tomography remains a useful investigation when CT is unavailable. It is helpful for confirming that an abnormality suspected on a plain film is genuine and that it is intrapulmonary, although the high kilovoltage film has reduced the need for tomo- Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� 2 A TEXTBOOK OF RADIOLOGY AND IMAGING The value of MRI for diagnosing pulmonary disease is still in Using a low kVp (60-80 kV) produces a high-contrast film the assessment stage. No distinct advantage over high-resolution ( Fig. 1.1) with miliary shadowing and calcification being more CT in the diagnosis of parenchymal disease has yet been shown clearly seen than on a high kV film. For large patients a grid but it is proven to be helpful in the diagnosis of hilar masses, reduces scatter. A FFD of 1.85 m (6 feet) reduces magnification and lymphadenopathy and mediastinal lesions. produces a sharper image. With high kilovoltagcs of I20-I70 kVp Diagnostic /nuecanolhorax is an obsolete procedure which was the films are of lower contrast (Fig. 1.2A,B) with increased visual- once used to differentiate a pleural-based from a pulmonary lesion. isation of the hidden areas of the lung due to better penetration of The h(11111111/contrast soul/onr has been supplanted by CT for overlying structures. The hones and pulmonary , calcification are less assessing he non-oesophageal mediastinal mass but may he indi- well seen. The exposure time is shorter so that movement blur due cated in the investigation of conditions associated with pulmonary to cardiac pulsation is minimised. A grid or air gap is necessary to changes such as scleroderma, hiatus hernia and achalasia. It is used reduce scatter and improve contrast. An air gap of 15-25 cm for demonstrating broncho-oesophageal fistulas, tracheal aspiration between patient and film necessitates an increased FFD of 2.44 m and vascular rings. (8 feet) to reduce magnification. Chylous reflex with the formation of a chylothorax may he An automatic exposure system and dedicated automatic chest demonstrated by conventional Irmphan,,iograp/it. unit are desirable in a busy department. The lateral view THE PLAIN FILM A high kVp or normal kVp technique may be used with or without a grid. For sharpness the side of interest is nearest the film. With The PA view shoulders parallel to the film the arms are elevated, or displaced By definition the patient faces the film chin up with the shoulders back if the anterior mediastinum is of interest. rotated forward to displace the scapulae from the Inngs. Exposure Lesions obscured on the PA view are often clearly demonstrated is made on full inspiration for optimal visualisation of the lung on the lateral view. Examples of this arc anterior mediastinal bases, centring at T5. The breasts should be compressed against masses, eneysted pleural fluid (Fig. 1.3) and posterior basal eon- the film to prevent them obscuring the lung bases. solidation. By contrast, clear-cut abnormalities seen on the PA There is no _*eneral consensus regarding the kV used for chest view may be difficult to identify on the lateral film because the radiography although the high kVp technique is widely used as a two lungs are superimposed. An example of this is a left lung standard departmental film. High kVp, low kVp or intermediate collapse (Fig. 1.4). This is particularly so with a large pleural kVp techniques arc used with various film-screen combinations, effusion. grids or air-gap techniques. Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� THE NORMAL CHEST: METHODS OF INVESTIGATION AND DIFFERENTIAL DIAGNOSIS 3 Fig. 1.2 (A,B) Radiographs of patient in Fig. 1.1 taken at 1 70 kVp. Note the improved visualisation of the main airways, vascular structures and the area behind the heart including the spine. Other views retrocardiae area, the posterior costophrenic angles and the chest Although not frequently requested, additional plain films may assist wall, with pleural plaques being clearly demonstrated. In the AP with certain diagnostic problems before proceeding to the more position (as for patients unable to stand or portable radiographs) the complex and expensive techniques. Oblique views demonstrate the ribs are projected over different areas of the lung from the PA view Fig. 1.3 Encysted pleural fluid. (A) PA film. A right pleural effusion with a large well-defined midzone mass. (B) Lateral film. Loculated fluid is demonstrated high in the oblique fissure. Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� Fig. 1.4 Collapse of the left lung. (A) PA film. (B) Lateral film. Only the right hemidiaphragm is visible. The radiolucency of the lower vertebrae is decreased. and the posterior chest is well shown. In contrast to the PA film the 50-60°, or downward. as in the lordotic • vid ii , with the patient in a scapulae overlie the upper lungs and the clavicles are projected lordotic PA position. In this view a middle lobe collapse shows more cranially over the apices. The disc spaces of the lower cer- clearly as a well-defined triangu lar shadow. vital spine are more clearly seen, whereas in the PA film the neural A suhpulmonary effusion is frequently difficult to distinguish arches arc visualised. When a portable radiograph is undertaken, from an elevated diaphragm or consolidation. On the PA view the the shorter FFD results in magnification of the heart and the longer apex of the effusion has a more lateral position than that of a exposure time in increased movement blur. normal diaphragm. In the supine and decuhifus positions (Fig. 1.5) Good visualisation of the apices requires projection of the free fluid becomes displaced. On the supine projection this results clavicles upward, as in the apical rice • with the tube angled up in the hemithorax becoming opaque with loss of the diaphragm 4 A TEXTBOOK OF RADIOLOGY AND IMAGING Fig. 1.5 Subpulmonary pleural fluid. (A) Erect PA radiograph. There is apparent elevation of the left hemidiaphragm. Increased translucency of the left lung is due to a left mastectomy. Note the abnormal axillary fold (arrow). (B) Left lateral decubitus film (with horizontal beam). Pleural fluid has moved to the most dependent part of the left hemithorax (arrows). Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� THE NORMAL CHEST: METHODS OF INVESTIGATION AND DIFFERENTIAL DIAGNOSIS 5 outline, an apical cap, blunting of the costophrenic angle and Penetration With a low kV film the vertebral bodies and disc decreased visibility of the pulmonary markings. spaces should be just visible down to the T8/9 level through the The decubitus films shows fluid levels particularly well. Small cardiac shadow. Underpenetration increases the likelihood of amounts of pleural fluid may be shown with the affected side missing an abnormality overlain by another structure. Over- dependent. penetration results in loss of visibility of low-density lesions such Paired inspiratory and expiratorv films demonstrate air trapping as early consolidation, although a bright light may reveal the and diaphragm movement. Traditonally it has been taught that small abnormality. pneumothoraces and interstitial shadowing may be more apparent Degree of inspiration On full inspiration the anterior ends of the on the expiratory film. However the inspiratory view is now consid- ered to be as accurate as the expiratory view for diagnosing a pneu- mothorax. Paired views are very important in children with a aphragm although the degree of inspiration achieved varies with possible diagnosis of an inhaled foreign body. patient build. On expiration the heart shadow is larger and there is - basal opacity due to crowding of the normal vascular markings. Pulmonary diseases such as fibrosing alveolitis are associated Viewing the PA film with reduced pulmonary compliance, which may result in reduced Before a diagnosis can be made an abnormality, if present, must be inflation with elevation of the diaphragms. identified. Knowledge of the normal appearance of a chest radio- graph is essential. In addition the radiologist must develop a routine The trachea which ensures that all areas of the radiograph are scrutinised. Some The trachea should be examined for narrowing, displacement and prefer initially to view the film without studying the clinical infot intraluminal lesions. It is midline in its upper 1part, then deviates mation. Comparison of the current film with old films is important slightly to the right around_ the aortic knuckle. On expiration devia- and often extremely helpful. A suggested scheme that examines lion to the right becomes more marked. In addition there is short- each point in turn is shown in Box L I. erring on expiration so that an endotracheal tube situated just above the carina on inspiration may occlude the main bronchus on Technical aspects expiration. Centring If the film is well centred the medial ends of the clavicles Its calibre should be even, with translucency of the tracheal air are equidistant from the vertebral spinous processes at the T4/5 column decreasing caudally. Normal maximum coronal diameter is level. Small degrees of rotation distort the mediastinal borders, and 25 mm for males and 21 rim for females. The right tracheal margin, the lung nearest the film appears less translucent. Thoracic deform- where the trachea is in contact with the lung, can be traced from the itics, especially a scoliosis, negate the value of conventional cen- clavicles down to the right main bronchus. This border is the right tring. The orientation of the aortic arch, gastric bubble and heart paratracheai stripe and is seen in 60%0 of patients, normally meas- should be determined to confirm normal situs and that the side urng less than 5 mm. Widening of the stripe occurs most corn- markers are correct. monly with mediastinal lymphadenopathy but also with tracheal malignancy, mediastinal tumours, mediastinitis and pleural effu- Box 1.1 Suggested scheme for viewing the PA film signs. A left paratracheal line is not visualised because the left border of the trachea lies adjacent to the great vessels and not the 1. Request form Name, age, date, sex lung. Clinical information The azygos rein l ies in the angle between the right main 2. Technical Adequate inspiration bronchus and trachea. On the erect film it should be less than Centring, patient position/rotation 1 0 turn in diameter. Its size decreases with the Valsalva manoeuvre z Side markers and on inspiration. Enlargement occurs in the supine position but % Exposure/adequate penetration also with enlarged subcarinal nodes, pregnancy. portal hyper- Collimation tension, IVC and SVC obstruction, right heart failure and constric- 3. Trachea Position, outline five pericarditis. 4. Heart and mediastinum Size, shape, displacement Widening of the carina occurs on inspiration. The normal angle is 5. Diaphragms outline, shape 60-75°. Pathological causes of widening include an enlarged left Relative position atrium (Fig. 1.6) and enlarged carinal nodes. 6. Pleural spaces Position of horizontal fissure Costophrenic, cardiophrenic angles The mediastinum and heart 7. Lungs Local, generalised abnormality The central dense shadow seen on the PA chest film comprises the Comparison of the translucency and vascular markings of the lungs mediastinum, heart, spine and sternum. With good centring two- thirds of the cardiac shadow lies to the left of midline and one-third 8. Hidden areas Apices, posterior sulcus Mediastinum, hila, bones to the right, although this is quite variable in normal subjects. The transverse cardiac diameter (normal for females less than 14.5 cm 9. Hila Density, position, shape and for males less than 15.5 cm) and the cardiothoracic ratio are 1 0. Below diaphragms Gas shadows, calcification assessed. The normal cardiothoracic ratio is less than 50% on a PA 11. Soft tissues Mastectomy, gas, densities, etc. 51 film. Measurement in isolation is of less value than when previous 1 2. Bones Destructive lesions, etcc figures are available. An increase in excess of 1.5 cm in the trans- verse diameter on comparable serial films is significant. However Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ

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931 Pages·2002·67.42 MB·English
by  David Sutton
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CONTENTS ���������� ��� ��������� ����� ������� SEVENTH EDITION EDITED BY DAVID SUTTON MD, FRCP, FRCR, DMRD, FCan.AR (Hon) Consulting Radiologist St Mary's Hospital and Medical School, London Director, Radiological Department (1963-1984) Consulting Radiologist, The National Hospital for Neurology and Neurosurgery, London, UK. ASSOCIAtE EDITORS Nuclear Medicine PHILIP J.A. ROBINSON FRCP, FRCR MRI JEREMY P.R. JENKINS FRCP DMRD, FRCR CT RICHARD W. WHITEHOUSE BSc, MB ChB, MD, FRCR Ultrasound PAUL L. ALLAN MSc, MBBS, DMRD, FRCR, FRCP(Ed) Cardiac Radiology PETER WILDE BSc, MRCP, FRCR Neuroradiology JOHN M. STEVENS MBBS, DRACR, FRCR I CHURCHILL LIVINGSTONE TEXTBOOK OF RADIOLOGY AND IMAGING VOLUME 1 Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� CHURCHILL LIVINGSTONE An imprint of Elsevier Science Limited 2003, Elsevier Science Ltd. All rights reserved. The right of David Sutton to be identified as editor of this work has been asserted by him in accordance with the Copyright, Designs and Patent Act 1988. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without either the prior permission of the publishers (Elsevier Science Limited, Robert Stevenson House, 1-3 Baxter's Place, Leith Walk, Edinburgh EH 13AF) or a licence permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London W I T 4LP. First Edition 1969 Second Edition 1975 Third Edition 1980 Fourth Edition 1987 Fifth Edition 1993 Sixth Edition 1998 ISBN 0 443 071098 International Student Edition ISBN 0 443 07108X British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record from this book is available from the Library of Congress Note Medical knowledge is constantly changing. As new information becomes available, changes in treatment, procedures, equipment and the use of drugs become necessary. The editors, contributors and the publishers have, as far as it is possible, taken care to ensure that the information given in this text is accurate and up to date. However, readers are strongly advised to confirm that the information, especially with regard to drug usage, complies with the latest legislation and standards of practice. The Publishers have made every effort to trace the copyright holders for borrowed material. If they have inadvertently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity. The publisher's policy is to use paper manufactured from sustainable forests Commissioning Editor: Michael J. Houston Project Development Manager: Martin Mellor Project Manager: Nora Naughton (Aoibhe O'Shea) Designer: Sarah Russell Printed in China by RDC Group Limited Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� Cover illustrations: Vol 1: Front: Figs. 2.09; 1.60; 1.61A,B; 15.1 39B Back: Figs. 25.144; 2.8; 15.144; 26.43C Vol 2: Front: Fias. 59.26A; 59.39; 58.94A-D; 59.37 Back: Figs . 33.7113; 55.43C; 58.43C CONTENTS SECTION 2 Cardiovascular system 10 The normal heart: anatomy and techniques of examination 265 Peter Wilde, Mark Callaway 11 Acquired heart disease I: the chest radiograph 283 Mark Callaway, Peter Wilde 12 Acquired heart disease II: non-invasive imaging 317 Mark Callaway, Peter Wilde 13 I nvasive imaging and interventional techniques 347 Peter Wilde, Mark Callaway 14 Congenital heart disease 363 Peter Wilde, Anne Boothroyd 15 Arteriography and interventional angiography 411 David Sutton, Roger H. S. Gregson, Paul L. Allan, Jeremy P. R. Jenkins 16 Phlebography 483 David Sutton, Roger H. S. Gregson, Paul L. Allan, Jeremy P. R. Jenkins 17 The lymphatic system 509 Graham R. Cherryman, Bruno Morgan SECTION 1 Respiratory system 1 The normal chest: methods of investigation and differential diagnosis 1 Janet Murfitt, Philip J. A. Robinson, Richard W. Whitehouse, Andrew R. Wright, Jeremy P R. Jenkins 2 The mediastinum 57 Roger H. S. Gregson, Richard W. Whitehouse, Andrew R. Wright, Jeremy P. R. Jenkins 3 The pleura 87 Michael B. Rubens, Simon P G. Padley 4 Tumours of the lung 107 Michael B. Rubens, Simon P. G. Padley, Jeremy P. R. Jenkins 5 Pulmonary infections 131 Simon P. G. Padley, Michael B. Rubens 6 Diseases of the airways: collapse and consolidation 1 61 Michael B. Rubens, Simon PG. Padley 7 Diffuse lung disease 187 Simon P G. Padley, Michael B. Rubens 8 Miscellaneous chest conditions 217 Simon P G. Padley, Michael B. Rubens 9 The paediatric chest 247 Catherine M. Owens, Karen E. Thomas CONTENTS Previous Page Next Page Next Page CONTENTS ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� TEXTBOOK OF RADIOLOGY AND IMAGING 32 The urethra and male genital tract 1017 Julian Kabala, Philip J. A. Robinson, Raj Persad, Robert Jones 33 Obstetric ultrasound 1 039 Roger Chisholm, Jeremy P R. Jenkins 34 Gynaecological imaging 1 069 Mary Crofton, Jeremy P R. Jenkins SECTION 5 Skeletal system: soft tissue 35 Congenital skeletal anomalies: skeletal dysplasias, chromosomal disorders 1107 Peter Renton, Ruth Green 36 Periosteal reaction; bone and joint i nfections; sarcoid 1153 Peter Renton 37 Avascular necrosis; osteochondritis; miscellaneous bone lesions 1179 Peter Renton, Ruth Green 38 Disease of joints 1 201 Peter Renton, Ruth Green 39 Tumours and tumour-like conditions of bone (1) 1247 Mark Cobby, lain Watt 40 Tumours and tumour-like conditions of bone (2) 1287 Mark Cobby, lain Watt 41 Disorders of the lymphoreticular system and other haemopoietic disorders 1321 Mark Cobby, lain Watt 42 Metabolic and endocrine disorders affecting bone 1351 Jeremy W. R. Young, Leonie Gordon 43 Skeletal trauma: general considerations 1371 Jeremy W R. Young 44 Skeletal trauma: regional 1389 Jeremy W R. Young 45 The soft tissues 1 417 Jeremy P R. Jenkins, Janet Murfitt, Fritz Starer , Richard W Whitehouse, W Gedroyc 46 The breast 1451 Michael J. Michell, Chris Lawinksi, Will Teh, Sarah Vinnicombe SECTION 3 Abdomen and gastrointestinal tract 18 The salivary glands, pharynx and oesophagus 533 A. H. A. Chapman, John A. Spencer, J. Ashley Guthrie, Philip J. A. Robinson 19 The stomach and the duodenum 575 A. H. A. Chapman, J. Ashley Guthrie, Philip J. A. Robinson 20 The small bowel and peritoneal cavity 615 Steve Halligan 21 The large bowel 635 Steve Halligan, Philip]. A. Robinson 22 The acute abdomen 663 Stuart Field, lain Morrison 23 The abdomen and major trauma 691 Otto Chan, loannis Vlahos 24 The biliary tract 711 John Karani 25 The liver and spleen 737 Robert Dick, Anthony Watkinson, Julie F. C. Olliff, Philip J. A. Robinson, Richard W. Whitehouse 26 The pancreas 787 Janet Murfitt, Richard W. Whitehouse, Philip J. A. Robinson, Richard Mason, Paul A. Dubbins, Andrew R. Wright 27 The adrenal glands 825 David Sutton, Philip J. A. Robinson 28 The paediatric abdomen 849 Karen E. Thomas, Catherine M. Owens SECTIONS Genito-urinary tract 29 The urogenital tract: anatomy and investigations 885 Julian Kabala, Tim Whittlestone, David Grier, Philip]. A. Robinson 30 The kidneys and ureters 929 Julian Kabala, Carl Roobottom 31 The bladder and prostate 989 Julian Kabala, Gary N. Sibley, Jeremy P R. Jenkins, Paul Hulse SECTION 4 Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� CONTENTS 7 SECTION 6 55 Angiography in neuroradiology 1673 David Sutton, John M. Stevens, Katherine Mizkiel 56 Interventional neuroradiology 1 707 Rolf Jager , Stefan Brew 57 Intracranial lesions (1) 1 723 David Sutton, John M. Stevens, Katherine Mizkiel 58 I ntracranial lesions (2) 1 767 David Sutton, John M. Stevens, Katherine Mizkiel, Philip J. A. Robinson, Keith Dewbury 59 Recent technical advances 1 819 Richard W Whitehouse, Philip l. A. Robinson, Jeremy P. R. Jenkins, Paul L. Allan, Nicola H. Strickland, Philip Gishen, Andrew R. Wright, Andrew P Jones Useful appendices 1 847 A. Centres of ossification 1 847 B. Glossary of CT terms 1850 C. Glossary of MR terms 1852 D. Radiopharmaceuticals for imaging 1 855 I ndex to volumes 1 and 2 47 The pharynx and larynx: the neck 1489 Peter D. Phelps, Philip J. A. Robinson, Richard W Whitehouse, Andrew R. Wright, Julie F. C. Olliff 48 The sinuses 1519 Swarupsinh V Chavda, Julie F. C. Olliff 49 Teeth and jaws 1531 Peter Renton 50 Ultrasound of the eye and orbit 1551 John A. Fielding 51 The orbit 1 573 Michael 1. Rothman, Gregg H. Zoarski 52 The petrous temporal bone 1597 Peter D. Phelps 53 The skull 1 617 David Sutton 54 Neuroradiology of the spine 1 643 John M. Stevens, Brian E. Kendall Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� CONTRIBUTORS Paul L. Allan MSc, MBBS, DMRD, FRCR, FRCP (Ed) Mark Cobby MBChB, MRCP, FRCR Honorary Consultant Radiologist Consultant Radiologist Royal Infirmary Frenchay Hospital Edinburgh, UK Bristol, UK Stefan Brew MB, ChB, MHB (Hons), MSc, FRANZCR, FRCR Keith Dewbury BSc, DMRD, FRCR Consultant Radiologist Consultant Radiologist National Hospital for Neurology and Neurosurgery Southampton General Hospital London, UK Southampton, UK Anne Boothroyd MBChB, FRCR Robert Dick MB, BS(Syd), FRCAR, FRCR Consultant Radiologist Department of Radiology Royal Liverpool Children's Hospital Royal Free Hospital Liverpool, UK London, UK Mark Callaway BM, MRCP, FRCR Paul Dubbins BSc, FRCR Consultant Radiologist Consultant Radiologist Bristol Royal Infirmary Imaging Directorate Bristol, UK Derriford Hospital Plymouth, UK Otto Chan FRCS, FRCR Ply Consultant Radiologist Stuart Field MA, MBBChir, DMRD, FRCR The Royal London Hospital Consultant Radiologist London, UK Kent and Canterbury Hospital Canterbury, UK Anthony H. A. Chapman FRCP, FRCR Head of Clinical Radiology John A. Fielding MD, FRCP(Edin), FRCR Leeds NHS Trust Consultant Radiologist Consultant Radiologist Royal Shrewsbury Hospital St James's University Hospital Shrewsbwy, UK Leeds, UK W. Gedroyc MRCP, FRCR Swarupsinh V. Chavda MBChB, DMRD, FRCR Consultant Radiologist Consultant Radiologist St Mary's Hospital St James's University Hospital London, UK Leeds, UK Philip Gishen MB, BCh, DMRD, FRCR Graham R. Cherryman M[3013, FRCR Consultant Radiologist and Director of Imaging Professor of Radiology Hammersmith Hospital London, of Leicester UK Honorary Consultant Radiologist Roger H. S. Gregson MSc, MB, FRCR, DMRD UHL NHS Trust Consultant Radiologist and Head of Training Leicester, UK University of Nottingham Roger Chisholm MA, MBBChir, MRCP, FRCR Nottingham, UK Consultant Radiologist Ruth Green FRCR Hope Hospital Consultant Radiologist Salford, UK Royal National Orthopaedic Hospital Mary Crofton FRCR, FRCP Middlesex. UK Consultant Radiologist David Grier MBChB, MRCP, FRCR Department of Radiology Consultant Radiologist St Mary's Hospital Bristol Royal Hospital for Children London, UK Bristol, UK Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� CONTRIBUTORS 9 Leonie Gordon MD Michael J. Michell FRCR Professor of Radiology and Nuclear Medicine Consultant Radiologist Medical University of South Carolina King's College Hospital Charleston, London, UK South Carolina, USA Katherine Mizkiel BM(Hons), MRCP, FRCR J. Ashley Guthrie BA, MRCP, FRCR Consultant Neuroradiologist Consultant Radiologist National Hospital for Neurology and Neurosurgery St James's University Hospital London, UK Leeds, UK Bruno Morgan MA, MRCP, FRCR Steve Halligan MBBS, MD, MRCP, FRCR Senior Lecturer and Honorary Consultant Radiologist Consultant Radiologist University Hospitals Leicester St Mark's Hospital Leicester, UK London, UK Hulse MRCP FRCR lain Morrison MB BS, MRCP, FRCR Paul Consultant Radiologist Consultant Radiologist Kent and Canterbury Hospital Christie Hospital Canterbury, UK Manchester, UK Janet Murfitt MB BS, MRCP, FRCR H. Rolf Jager MD, FRCR Consultant Radiologist and Director of Diagnostic Imaging Consultant Radiologist St Bart's and The London NHS Trust National Hospital for Neurology and Neurosurgery London, UK London, UK Jeremy P. R. Jenkins FRCP, DMRD, FRCR Julie F.C. Olliff B Med Sci, BM BS, MRCP, FRCR Consultant Radiologist Consultant Radiologist Honorary Senior Clinical Lecturer Honorary Senior Clinical Lecturer University of Birmingham Manchester Royal Infirmary and University of Manchester Birmingham, UK Manchester, UK Andrew P. Jones MSc Catherine M. Owens BSc, MRCP, PFCR Clinical Director Consultant Paediatric Radiologist Consultant Clinical Scientist Department of Radiology Head of MR Physics Group Great Ormond Street Hospital for Children Christie Hospital London, UK Manchester, U K Robert Jones BmedSci, BMBS, FRCS(Ed) Simon PG. Padley MRCP, FRCR Consultant Radiologist Urology Research Fellow Chelsea and Westminster Hospital Bristol Royal Infirmary London, UK Bristol, UK John Karani MSc, MBBS, FRCR Raj Persad ChM, FRCS, FRCS(Urol), FEBU Consultant Radiologist Consultant Urologist Bristol Royal Infirmary King's College Hospital Bristol, UK London, U K Peter D. Phelps MD, FRCS, FRCR Julian Kabala MRCP, FRCR Former Consultant Radiologist Consultant Radiologist Royal National Orthopaedic Hospital and University Bristol Royal Infirmary College Hospital Bristol, UK Honorary Senior Lecturer Brian E. Kendall FRCR, FRCP, FRCS I nstitute of Orthopaedics Consulting Radiologist London, UK The National Hospital for Neurology and Neurosurgery Peter Renton FRCR, DMRD and the Middlesex Hospital Consultant Radiologist London, UK Honorary Senior Lecturer Chris Lawinksi BSc, MSc, MPhil Royal National Orthopaedic Hospital Consultant Physicist and University College London Hospitals King's College Hospital London, UK London, UK Philip J.A. Robinson FRCP, FRCR Richard Mason FRCS, MRCP, FRCR Professor of Clinical Radiology Consulting Radiologist University of Leeds Middlesex Hospital Consultant Radiologist University College of London Hospitals Leeds Teaching Hospitals London, UK Leeds, UK Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� 10 TEXTBOOK OF RADIOLOGY AND IMAGING M. I. Rothman MD Sarah Vinnicombe BSc, MRCP, FRCR Assistant Professor of Radiology, Neurosurgery and Consultant Radiologist Otolaryngology /Head and Neck Surgery, Department of Diagnostic Imaging Medical Director. Anna Gudelsky Magnetic Resonance Center St Bartholomew's Hospital Baltimore, London, UK Maryland, USA loannis Viahos MSc, MBBS, MRCP, FRCR Carl Roobottom MSc, MBChB(Hon), MRCP, FRCR Research Fellow Consultant Radiologist Department of Diagnostic Imaging Dcrriford Hospital St Bartholomew's Hospital Plymouth, UK London, UK Michael B. Rubens MB, DMRD, FRCR lain Watt FRCP, FRCR Consultant Radiologist and Director of Imaging Consultant Clinical Radiologist Royal Brompton Hospital Bristol Royal Infirmary London, UK Bristol, UK Gary N. Sibley FRCS Anthony Watkinson Bmet, MSc, MBBS, FRCS, FRCR Consultant Urologist Consultant and Senior Lecturer in Radiology Department of Urology Royal Free Hospital Bristol Royal Infirmary London, UK Bristol, UK Peter Wilde BSc, MRCP, FRCR John A. Spencer MA, MD, MRCP, FRCR Consultant Cardiac Radiologist Consultant Radiologist Directorate of Clinical Radiology St James's University Hospital Bristol Royal Infirmary Leeds, UK Bristol, UK John M. Stevens MBBS, DRACR, FRCR Richard W. Whitehouse BSc, MB ChB, MD, FRCR Consultant Radiologist Consultant Radiologist Department of Radiology Manchester Royal Infirmary National Hospital for Neurology and Neurosurgery Manchester, UK London. UK Tim Whittlestone MA, FRCS (Ebg), MD, FRCS(Urol) Nicola H. Strickland BM, BCh, MA(Hons)(Oxon), FRCP, FRCR Hunterian Professor of Surgery Consultant Radiologist Specialist Registrar in Urology Hammersmith Hospital NHS Trust Bristol Royal Infirmary London, UK Bristol, UK David Sutton MD, FRCP, FRCR, DMRD, FCan.AR (Hon) Andrew R. Wright MA, MBBS, MRCP, FRCR Consulting Radiologist Consultant Radiologist St Mary's Hospital and Medical School, London Honorary Senior Lecturer Director, Radiological Department (1963-1984) St Mary's Hospital Consulting Radiologist, The National Hospital for Neurology Imperial College and Neurosurgery London, UK London, UK Jeremy W. R. Young MA, BM, BCh, FRCR Will Teh MBChB, MRCP, FRCR Professor and Chairman of Radiology, Medical University Consultant Radiologist of South Carolina Northwick Park Hospital Charleston Middlesex, UK South Carolina, USA Karen E. Thomas MA, BM BCh, MRCP, FRCR Gregg Zoarski MD Consultant Paediatric Radiologist Department of Diagnostic Radiology Hospital for Sick Children University of Maryland Medical Center Toronto Baltimore Ontario, Canada Maryland, USA Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� PREFACE The First Edition of this Textbook was conceived in the 1960s syllabus for Specialist Radiologists, the change was highly and published in 1969. 1, like many of my contemporaries began successful from a purely practical point of view. Sales rose by my studies in Radiology at the end of the Second World War. 300°% (from 1000 to 4000 copies per annum). My first post as an ex military service registrar was in the The first edition of this popular text-hook was published in Radiology Department of the National Hospitals for Nervous 1 969 and this seventh edition in still growing strongly at the Disease at Queen Square. It was pure serendipity that I should mature age of thirty three years. Review of the last five editions thus become associated with James Bull, the only British cover a period of exponential growth in radiological facilities and radiologist trained in Scandinavian neuroradiological techniques, imaging. New fields were just beginning to open at the time of the including percutaneous angiography. and at that tine representing first edition and these included ultrasound and nuclear medicine. the most advanced aspects of radiology. Computer tomography began in the 1970s to he overtaken in the My training in percutaneous cerebral angiography laid the 1 980s by magnetic resonance. It was generally felt that CT would foundation for other percutaneous techniques which I was able to soon be out-moded, but the last few years have seen a remarkable apply when appointed to St. Mary's hospital in 1952. Here again comeback from CT in the form of multi-slice spiral CT. As a pioneer work had already begun exploiting the potential for new result the versatility, speed and scope of CT examinations has methods in vascular surgery. been transformed. As a result of this background we were able to publish in 1962 In general, we hope this book reflects British Teaching Hospital the first personal monograph based on an experience of more than Practice in the field of Imaging. The ISE edition remains very ten thousand cases. (See Ch. I5). popular with non British readers and the 6th Edition has also been X-Rays were discovered by Roentgen in 1895, and though the translated into two further languages, Greek and Portuguese. We importance of the discovery was immediately realised and widely believe that much of its success is due to the decision to discussed the impact on medical practice was surprisingly slow. concentrate on Clinical rather than Technical aspects of our The diagnosis and treatment of fractures and lesions of bones and rapidly expanding and evolving specialty. joints was the first area to be thoroughly studied and surveyed. At Whilst each new edition has emphasised clinical rather then the same tine, the dangers and potential hazards of the new rays technical progress, the student must also be aware of. and absorb. were becoming apparent for the first time, as was the therapeutic the technical advances. The new edition therefore includes a chapter use of X-Rays. devoted to explaining this area. Other features of this new edition In the Post war period, paining and experience of a specialist are the complete rewriting by mainly new authors of major sections radiologist was still a matter of considerable debate and concern. of the text. These include the Cardiac. GU. Paediatric, Small and Broadly speaking, there were those who favoured a technical Large bowel, Major Abdominal Trauma and Intcrventional approach and paining, usually pure scientists or physicists, and Neuroradiology chapters. Other chapters have been revised by others who preferred a largely clinical approach with a minimum deleting obsolete material or including new material. Recent clinical of technical training. Thus advanced paining in medicine or trends are also reflected in the revision. Thus imaging and Staging surgery was regarded by many as essential for high quality of malignant tumors has been revised and updated in many areas. radiology. The British Faculty of Radiologists was expanding and the opportunity has been taken to integrate the latest version of rapidly and soon became the Royal College of Radiologists. The the World Health Organisation (WHO) reclassification on a FRCR thus became the essential higher radiological qualification histopatholigical basis of primary cerebral tumoii s. The expansion on a par with the MRCP or FRCS, and the DMRD was of non invasive and minimally invasive angioaraphy is monitored, downgraded to a qualifying diploma. and discussed. However, this is to some extent balanced by the At the time of this controversy, I took the opportunity to broaden increasing use of interventional techniques. my experience and expertise with the MD thesis, Membership of Radiology is a graphic subject. and images and illustrations are the Royal College of Physicians, London and Fellowship of the its vital tool. This edition contains no less then 5600 illustrations. Faculty of Radiologists. This was undoubtedly the clinical, rather some 2000 of which are new. than technical approach to radiological expertise. As in previous editions, we would remind the student that large In 1955 1 was appointed Editor to the Faculty .Journal, and took textbooks. like large animals, have a longer period of gestation. It the opportunity to persuade the Editorial Board to change its is therefore important to keep up with the current literature and name to Clinical Radiology. Apart from showing where my own attend up to date seminars. interest lay in the continual medico-political controversy between pure scientists (mainly physicists) and clinicians which many felt David Sutton could adversely affect the future paining and examination '_002 Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� THE NORMAL CHEST: METHODS OF I NVESTIGATION AND DIFFERENTIAL DIAGNOSIS J anet Murfitt with contributions from Philip J. A. Robinson, Richard W. Whitehouse, Andrew R. Wright and Jeremy P. R. Jenkins graphy in these circumstances. In addition it is still used in some centres to assess a peripheral lung mass, the lung apices and the abnormal hilum. However, conventional CT scanning i s far superior for staging malignancy, detecting pulmonary metastases, and assessing chest wall and pleural lesions, the lung mass, the hilum and mediastinum. High-resolution CT scanning is of proven value in the diagnosis of diffuse lung disease, particularly in the early stages when the chest radiograph is normal, and for follow-up. In most centres high- resolution scanning is used for the detection of bronchicctasis, and surgery is undertaken without preoperative bronchography. Radionuclide scanning is used as the first-line investigation of suspected pulmonary embolus in the majority of cases, with a normal scan excluding the presence of an embolus. Pulmonary angiography remains the gold standard for the diag- nosis of pulmonary embolism. It is usually undertaken in those patients with massive embolism when embolectomy or thrombo- lysis is contemplated. However, spiral CT angiography is showing sensitivity and specificity rates approaching those of conventional angiography in the diagnosis of pulmonary embolism, and can reliably demonstrate vessels down to the subsegmental level. Ultrasound is of use for investigating chest wall and pleural lesions and lung lesions adjacent to the chest wall. It should be used for the localization of pleural fluid prior to a diagnostic tap or drainage to reduce the risk of a malpositioned catheter and pneumo- thorax. However, the acoustic mismatch between the chest wall and air-containing lung results in reflection of the ultrasound beam at the lung-pleura interface, so that normal lung cannot be demonstrated. Biopsy of pulmonary lesions using a fine needle for aspiration has a high diagnostic yield for malignancy, excluding lymphoma. with a low incidence of complications. A cutting needle is associ- ated with a higher complication rate but is more helpful in the diagnosis of lymphoma and benign lung conditions. 1 • Plain films: a PA, lateral b AP, decubitus, supine, oblique • Inspiratory-expiratory d Lordotic, apical, penetrated • Portable/mobile radiographs • Tomography • CT scanning • Radionuclide studies • Needle biopsy • Ultrasound • Fluoroscopy • Bronchography • Pulmonary angiography • Bronchial arteriography • MRI • Digital radiography • Lymphangiography. The plain postero-anterior (PA) chest film i s the most frequently requested radiological examination. Visualisation of the lungs is excellent because of the inherent contrast of the tissues of the thorax. Lateral films should not be undertaken routinely. Comparison of the current film with old films is valuable and should always be undertaken if the old films are available. A current film is mandatory before proceeding to more complex investigations. Simple linear tomography remains a useful investigation when CT is unavailable. It is helpful for confirming that an abnormality suspected on a plain film is genuine and that it is intrapulmonary, although the high kilovoltage film has reduced the need for tomo- Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� 2 A TEXTBOOK OF RADIOLOGY AND IMAGING The value of MRI for diagnosing pulmonary disease is still in Using a low kVp (60-80 kV) produces a high-contrast film the assessment stage. No distinct advantage over high-resolution ( Fig. 1.1) with miliary shadowing and calcification being more CT in the diagnosis of parenchymal disease has yet been shown clearly seen than on a high kV film. For large patients a grid but it is proven to be helpful in the diagnosis of hilar masses, reduces scatter. A FFD of 1.85 m (6 feet) reduces magnification and lymphadenopathy and mediastinal lesions. produces a sharper image. With high kilovoltagcs of I20-I70 kVp Diagnostic /nuecanolhorax is an obsolete procedure which was the films are of lower contrast (Fig. 1.2A,B) with increased visual- once used to differentiate a pleural-based from a pulmonary lesion. isation of the hidden areas of the lung due to better penetration of The h(11111111/contrast soul/onr has been supplanted by CT for overlying structures. The hones and pulmonary , calcification are less assessing he non-oesophageal mediastinal mass but may he indi- well seen. The exposure time is shorter so that movement blur due cated in the investigation of conditions associated with pulmonary to cardiac pulsation is minimised. A grid or air gap is necessary to changes such as scleroderma, hiatus hernia and achalasia. It is used reduce scatter and improve contrast. An air gap of 15-25 cm for demonstrating broncho-oesophageal fistulas, tracheal aspiration between patient and film necessitates an increased FFD of 2.44 m and vascular rings. (8 feet) to reduce magnification. Chylous reflex with the formation of a chylothorax may he An automatic exposure system and dedicated automatic chest demonstrated by conventional Irmphan,,iograp/it. unit are desirable in a busy department. The lateral view THE PLAIN FILM A high kVp or normal kVp technique may be used with or without a grid. For sharpness the side of interest is nearest the film. With The PA view shoulders parallel to the film the arms are elevated, or displaced By definition the patient faces the film chin up with the shoulders back if the anterior mediastinum is of interest. rotated forward to displace the scapulae from the Inngs. Exposure Lesions obscured on the PA view are often clearly demonstrated is made on full inspiration for optimal visualisation of the lung on the lateral view. Examples of this arc anterior mediastinal bases, centring at T5. The breasts should be compressed against masses, eneysted pleural fluid (Fig. 1.3) and posterior basal eon- the film to prevent them obscuring the lung bases. solidation. By contrast, clear-cut abnormalities seen on the PA There is no _*eneral consensus regarding the kV used for chest view may be difficult to identify on the lateral film because the radiography although the high kVp technique is widely used as a two lungs are superimposed. An example of this is a left lung standard departmental film. High kVp, low kVp or intermediate collapse (Fig. 1.4). This is particularly so with a large pleural kVp techniques arc used with various film-screen combinations, effusion. grids or air-gap techniques. Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� THE NORMAL CHEST: METHODS OF INVESTIGATION AND DIFFERENTIAL DIAGNOSIS 3 Fig. 1.2 (A,B) Radiographs of patient in Fig. 1.1 taken at 1 70 kVp. Note the improved visualisation of the main airways, vascular structures and the area behind the heart including the spine. Other views retrocardiae area, the posterior costophrenic angles and the chest Although not frequently requested, additional plain films may assist wall, with pleural plaques being clearly demonstrated. In the AP with certain diagnostic problems before proceeding to the more position (as for patients unable to stand or portable radiographs) the complex and expensive techniques. Oblique views demonstrate the ribs are projected over different areas of the lung from the PA view Fig. 1.3 Encysted pleural fluid. (A) PA film. A right pleural effusion with a large well-defined midzone mass. (B) Lateral film. Loculated fluid is demonstrated high in the oblique fissure. Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� Fig. 1.4 Collapse of the left lung. (A) PA film. (B) Lateral film. Only the right hemidiaphragm is visible. The radiolucency of the lower vertebrae is decreased. and the posterior chest is well shown. In contrast to the PA film the 50-60°, or downward. as in the lordotic • vid ii , with the patient in a scapulae overlie the upper lungs and the clavicles are projected lordotic PA position. In this view a middle lobe collapse shows more cranially over the apices. The disc spaces of the lower cer- clearly as a well-defined triangu lar shadow. vital spine are more clearly seen, whereas in the PA film the neural A suhpulmonary effusion is frequently difficult to distinguish arches arc visualised. When a portable radiograph is undertaken, from an elevated diaphragm or consolidation. On the PA view the the shorter FFD results in magnification of the heart and the longer apex of the effusion has a more lateral position than that of a exposure time in increased movement blur. normal diaphragm. In the supine and decuhifus positions (Fig. 1.5) Good visualisation of the apices requires projection of the free fluid becomes displaced. On the supine projection this results clavicles upward, as in the apical rice • with the tube angled up in the hemithorax becoming opaque with loss of the diaphragm 4 A TEXTBOOK OF RADIOLOGY AND IMAGING Fig. 1.5 Subpulmonary pleural fluid. (A) Erect PA radiograph. There is apparent elevation of the left hemidiaphragm. Increased translucency of the left lung is due to a left mastectomy. Note the abnormal axillary fold (arrow). (B) Left lateral decubitus film (with horizontal beam). Pleural fluid has moved to the most dependent part of the left hemithorax (arrows). Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ ���������� ��� ��������� ����� ������� THE NORMAL CHEST: METHODS OF INVESTIGATION AND DIFFERENTIAL DIAGNOSIS 5 outline, an apical cap, blunting of the costophrenic angle and Penetration With a low kV film the vertebral bodies and disc decreased visibility of the pulmonary markings. spaces should be just visible down to the T8/9 level through the The decubitus films shows fluid levels particularly well. Small cardiac shadow. Underpenetration increases the likelihood of amounts of pleural fluid may be shown with the affected side missing an abnormality overlain by another structure. Over- dependent. penetration results in loss of visibility of low-density lesions such Paired inspiratory and expiratorv films demonstrate air trapping as early consolidation, although a bright light may reveal the and diaphragm movement. Traditonally it has been taught that small abnormality. pneumothoraces and interstitial shadowing may be more apparent Degree of inspiration On full inspiration the anterior ends of the on the expiratory film. However the inspiratory view is now consid- ered to be as accurate as the expiratory view for diagnosing a pneu- mothorax. Paired views are very important in children with a aphragm although the degree of inspiration achieved varies with possible diagnosis of an inhaled foreign body. patient build. On expiration the heart shadow is larger and there is - basal opacity due to crowding of the normal vascular markings. Pulmonary diseases such as fibrosing alveolitis are associated Viewing the PA film with reduced pulmonary compliance, which may result in reduced Before a diagnosis can be made an abnormality, if present, must be inflation with elevation of the diaphragms. identified. Knowledge of the normal appearance of a chest radio- graph is essential. In addition the radiologist must develop a routine The trachea which ensures that all areas of the radiograph are scrutinised. Some The trachea should be examined for narrowing, displacement and prefer initially to view the film without studying the clinical infot intraluminal lesions. It is midline in its upper 1part, then deviates mation. Comparison of the current film with old films is important slightly to the right around_ the aortic knuckle. On expiration devia- and often extremely helpful. A suggested scheme that examines lion to the right becomes more marked. In addition there is short- each point in turn is shown in Box L I. erring on expiration so that an endotracheal tube situated just above the carina on inspiration may occlude the main bronchus on Technical aspects expiration. Centring If the film is well centred the medial ends of the clavicles Its calibre should be even, with translucency of the tracheal air are equidistant from the vertebral spinous processes at the T4/5 column decreasing caudally. Normal maximum coronal diameter is level. Small degrees of rotation distort the mediastinal borders, and 25 mm for males and 21 rim for females. The right tracheal margin, the lung nearest the film appears less translucent. Thoracic deform- where the trachea is in contact with the lung, can be traced from the itics, especially a scoliosis, negate the value of conventional cen- clavicles down to the right main bronchus. This border is the right tring. The orientation of the aortic arch, gastric bubble and heart paratracheai stripe and is seen in 60%0 of patients, normally meas- should be determined to confirm normal situs and that the side urng less than 5 mm. Widening of the stripe occurs most corn- markers are correct. monly with mediastinal lymphadenopathy but also with tracheal malignancy, mediastinal tumours, mediastinitis and pleural effu- Box 1.1 Suggested scheme for viewing the PA film signs. A left paratracheal line is not visualised because the left border of the trachea lies adjacent to the great vessels and not the 1. Request form Name, age, date, sex lung. Clinical information The azygos rein l ies in the angle between the right main 2. Technical Adequate inspiration bronchus and trachea. On the erect film it should be less than Centring, patient position/rotation 1 0 turn in diameter. Its size decreases with the Valsalva manoeuvre z Side markers and on inspiration. Enlargement occurs in the supine position but % Exposure/adequate penetration also with enlarged subcarinal nodes, pregnancy. portal hyper- Collimation tension, IVC and SVC obstruction, right heart failure and constric- 3. Trachea Position, outline five pericarditis. 4. Heart and mediastinum Size, shape, displacement Widening of the carina occurs on inspiration. The normal angle is 5. Diaphragms outline, shape 60-75°. Pathological causes of widening include an enlarged left Relative position atrium (Fig. 1.6) and enlarged carinal nodes. 6. Pleural spaces Position of horizontal fissure Costophrenic, cardiophrenic angles The mediastinum and heart 7. Lungs Local, generalised abnormality The central dense shadow seen on the PA chest film comprises the Comparison of the translucency and vascular markings of the lungs mediastinum, heart, spine and sternum. With good centring two- thirds of the cardiac shadow lies to the left of midline and one-third 8. Hidden areas Apices, posterior sulcus Mediastinum, hila, bones to the right, although this is quite variable in normal subjects. The transverse cardiac diameter (normal for females less than 14.5 cm 9. Hila Density, position, shape and for males less than 15.5 cm) and the cardiothoracic ratio are 1 0. Below diaphragms Gas shadows, calcification assessed. The normal cardiothoracic ratio is less than 50% on a PA 11. Soft tissues Mastectomy, gas, densities, etc. 51 film. Measurement in isolation is of less value than when previous 1 2. Bones Destructive lesions, etcc figures are available. An increase in excess of 1.5 cm in the trans- verse diameter on comparable serial films is significant. However Next Page CONTENTS Previous Page ﯽﮑﻴﻧوﺮﺘﮑﻟا ﺮﺸﻧ ﯽﺗارﺎﺸﺘﻧا ﻪﺴﺳﻮﻣ ﺶﻧادرﻮﻧ

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