Clinical Radiology The Essentials Clinical Radiology The Essentials f o u R t h e d i t i o n Richard h. daffner, md, faCR Professor of Radiologic Sciences Drexel University College of Medicine Department of Diagnostic Radiology Allegheny General Hospital Clinical Professor of Radiology Temple University College of Medicine, Allegheny Campus Pittsburgh, Pennsylvania matthew S. hartman, md Assistant Professor, Radiologic Sciences Drexel University College of Medicine Residency Program Director Allegheny General Hospital Forbes Regional Hospital The Western Pennsylvania Hospital Adjunct Assistant Professor, Radiology/Diagnostic Imaging Temple University School of Medicine, Allegheny Campus Pittsburgh, Pennsylvania Acquisitions Editor: Susan Rhyner Product Manager: Angela Collins Marketing: Joy Fisher-Williams, Laura Harrington Vendor Manager: Alicia Jackson Design & Art Direction: Joan Wendt, Doug Smock Compositor: Integra Software Services Pvt. Ltd. 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First Edition, 1993 Second Edition, 1999 Third Edition, 2007 Library of Congress Cataloging-in-Publication Data Daffner, Richard H., 1941- author. Clinical radiology : the essentials / Richard H. Daffner, Matthew S. Hartman. -- 4th edition. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4511-4250-1 I. Hartman, Matthew S., author. II. Title. [DNLM: 1. Diagnostic Imaging--methods--Atlases. WN 17] RC78.7.D53 616.07’54--dc23 2013007058 DISCLAIMER Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. 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Preface November 1995 marked the centennial of the discovery of x-rays by Roentgen. During those first 100 years, diagnostic imaging, through a variety of modalities, has greatly influ- enced medical diagnosis and treatment. In 1940, the management of approximately 1 in 10 patients was influenced by a radiographic study. By 1980, virtually all patients under- went some sort of diagnostic imaging study. Now, in the new millennium, imaging is used to guide many therapeutic procedures that previously would have required surgical exposure and prolonged hospitalization. Diagnostic radiology has undergone dramatic changes in the past four decades. Prior to 1970, the specialty relied primarily on radiographs that were often supplemented by various contrast examinations for clinical problem solving. A revolution in diagnostic imaging began in the early 1970s with the development of cross-sectional and longi- tudinal imaging using ultrasound. Almost concomitantly, computed tomography (CT) followed, and soon rapid improvements in technology afforded us the ability to directly image areas of the body that previously were accessible only to the surgeon’s knife. Mag- netic resonance imaging (MRI) joined the diagnostic armamentarium in the early 1980s and added a new dimension for the diagnosis of disorders of the central nervous system, musculoskeletal system, the heart, and the gastrointestinal tract. Now, molecular imaging has emerged as a method of identifying specific tissues in the body. In the next decade, this new imaging technique should move rapidly from the laboratory to practical applica- tions in improving cancer diagnosis and treatment. Improvements in imaging have also changed the diagnostic approach to many condi- tions. Invasive procedures such as bronchography, cholecystography, cholangiography, cisternography, laryngography, lymphangiography, pneumoencephalography, and con- ventional tomography are, thankfully, no longer performed and have all been replaced by CT and/or MRI. Many other procedures such as intravenous urography, sinus radiog- raphy, and endoscopic retrograde cholangiopancreatography are on an “endangered spe- cies” list of studies and have been largely replaced by CT and/or MRI. Refinements in existing technology facilitated whole new fields of endeavor for radi- ologists—interventional and invasive radiology. Radiologists are no longer limited in their abilities to simply make diagnoses. They have now developed the tools and skills to treat many conditions such as aneurysms, gastrointestinal bleeding, tumors, recurrent pulmonary emboli, and certain posttraumatic joint instabilities. Furthermore, using CT guidance, radiologists are now able to safely perform biopsies, drainages, excision, tumor ablation procedures, and surgical screw placements. Our specialty is in a constantly evolving state. Improvements in computer technology have produced highly detailed multiplanar and three-dimensional imaging, as well as digital imaging. Digital processing of data is now the norm and picture archiving and computer storage is now the standard method of viewing and storing imaging studies, having replaced the conventional film radiography. This new format now allows images to be rapidly sent electronically from the source of origin to the physicians who need to see them. In the 1990s, the general awareness of the cost of health care led us to seek alternative methods for making diagnoses and treating patients. While there is now an exciting new field of minimally invasive surgery, radiologic-guided intervention is now replacing many surgical procedures. At the beginning of the new millennium, there are more demands for accountability on the part of the medical profession. Diagnostic radiology is ready to vii viii Preface answer the call. In addition, while the cost of health care is foremost in everyone’s minds, there is also a growing awareness of the dangers of exposure to radiation from diagnostic studies, particularly CT scans. The American College of Radiology (ACR) has responded to these two challenges by developing programs to guide clinicians to ordering the right study for the right reasons, and for radiologists to perform them the right way. The ACR Appropriateness Criteria® attempt to recommend appropriate imaging for a large variety of clinical conditions. Their recommendations are based on reviews of current literature by panels of experts in radiology in consultation with applicable clinicians. This book is intended for the medical student who is beginning his or her clinical rotations. It is a thorough revision of the third edition and includes the state-of-the-art changes that have occurred in the field. There have been a number of significant changes to the book. The previous editions were a solo effort by myself. In writing the chapters out of my particular area of expertise (musculoskeletal and spine imaging), I relied on my colleagues at Allegheny Radiology Associates for expert advice. For this edition, I enlisted the services of my colleague Matthew S. Hartman, MD, as coauthor/coeditor. In addition, each chapter was revised by a colleague who was, in our estimate, an expert in his/her field. Furthermore, there will be web-based additional material that will include selective case studies. These case studies will be updated on a periodic basis, whereas the main text will have to wait for a new edition for updates. Significant new material includes discussions on newer interventional techniques and cardiac imaging the reader is likely to encounter. As before, disorders of the pediatric age group are integrated into each chapter rather than considered separately to avoid duplica- tion of material. Other significant changes include the addition of nearly 300 new figure parts and the replacement of many older figures with those that reflect state-of-the-art imaging. In writing the original edition of this book as well as in its revisions, we have kept the orientation based on clinical problem solving, rather than listing the radiographic signs of various conditions as isolated facts without attempting to correlate them with the pathophysiology that produces them. Diagnostic imaging is true detective work. The image represents the patient at that particular point in time. By knowing one’s anatomy, and by observing the changes that the disease has produced to that anatomy, it is possible to identify the pathologic process(es) that produced those changes. It is our goal to show that by recognizing a radiographic pattern, it is possible to define the pathophysiologic process producing that pattern. The first chapter provides an overview of diagnostic imaging, listing the “menu” of imaging options available to help solve clinical problems. The physical basis for each type of imaging is briefly stated. The second chapter discusses radiographic contrast agents, with attention to contrast-induced nephritis. The third chapter is devoted to interventional or invasive radiology. The remainder of the book consists of individual chapters describing imaging of the lungs, heart, breast, abdomen, gastrointestinal tract, urinary tract, obstet- rics and gynecology, the musculoskeletal system, and the brain and spinal cord. Each of the clinical chapters is divided into three sections: technical considerations, anatomic considerations, and pathologic considerations. The technical considerations por- tion of each chapter discusses the types of examinations performed for that area, the use of special imaging, and a description of how each particular examination may be of help in clinical problem solving. The anatomic considerations portion reviews pertinent anatomy of the region being stud- ied. No attempt is made to be encyclopedic; rather, the approach is very brief but covers all of the essentials. It is important for you, the reader, to recognize that the images that you are viewing are two-dimensional representations of three-dimensional structures. You must remember the adage that if you know the gross appearance of a structure, you can easily predict its radiographic or other imaging appearance. The pathologic considerations include those pathophysiologic alterations of normal ana- tomic structures that produce the abnormalities shown on the images. Logic tells us that there are a limited number of ways for a disease to affect an organ. Similarly, there are limitations in the way an organ responds to that disease process. For example, in the gas- trointestinal tract, a mucosal tumor appears the same whether it is located in the esopha- gus, stomach, small intestine, or colon. The same holds true for other lesions of this system. Furthermore, an extrapolation may be made to other tubular structures in the body—airways, urinary tract, and blood vessels. Once the reader recognizes the p attern of a lesion, he/she will recognize it anywhere in the body, even if it is in an unusual location.