Imaging modalities in anatomy- X-ray,

fluoroscopy, thermography, xerography,

historadiology, mammography,
ultrasonography, tomog
raphy, and CAT scan, NMR, PET
BY
MISS UMEANO A.V

17th JANUARY, 2024

 OUTLINE
• Introduction
• X-rays
• Fluoroscopy
• Tomography
• Computed tomography scan
• Historadiography
• Xeroradiography
• Thermoradiography
• Mammography
• Ultrasound
• Magnetic Resonance Imaging
 OUTLINE
• Nuclear Medicine
• Single proton emission computed tomography
• Positron emission tomography
• Nuclear Medicine therapy
• Choosing the right modality
• Examples of best imaging modalities for common clinical conditions
 INTRODUCTION
• Imaging modalities, also known as radiology modalities, are the different types of medical
imaging techniques used to visualize the body for diagnostic and therapeutic purposes.

• The four main types of imaging modalities are x-ray imaging ( including computed
tomography and fluoroscopy), ultrasound, magnetic resonance imaging, and nuclear
medicine (including positron emission tomography [PET]).

• Other imaging techniques include xerography, thermography, historadiography and

mammography

• These imaging modalities are often categorized by the method in which images are generated
 X-RAY
• X-rays are a form of electromagnetic radiation (a.k.a. photons; light particles) that were
discovered in 1895, giving birth to the field of radiology.
• X-rays led to the formation of radiology as a medical specialty

• X-rays consist of ionizing radiation, Images are created by the x-rays that travel through the
object/ part of the body being imaged to reach a detector on the other side.
• These images are referred to as “radiographs” or “plain films.”

• X-rays are variably absorbed by the structures they pass through with denser structures/items
absorbing a larger amount of x-rays. In essence, x-ray images are density maps of people.

• hence, they are best at detecting significant differences in density, such as lungs and bones on
chest radiographs, bones on extremity and spine imaging, and bowel gas and kidney stones
when imaging the abdomen and pelvis.
 X-RAY
• The area of the body being investigated can
place limitations on the efficacy of X-rays.

• In regions where several structures overlap

(e.g lung), an abnormality is less likely to
be visible than on an X-ray of the forearm.

• Specialized X-ray techniques may be used

to screen for particular conditions.
 Example, digital mammography is an
X-ray technique that uses low dose
radiation to detect breast cancer A plain radiograph (X-ray) of the
 Panoramic X-rays are used to detect pelvic bones showing the hip
dental disease. joint and lower back. Source:
dreamtime.com
 X-RAY
• A panoramic X-Ray is a type of X-ray that
gives the dentist a “snapshot” or overview of
the entire mouth and jaws including: all the
teeth, the temporomandibular joint (TMJ)
and the sinus cavity.

• Panoramic images are not good for detecting

very small cavities.

• But they are good at finding larger concerns

like infections, impacted teeth, tumors,
degenerative joint disease and cysts.
Panoramic x-ray image. Source: Mint hill
dentistry
 Advantages and Disadvantages of X-ray
• Advantages:
• X-ray machines are widely available and
relatively quick, cheap, and easy to
perform.

• Disadvantages:
• X-rays consist of harmful ionizing radiation
that can damage cells
• Imaging modalities using x-rays have
limited soft tissue contrast resolution (it can
be hard to differentiate adjacent soft tissues
of similar density from one another).

• Image of an X-ray machine

 Fluoroscopy (Video X-ray)
• Seeing an x-ray machine as a camera, fluoroscopy is like a video camera – x-rays are
produced in a pulsed or continuous fashion and generate real-time images of the body.
.
• This allows radiologists and physician to see what’s happening real time.

• In fluoroscopy, a fluorescent screen and image intensifier tube is connected to a closed-circuit

television system. Due to continuous monitoring, multiple images are taken over time.
Hence, the radiation exposure with fluoroscopy is significantly higher than that of
conventional X-rays.

• In some settings, these real-time images are particularly important and radiocontrast agents
are used.

• The images are of much lower quality than conventional radiographs to limit the patient’s
overall radiation exposure
 FLUOROSCOPY
• Presently, Two radiocontrast agents are in common use.
• Barium sulfate (BaSO4) is given orally or rectally for evaluation of the GI tract.
• Iodine, in multiple proprietary forms, is given by oral, rectal, vaginal, intra-arterial
or intravenous routes.
• These radiocontrast agents strongly absorb or scatter X-rays, and in conjunction with
the real-time imaging, allow demonstration of dynamic processes, such as peristalsis
in the digestive tract or blood flow in arteries and veins.
• Iodine contrast may also be concentrated in abnormal areas more or less than in
normal tissues and make abnormalities (tumors, cysts, inflammation) more
conspicuous
• .In specific circumstances, air can be used as a contrast agent for the gastrointestinal
system and carbon dioxide can be used in the venous system
• In these cases, the contrast agent attenuates the X-ray radiation less than the
surrounding tissues.
• Fluoroscopy is also done to monitor progress during the insertion of a pacemaker.
 FLUOROSCOPY
• Common fluoroscopy exams include (Application): upper GI series,
esophagrams, barium swallows in conjunction with speech pathology,
enemas, cystograms, sniff tests, and hysterosalpingograms (HSGs)

• Common procedures that require fluoroscopy: joint injections, lumbar

puncture, various interventional radiology procedures, heart
catheterizations, and in some surgical specialties such as orthopedic
surgery and urology
 Advantages and disadvantages of fluoroscopy
• Advantages: Allows you to see what
is happening in real-time and each
image uses an incredibly low dose.

• Disadvantages: Radiation dose is

cumulative throughout the
exam/procedure, image quality is
relatively poor to limit radiation to
the patients.

Barium enema or BE is image of

large bowel after injection of barium
contrast fill into colon under
fluoroscopic control isolated on
white background for diagnosis
 TOMOGRAPH
• Tomography is simply imaging by sections or sectioning through the use of
any kind of penetrating wave example x-ray, gamma, radiofrequency waves,
ions etc.

• More modern variations of tomography involve gathering projection data

from multiple directions and feeding the data into a tomographic
reconstruction software algorithm processed by a computer.

• Tomography is a technology that uses a tomographic optical system to obtain

virtual 'slices' (a tomographic image) of specific cross section of a scanned
object.
TYPES OF TOMOGRAPHS
 Computed Tomography (CT) Scan
• Computed tomography (CT scan) is a form of
imaging that contains a donut-shaped ring
(gantry) of x-ray generators that rotates around
the patient, getting information from multiple
different angles.

• This produces a stack of two-dimensional (2D)

cross-sectional images of the body that can be
combined to create three-dimensional (3D)
appearance

• CT scans rapidly obtain high quality images of

the body and are capable of scanning the entire
body under a minute. Because of this, CT is a • image of a CT-scan
workhorse of medical imaging, particularly in
the emergency setting.
 CT SCAN
• CT uses a series of X-rays plus a computer to produce a cross-sectional image of the
inside of the body.
• CT provides more detail than an X-ray, and can better define areas where tissues overlap.
• CT scans can detect smaller abnormalities that can’t be found with a conventional X-ray.
• The use of contrast dyes for CT scan further improves visualization in some areas, such
as the digestive tract
• CT scanning has become the test of choice in diagnosing some urgent and emergent
conditions, such as;
i. cerebral hemorrhage,
ii. pulmonary embolism,
iii. aortic dissection,
iv. appendicitis,
v. diverticulitis, and
vi. obstructing kidney stones
 CT SCAN

• Advantages: CT scans are widely

available, quick, and give a lot of
useful information.

• Disadvantages: Expensive and expose

patients to higher levels of harmful
ionizing radiation.

Image showing a 3d colored CT

scan of the lumbar vertebrae.
Source: shutter stock images
 Historadiography
• Historadiography is a technique formerly utilized in the fields of histology and cellular
biology to provide semiquantitative information regarding the density of a tissue sample. It is
usually synonymous with microradiography.

• This is achieved by layering a ground section of mineralized tissue (such as bone) with
photographic emulsion on a glass slide and exposing the sample to a beam of X-rays.
• After developing the emulsion, the resulting radiograph can be viewed with a microscope.

• A side-by-side comparison with a slide containing radiographs of various substances of

known mass can provide a rough mass estimate, and therefore a rough approximation of the
concentration of calcium salts in the sample.

• Historadiography has also been used to visualize staining of tissue, such as spinal cord
samples with thorotrast, which contains thorium that is opaque to X-rays.
 Xeroradiography
• Xeroradiography was developed by engineer Dr. Robert C. McMaster in 1950 and it is a type
of X-ray imaging in which a picture of the body is recorded on paper rather than on film.

• In this technique, a plate of selenium, which rests on a thin layer of aluminium oxide, is
charged uniformly by passing it in front of a scorotron.

• As X-ray photon impinges on this amorphous coat of selenium, charges diffuse out, in
proportion to energy content of the X-ray. This occurs as a result of photoconduction.

• The resulting imprint, in the form of charge distribution on the plate, attracts toner particles,
which is then transferred to reusable paper plates.

• In contrast to conventional X-rays, photographic developers are not needed, Hence the term
xeroradiography; It requires more radiation exposure.
• Historically used in mammography prior to the advent of digital mammography.
 TYPES OF XEROGRAPHY
• Negative mode xeroradiography; a
xeroradiographic image that is blue
and white but that has been reversed
so that white represents the dense
areas.

• Positive mode xeroradiography; a

xeroradiographic image that is blue
and white, with blue representing the
dense areas.
• IMAGE OF AN ANKLE XEROGRAPH
 THERMOGRAPHY
• Thermography (clinical thermography) is a test that uses an infrared camera to detect heat
patterns and blood flow in body tissues.

• Clinical thermography is also known as a physiologic imaging technology that provides

information on the normal and abnormal functioning of the sensory and sympathetic
nervous systems, vascular system, musculoskeletal system, and local inflammatory
processes.

• The procedure also provides valuable diagnostic information with regard to dermatologic,
endocrine, and breast conditions.

• Digital infrared thermal imaging (DITI) is the type of thermography that’s used to diagnose
breast cancer. DITI reveals temperature differences on the surface of the breasts to diagnose
breast cancer.
.
 THERMOGRAPHY
• The idea behind this test is that, as cancer
cells multiply, they need more oxygen-rich
blood to grow. When blood flow to the tumor
increases, the temperature around it rises

• Thermography has been around since the

1950s when it first caught the interest of the
medical community as a potential screening
tool. But in the 1970s, a study called the
Breast Cancer Detection Demonstration
Project found that thermography was far less
sensitive than mammography at picking up
cancer, and interest in it waned
 Advantages and limitations of thermography
• Thermography has been promoted as a more effective screening test for women under 50
and for those with dense breasts where Mammograms aren’t as sensitive in these two
groups.

• But because thermography isn’t very good at picking up breast cancer on its own, The FDA
recommends that women only use thermography as an add-on to mammograms for
diagnosing breast cancer.

• Thermography is a noninvasive test that uses a camera to take images of your breasts. There
is no ionizing radiation exposure as it uses non-ionizing radiation, no compression of your
breasts, and no real risks associated with the test.

• Although thermography is safe, there isn’t any evidence to prove it’s effective. The test has a
high false-positive rate, meaning that it sometimes finds cancer when none is present. It’s
also worth noting that the test isn’t as sensitive as mammography at finding early
 MAMMOGRAPHY
• Mammography (mastography) is the process of using low-energy X-rays (usually around 30
kVp) to examine the human breast for diagnosis and screening.

• The goal of mammography is the early detection of breast cancer, typically through detection
of characteristic masses or microcalcifications.

• As with all X-rays, mammograms use doses of ionizing radiation to create images.

• During a mammogram, your breasts are compressed between two firm surfaces to spread out
the breast tissue. Then an X-ray captures black-and-white images that are displayed on a
computer screen and examined for signs of cancer.

• A traditional mammogram creates two-dimensional images of the breast. A newer type of

mammogram called a 3D mammogram (breast tomosynthesis) creates three-dimensional
images of the breast
THE TRADITIONAL VS 3D
MAMMOGRAM
THE TRADITIONAL VS 3D
MAMMOGRAM
MAMMOGRAPHY
 USES OF MAMMOGRAM
• A mammogram can be used either for screening or for diagnostic purposes:

Screening mammogram.: is used to detect breast changes that could be cancerous in people
who have no signs or symptoms. The goal is to detect cancer when it's small, so that
treatment may be less invasive.

Diagnostic mammogram: A diagnostic mammogram is used to investigate suspicious breast

changes, such as a new breast lump, breast pain, an unusual skin appearance, nipple
thickening or nipple discharge.
• It's also used to evaluate unexpected findings on a screening mammogram. A diagnostic
mammogram includes additional mammogram images and images are gotten from multiple
positions
 Risks and limitations of mammograms

• Mammograms expose you to low-dose radiation.

• Having a mammogram may lead to additional testing. If something unexpected is detected

on your mammogram, you may need other tests. These might include additional imaging
tests such as ultrasound, and a procedure (biopsy) to remove a sample of breast tissue for
laboratory testing. However, most findings detected on mammograms aren't cancer.

• Screening mammography can't detect all cancers. Some cancers detected by physical
examination may not be seen on the mammogram. A cancer may be missed if it's too small
or is located in an area that is difficult to view by mammography, such as your armpit.

• Not all of the cancers found by mammography can be cured. Some breast cancers are
aggressive, grow rapidly and quickly spread to other parts of the body.
 Ultrasound
• Ultrasound is a non-ionizing form of radiology that
uses sound waves to create images of the inside of
the body.

• The sound waves are created by the ultrasound

probe (transducer), which enter the body, interact
with various tissues, and return to the probe where
the sound waves are detected.

• A computer converts those sound waves into

images.

• image of an ultrasound machine

 ULTRASOUND
• Ultrasound is often used to visualize organs such as the liver, gallbladder, kidneys,
spleen, portions of the pancreas, uterus, ovaries, Breast etc. Ultrasound can also be
used to visualize blood vessels (flow direction, speed, and even waveform), evaluate
hernias and joints, and to assess the health of fetuses (unborn babies).

• Ultrasound allows for dynamic imaging where you can watch what is being scanned in
real-time. Needles are generally visible by ultrasound as well, making it an excellent
modality for image-guided procedures (biopsies, paracentesis, thoracentesis, etc.).

• Advantages: Widely available, relatively inexpensive, safe in pregnancy, and does not
use harmful radiation.
• Disadvantages: Operator-dependent (requires a skilled sonographer or radiologist),
limited by body habitus/increased subcutaneous fat and bowel gas, susceptible to
artifacts, and unable to see through bone or gas.
 Magnetic Resonance Imaging (MRI)

• Magnetic resonance imaging uses strong magnetic fields and radio waves to produce
images of the inside of the body.

• Though CT is often a better method for evaluating bones and blood vessels, MRI is a
better test for evaluating soft tissue, such as the brain, spinal cord, nerves, muscles,
tendons, and breast tissue.

• MRI has allowed doctors to diagnose conditions that could only be assumed in the past e.g.
brain, spinal cord, and peripheral nerve disorders.

• For example, diagnosis of multiple sclerosis was limited to an assessment of symptoms

alone and could only be confirmed on an autopsy before MRI was available
 MRI OF THE BRAIN SHOWING HEALTHY BRAIN VS
DAMAGED BRAIN CAUSED BY MULTIPLE SCLEROSIS
 Magnetic Resonance Imaging (MRI)
• For breast cancer screening, MRI is more
accurate than mammography.

• Other than PET/CT, most imaging

techniques are structural but not functional.

• This means that they reveal the structure of

an area of the body but does not provide
information as to function.

• One form of MRI called functional MRI,

can, however, give an estimate of brain
activity. MRI of the head. Source:
shutter stock images
Magnetic Resonance Imaging (MRI)
• Contrast is often used to better define regions that are being scanned, with a
common agent called gadolinium.

• Magnetic resonance technology may also be used as an alternative to more invasive

procedures at times, such as with magnetic resonance angiography (MRA).

• A major advantage of MRI is that it does not use ionizing radiation, which has been
linked to an increased risk of cancer, especially in children. (Baysson et al., 2012).

• Limitations include the cost, body mass index (MRI is difficult in very overweight
people), and it may not be used in people who have metal in their body
 MRI
• Advantages: Superior soft tissue contrast
• image of MRI machine
resolution making MRI the best medical imaging
option for the spinal cord, preferred choice over
other imaging modalities for evaluating masses
and infection in the brain and masses in the
abdomen and pelvis, and lack of ionizing
radiation.
• Disadvantages: MRI is very sensitive to various
artifacts (breathing, gas, motion, metal),
expensive, exams may be long (upwards of 60
minutes of laying still in the scanner) and
incredibly difficult for patients with significant
claustrophobia, will be contraindicated in some
patients with implantable devices or with a
magnetic foreign body, and are still somewhat
operator-dependent.
 Nuclear Medicine
• Nuclear medicine, occasionally referred to as “unclear medicine,”
• Nuclear medicine involves giving patients a radioactive medication via IV or by mouth. That
radioactive drug will go through a physiological pathway in the body and “trace” that
pathway. Hence, radioactive drugs are frequently referred to as “radiotracers.”

• Patients become walking x-ray machines (technically gamma rays).

• Since a gamma ray is analogous to an x-ray, they also fall into the harmful ionizing radiation
category (they interact with other elements and convert them into ions by knocking off an
electron).

• PET Scans use ANTIMATTER and image the annihilation reactions between positrons and
electrons (E=mc2).
 Nuclear Medicine
• Examples:
• Hepatobiliary iminodiacetic acid (HIDA) Scan(Cholescintigraphy: done to diagnose problems
of the liver, gall bladder and bile duct eg cholecystitis, bile leak): An injected radiotracer is
absorbed by the liver and excreted into the bile. The radiotracer will go wherever the bile
goes. Patients with acute cholecystitis have a blocked cystic duct and the gallbladder will not
fill with radiotracer. If there is a bile leak, the radiotracer will also leak out.

• Gastric Emptying Study: Patients eat radioactive eggs (or substitute such as oatmeal) and the
radiologist watch how long it takes the stomach to empty to see if it’s rapid, normal, or
delayed.

• F-18 fluorodeoxyglucose (FDG) PET/CT: Inject radioactive sugar. Cancer cells use higher
amounts of sugar than most noncancer cells and cancer cells literally “light up.”

• Nuclear medicine is split into two categories: single photon imaging and dual photon
Conventional Nuclear Medicine –Single photon emission computed tomography (SPECT)

• Use radioactive materials (99m-technetium is the radioactive element of choice) and a specially
designed gamma camera to produces three-dimensional images of the inside of your organs.

• Used to evaluate the health of certain parts of your body, most commonly the heart, brain, and
bones.

• SPECT scans is different from other methods of imaging because the scan can show how well
certain organs are functioning.

• For example, the images made by the SPECT scan can help pinpoint the location of seizures in
people with epilepsy and assess whether there's sufficient blood flow to different areas of the
brain (National Institute of Biomedical Imaging and Bioengineering. 2016).

• Hence it is used to monitor brain and neurological conditions, cardiac conditions and bone
disorders
 SPECT
• All radioactive elements in this category decay by emitting a single photon (gamma ray) per
element (hence “single photon imaging”).

• Examples include: HIDA scans (cholecystitis, bile leak), ventilation/perfusion scans

(pulmonary embolism), myocardial perfusion/stress test, lymphoscintigraphy (sentinel
lymph node detection in breast cancer and melanoma patients), gastric emptying scan
(gastroparesis), Octresoscan (images neuroendocrine tumors), and many more.

• image of a single photon imaging machine

Positron Emission Tomography (PET) – Dual Photon
Imaging
• Positron emission tomography (PET) is
a type of nuclear medicine that uses
radioactive elements that create
positrons (the antimatter equivalent to an
electron) and images the light (photons)
produced when a positron annihilates
with an electron (E=mc2 – the mass of
each particle turns into a light particle,
aka photon).

• 18-fluorine is the most commonly used

PET radiotracer and 18F-FDG
(radioactive sugar) is the most
commonly used PET agent and is used
for staging/restaging many cancers. • image of PET machine
 PET
• Because annihilation reactions create 2 photons per interaction, PET scans have more
photons reach the detector and the image quality is far superior to images created by single-
photon emitters.
• With a PET scan, radioactive glucose (sugar) is injected into a vein, and then a positron
emission scanner is used to record the radiation emitted.

• The radioactive glucose concentrates in areas of the body with a high metabolic rate (i.e.,
are actively growing).

• They can be particularly helpful in some situations in which a diagnosis is uncertain.

• For example, in someone who has had cancer, it may be difficult to determine if an
abnormal region in the lungs (or elsewhere) is due to a new and actively growing tumor, or
instead is old scar tissue related to previous treatment.
 Nuclear Medicine Therapy
• Switching out a photon emitting element for a radioactive element that emits more harmful
particles (electrons, alpha particles) in a radiotracer that seeks out cancer cells gives rise to
cancer treatment

• Most of these radioactive compounds isolate within the cancer cells and the body gets rid of
any harmful radiotracer not localized to the cancer cells leaving us with cancer treatment with
far fewer side effects!

• Pros and Cons of Nuclear Medicine

• Advantages: Excellent at assessing physiologic processes and instrumental in cancer staging
and restaging. Newer PET agents are appearing, drastically changing/improving cancer
management.
• Disadvantages: Expensive, newer PET agents are currently in somewhat limited supply with
growing demand, some agents result in fairly high patient exposure/dose, and not all agents
are widely available and/or have to be ordered day(s) in advance.
 Choosing the Right Modality
• The best radiology modality for a particular patient will depend on a number of
factors which includes;
1. the type of condition being diagnosed,

2. the patient’s age, and

3. the availability of equipment.

Examples of the Best Imaging Modalities for
Common Clinical Conditions
• Broken bone: X-ray
• Pregnancy: Ultrasound
• Pelvic pain (female): Ultrasound
• Right upper quadrant pain: Ultrasound
• Appendicitis/Diverticulitis: CT (contrast preferred)
• Appendicitis in pregnancy: Noncontrast MRI
• Indeterminate abdominal mass on CT: MRI
• Stroke: CT (rule out hemorrhage that would preclude treatment), MRI (diagnosis)
• Spinal cord compression: MRI
THANKS FOR SHARING YOUR TIME
WITH ME