UPHS Radiology -- Radiology Handbook

Radiology Handbook

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Thoracic Imaging

Thoracic Imaging Quick Links Chest - PA & Lateral Films Supplemental Chest Radiographic Evaluations Oblique Chest Films Lordotic Chest Film Decubitus Films Rib Films Chest Fluoroscopy Portable Chest X-Ray Percutaneous Biopsy of the Lung or Mediastinum CT of the Chest High Resolution CT of the Chest Cardiac CT Body CT Angiography Cardiac MRI Body MR Angiography

CHEST - PA AND LATERAL FILMS

Description:

Erect films are exposed in deep inspiration in the PA and lateral projections.

Indications:

Most adult hospital admissions.
To investigate pulmonary or cardiac symptoms.
To follow some known pulmonary or cardiac lesion.
To search for a primary lung carcinoma in the appropriate clinical situation.
To evaluate the lungs for the presence of metastatic tumor.
To evaluate the patient with suspected pneumoconiosis.
To look for the lung disease associated with various systemic diseases: e.g., collagen vascular disease, vasculitis, and lymphoma.
To search for pneumonia or pulmonary infarction in the appropriate situation.
To evaluate cardiac size, chamber enlargement and to search for congestive failure.
To search for and evaluate pleural disease.
To search for and evaluate mediastinal disease such as suspected tumor adenopathy.
To search for and evaluate suspected aortic disease such as aneurysm, dissection, traumatic rupture, or anomaly.

Low Yield Indications:

Routine yearly evaluation of an asymptomatic patient.
Screening for tuberculosis, unless the patient has a positive PPD or recent contact.
Screening for carcinoma of the lung, unless the patient has high risk factors.

SUPPLEMENTAL CHEST RADIOGRAPHIC EVALUATIONS OBLIQUE CHEST FILMS

Description:

Films are exposed with the patient in deep inspiration in the right anterior oblique and left anterior oblique positions. The obliquity can vary from 30 to 60 degrees, depending upon the indication.

Indications:

A nodule poorly seen in one of the routine films.
Suspected pleural disease such as pleural plaques.
Better evaluation of mediastinal masses.
To move chest wall nodules (nipple shadows, moles and so forth) off lung fields.
To evaluate a suspected rib lesion.
To evaluate a suspected pulmonary infiltrate which is equivocal on the routine films.
To better show atelectasis, if the routine films are equivocal.
To identify additional nodules (metastases) when only a solitary nodule is seen on the routine study.

Note: If a density is seen on only one of the routine views (PA or lateral), the initial film should be a repeat of that film to be certain that the original density was a true finding. Oblique films will then be useful for localizing that particular finding.

LORDOTIC CHEST FILM

Description:

The film is exposed in the AP position with the patient leaning backwards in the lordotic pose, or the tube is angled cephalad to create the same effect.

Indications:

To evaluate densities in the lung apices which are unclear on the routine films because of overlying rib or clavicle shadows.
To search for rib destruction in a suspected Pancoast tumor.

Low Yield Indication:

Search for tuberculosis or other apical lesion if the routine PA film is perfectly normal.
Evaluation of an apical lesion, which is obvious on the PA radiograph.

DECUBITUS FILMS

Description:

An AP or PA film is exposed with the patient lying on his right/left side.

Indications:

To confirm or rule out the presence of a free pleural effusion when there is blunting of the costophrenic sulcus on the routine films.
To demonstrate that a suspected effusion is free and not loculated.
To better evaluate the lower lung fields, when they are partially obscured by a large effusion.
To demonstrate air fluid levels if the erect films are equivocal.
To demonstrate the mobility of a suspected fungus ball.

Low Yield Indications:

Documentation of residual fluid following thoracentesis; the routine films are sufficient.
Documentation of a pleural effusion when there has been an acute change in the routine films over a short period of time, which clearly indicates a pleural effusion.
The routine follow-up of a free pleural effusion, unless it is necessary to demonstrate that all of the fluid is resolved.

RIB FILMS

Description:

Low kilovoltage-high contrast films are made in the area of the suspected rib pathology in PA, AP and both oblique projections.

Indications:

Suspected rib fracture, when it is important to document that a fracture is present.
Suspected metastatic tumor.
Evaluation of a rib for invasion by an adjacent mass.
Improved evaluation of a rib lesion identified on chest radiograph.

Low Yield Indication:

May not be indicated in many patients with chest wall trauma, since knowledge of the presence or absence of a rib fracture will not alter patient therapy.

CHEST FLUOROSCOPY

Description:

The heart, lungs and diaphragm are observed on a fluoroscopic screen while the patient is asked to perform various maneuvers.

Indications:

The current principal indication for chest fluoroscopy is the evaluation of diaphragmatic motion in cases of suspected paralysis of the diaphragm ("sniff test").
Differentiation of fixed tracheal stenosis vs. dynamic airway collapse (tracheomalacia). (This is often evaluated by CT.).
Rarely used for localization of a pulmonary nodule.

Low Yield Indications:

Most lung lesions and most pulmonary problems can be better studied by films or CT, which have much better detail.

PORTABLE CHEST X-RAY

Description:

A portable x-ray unit is brought to the patient's bedside where a single AP or PA radiograph (frequently a digital image) in the supine or erect position is exposed.

Indications

Should be done only if the patient cannot be readily transported to the Radiology Department since films with much better detail can be obtained in the Radiology Department to yield more information. Also, a surcharge is added for portable examinations, making them more expensive to the patient.
To evaluate tube and line placements.
To grossly evaluate pulmonary or cardiac pathology, particularly for patients in the intensive care unit.

Low Yield Indication:

Of limited value in an absolute emergency situation, since five to ten minutes for processing is required in the best of situations. Thus emergency decisions must be made before the film becomes available.

Note: See discussion on portable x-ray examinations in the General Information section of the handbook.

PERCUTANEOUS BIOPSY OF THE LUNG OR MEDIASTINUM

Description:

A thin needle is introduced percutaneously into the lesion in the lung or mediastinum and a small amount of tissue is aspirated by suction into the needle and the syringe. Small core biopsy samples can also be obtained. This may be done under fluoroscopic or computerized tomography guidance.

Indications:

To establish the diagnosis of malignancy in a pulmonary mass or nodule and in some mediastinal lesions.
To obtain material for culture in cases of pulmonary infection, particularly in the immunocompromised host.
To establish a benign cytologic diagnosis when the only therapy contemplated for a pulmonary lesion is continued follow-up. In this instance, a Class V cytology would lead to surgery rather than follow up.
Certain mediastinal masses such as metastatic tumor, malignant thymoma, etc.

Contraindications:

Severe bleeding diathesis (anticoagulation).
In patients with severe pulmonary disease, where a pneumothorax might pose a considerable clinical problem, alternative diagnostic methods should be considered.

Low Yield Indication:

Not indicated if surgery will be done no matter what cytologic diagnosis is established.

Preparation:

Discussion of case and images with chest radiologist. Signed informed consent form required.

Most Frequent Complications:

In 20-30% of patients, some degree of pneumothorax occurs, most of these small. Five percent of patients require chest tube drainage of a pneumothorax when large, unstable, or symptomatic.
Bleeding - rare.

CT OF THE CHEST

Description:

Patient lies in a supine position and is scanned generally following administration of intravenous contrast material. Contiguous axial sections are acquired using 1-10mm slice thickness depending on the region of anatomy to be surveyed and the study indications. Routine studies are performed from the level of the apices through the adrenals.

Indications:

Diagnosis and staging of suspected mediastinal mass lesions.
Evaluation of mediastinal adenopathy when staging neoplasms (e.g. primary lung carcinoma, lymphoma) or evaluating infectious diseases (e.g. TB).
Staging of esophageal carcinoma.
Differentiation of pleural and parenchymal lung processes.
Diagnosis and staging of chest wall masses.
To search for occult pulmonary metastases.
To identify chest wall involvement in peripheral lung masses.
To help differentiate hilar adenopathy from prominent pulmonary vasculature.
Diagnosis and staging of endobronchial lesions.
Evaluation of suspected AVM's, bronchogenic cysts, pulmonary sequestration.
Localization of loculated areas of pleural effusion or pneumothorax.
Trauma survey (aortic or other mediastinal vascular injury, rib fractures, pneumothorax, bronchial fracture, etc.).
Localization of thoracic lesions for biopsy (see “Percutaneous Biopsy of the Lung or Mediastinum) or drainage procedures.
Evaluation of suspected aortic disease, including dissaction and aneurysms.
Evaluation of suspected acute pulmonary emboli.
Evaluation of suspected chronic central pulmonary thromboemboli.

Preparation:

Patient should remain NPO 3 hrs. prior to examination. Autecubital I.V. access of 18g or larger (20g minimum) needed for pulmonary embolism examinations.

HIGH RESOLUTION CT OF THE CHEST

Description:

Patient lies either supine or prone and 1mm thick high-resolution sections (non-contiguous) are obtained. Routinely performed in inspiration and generally supplemented by scans in expiration.

Indications:

Evaluation of interstitial lung disease.
Evaluation of hemoptysis.
Search for bronchiectasis.
Evaluation of pulmonary nodule for presence of calcification or fat, to help differentiate a benign calcified granuloma or hamartoma from a potentially malignant lesion.
Evaluation of emphysema.
Evaluation of air-trapping (e.g. bronchiolitis obliterans).

Preparation:

None. IV contrast not routinely utilized.

CARDIAC CT

Description:

New developments in multidetector CT technology have enabled gated CT studies of the heart to be performed in a single breath hold, allowing high resolution imaging of the coronary arteries, and cardiac structure and function. Cardiac CT examinations usually take about 10 minutes to complete and require 2-3 breathholds of 10-15 seconds.

Ordering and Indications (Radiology department exam scheduling codes in parenthesis):

Coronary artery imaging with calcium scoring (CCCS) - In general, studies are indicated only in symptomatic patients, and not for screening.
1. Evaluation of patients with atypical chest pain as an alternative to stress testing or catheter angiography
2. Further evaluation of patients with equivocal stress testing
3. Note – coronary calcium scoring, by itself, is currently not reimbursed by most payers. Patients can self-pay for this exam if desired (CACS).
Coronary artery imaging without calcium scoring
1. Evaluation of the native coronary arteries and bypass grafts in patients with recurrent symptoms after CABG or PCI
2. Evaluation of coronary anomalies
Cardiac structural imaging (CCSO)
1. For planning prior to an electrophysiology procedure – atrial or ventricular
2. Evaluation of complications after an electrophysiology procedure
3. Pericardial disease
4. Intra or extracardiac tumors in patients unable to have MRI (pacemakers, claustrophobia – see Cardiac MR section)
Congenital Heart Disease (CCHD)

Note: Evaluation of ventricular function (LV and RV ejection fractions, volumes, global and regional wall motion) can be added on to any of the exams codes above by requesting exam code CCFM – this code must be ordered by the referring physician.

Preparation:

18 or 20 g antecubital IV for rapid bolus IV contrast administration
Oral or intravenous beta blockers for heart rate control (ideal HR is 60 bpm), we use 50-100 mg oral or 5-10 mg IV metoprolol in approximately 50% of patients; this may decrease with new technological developments
Nitroglycerin sublingual or spray may be given just prior to the exams for coronary vasodilation

Contraindications:

Severe contrast allergy, those with history of mild contrast allergy can be premedicated according to departmental protocol
Impaired renal function
Atrial fibrillation – relative, please contact the CVI section
Elevated heart rate with contraindication to beta blocker administration – relative, please contact CVI section a. Asthma, using two or more medications or short acting inhaler more than twice per week
Known elevated coronary calcium score (>1000) – a large amount of calcium will cause artifact and obscure the underlying arterial lumen. Medicare reimbursement guidelines specifically state that studies should not be performed when calcium score is known to be high.

BODY CT ANGIOGRAPHY

Description:

Multidetector CT allows high resolution imaging of the arterial and venous systems and has been shown to have high accuracy compared to catheter angiography without the need for arterial puncture.

Ordering and Indications (Radiology department exam scheduling codes in parenthesis):

Chest (CANC)
1. Thoracic aneurysm or dissection
2. Evaluation for thoracic aortic stent graft, followup after stent placement
3. Aortic root pathology, before or after surgery
4. Pulmonary arteriovenous malformations
5. SVC syndrome
Abdomen (CANA)
1. Abdominal aortic aneurysm or dissection
2. Evaluation for abdominal aortic stent graft, followup after stent placement
3. Mesenteric ischemia
4. Renal artery stenosis
5. Renal or hepatic transplant evaluation
6. Portal/Mesenteric venous occlusion
Pelvis (CANP)
1. Iliac artery aneurysms, dissection, or occlusive disease
2. Evaluation of abdominal aortic stent graft, followup after stent placement
3. DVT, May-Thurner syndrome
Abdominal aorta and ilio-femoral runoff, imaging to the toes (CAAO)
1. Claudication, ischemic extremity
2. Assess patency of arterial graft
Upper Extremity (CAUE)
1. DVT
2. Thoracic outlet syndrome (with CANC)
3. Ischemic hand or digit
4. Vascular malformation
Lower Extremity (CALE)
1. DVT
2. Vascular malformation
3. Note: use CAAO as above for lower extremity ischemia

Preparation:

18 or 20 g antecubital IV for rapid bolus contrast administration

Contraindications:

Severe contrast allergy, those with history of mild contrast allergy can be premedicated according to departmental protocol
Impaired renal function

CARDIAC MRI

Description:

New developments in MRI hardware, pulse sequences, and post-processing have opened up new applications for cardiac imaging including MR stress testing and perfusion imaging, coronary MRA, and late gadolinium enhancement imaging for myocardial viability. Cardiac MR continues to be the gold standard examination for evaluation of congenital heart disease, cardiomyopathy such as ARVD/C, quantification of ventricular function, mass and volume, and quantification of valvular function and intra and extracardiac shunts.

Cardiac MR examinations typically take about 1 hour and require up to 30 breath holds of up to 20 seconds each.

Ordering a Cardiac MR:

At present, all Cardiac MR exams, whether for inpatients or outpatients, must be approved by an attending Cardiovascular Imaging radiologist by calling 215-614-0336. This policy has been instituted for several reasons:

To ensure that exams are scheduled appropriately (certain exams can only be performed on specific scanners and/or days, such as stress MRI)
To ensure that CVI radiologists have the appropriate clinical history prior to performing the study
To provide the correct exam and CPT codes and to discuss the need for appropriate referral/insurance pre-certification prior to the scheduled appointment with the referring physician

Almost all cardiac MR studies at HUP will be performed using the MCFM code – which corresponds to CPT code 75554. NO EXAMINATION WILL BE PERFORMED WITHOUT APPROPRIATE REFFERALS AND INSURANCE PRECERTIFICATION.

Indications:

Imaging of nonischemic cardiomyopathy ARVD/C
1. Hypertrophic cardiomyopathy
2. Cardiac sarcoidosis, amyloidosis and other infiltrative cardiomyopathy
3. Myocardial noncompaction
4. Myocarditis
Evaluation of pericardial disease and intra/peri/extra-cardiac masses
1. Constrictive pericarditis
2. Pericardial masses
3. Intracardiac masses – myxoma, lipomatous hypertrophy of the interatrial septum, other cardiac tumors
Evaluation of congenital heart disease
1. Anatomic imaging
2. Chamber volumes, ejection fraction, regional wall motion
3. Shunt quantification
4. Quantification of valvular stenosis and regurgitation
Evaluation of ischemic heart disease
1. Late gadolinium enhancement for imaging of myocardial viability after MI or prior to revascularization
2. Chamber volumes, ejection fraction
3. Imaging of myocardial perfusion at rest and with adenosine stress, especially for discrimination of transmural vs. subendocardial ischemia
4. Imaging of regional wall motion at rest and with dobutamine stress, especially in patients with inadequate echo windows
Electrophysiology procedure planning or monitoring for complications – order with MRA chest

Preparation:

18 or 20 g antecubital IV for rapid bolus IV contrast administration

Contraindications:

Pacemaker, ICD or other non-MR compatible implanted device. Note, there is increasing evidence that the presence of a pacemaker may not be an absolute contraindication to MR imaging. Please contact the CVI section if you have a patient with a device with an urgent clinical need for MRI, for whom there is no other diagnostic alternative.
Metallic objects in the chest, such as embolization coils, metallic valves, etc. may cause severe artifacts, rendering the study nondiagnostic. Contact the CVI section or consider cardiac CT for such patients.
Cardiac arrhythmia. Cardiac MR is very challenging in the presence of irregular heart beats, a diagnostic exam may still be possible, please consult the CVI section when considering a cardiac MR in a patient with atrial fibrillation or other "irregular" arrhythmia.
Claustrophobia – relative contraindication – our newer magnets have bores which have the same diameter as a CT scanner and are not much longer. Almost all patients will be able to tolerate a study in these new machines with oral anxiolytics added as needed.
Stress MR studies have specific contraindications and complications depending upon the pharmacologic stress agent used and the specific question being asked, contact the CVI section for details.

BODY MR ANGIOGRAPHY

Description:

MR angiography (MRA) can provide high-resolution non-invasive imaging of the arteries and veins of the body, from the aortic arch through the toes. Examinations take from 15 minutes to 1 hour and require 5-15 breath holds of 15-20 seconds each. Therefore, in general, MRA is not used in the acute setting and CTA is preferred. In general, gadiolinium DTPA MR contrast is considered to be less nephrotoxic than iodinated CT contrast, but caution is advised in patients with pre-existing renal failure.

Ordering and Indications (Radiology department exam scheduling codes in parenthesis):

MRA chest (MACI)
1. Evaluation of thoracic aortic aneurysm or dissection, follow-up or other non-acute setting
2. Thoracic outlet/inlet syndrome
3. Subclavian steal syndrome
4. Evaluation of large vessel vasculitis
5. Central venous thrombosis/SVC syndrome
MRA abdomen (MAAI)
1. Evaluation of abdominal aortic aneurysm or dissection, surgical planning, follow-up or other non-acute setting
2. Mesenteric ischemia/mesenteric venous occlusion
3. Renovascular hypertension
4. Evaluation of large vessel vasculitis
5. Hepatic or renal transplant evaluation
6. IVC thrombosis
MRA pelvis (MAPI)
1. Evaluation of aorto=iliac occlusive disease
2. Evaluation of iliac artery aneurysms
3. Pre or post- uterine artery embolization
4. Post- kidney or kidney/pancreas transplant complications
5. Pelvic DVT
MRA lower extremity (MALE)
1. Claudication, ischemic extremity (order MAAI, MAPI, MALE/bilateral runoff)
2. Assess graft patency
3. Vascular malformation
4. Venous insufficiency/DVT

Preparation:

20 or 22 g antecubital IV for bolus IV contrast administration

Contraindications:

Pacemaker, ICD or other non-MR compatible implanted device. Note, there is increasing evidence that the presence of a pacemaker may not be an absolute contraindication to MR imaging. Please contact the CVI section if you have a patient with a device with an urgent clinical need for MRI, for whom there is no other diagnostic alternative.
Metallic objects, such as embolization coils, metallic valves, stainless steel aortic or other stents, spinal hardware, etc. may cause severe artifacts, rendering the study nondiagnostic. Contact the CVI section or consider CTA for such patients. Note: nitinol stents do not cause significant MR artifact.
Claustrophobia – relative contraindication – our newer magnets have bores which have the same diameter as a CT scanner and are not much longer. Almost all patients will be able to tolerate a study in these new machines with oral anxiolytics added as needed.
Inability to tolerate lying flat and/or multiple breath-holds. Consider CTA.