PEDIATRIC
• Newborn respiratory distress
– Epiglottitis
– Transient tachypnea of the
– Croup
newborn
– Ingested foreign bodies
– RDS (Hyaline membran• Other diseases
disease)
– Cardiomegaly in infants
– Meconium aspiration
– Salter-Harris
epiphyseal
– Bronchopulmonary dysplasia
plate fractures
• Childhood lung disease
– Child abuse
– Reactive airways disease/
– Necrotizing enterocolitis
bronchiolitis
– Esophageal atresia with/
– Asthma
without tracheo-esophageal
– Pneumonia
fistula
• Soft tissues of the neck
– Enlarged tonsil and adenoid
• NEWBORN
RESPIRATORY
DISTRESS
• Transient Tachypnea of the
Newborn
– Result of delay in the
resorption of fetal lung fluid.
– TTN is more common in
shortened labor, cesarean
section, and in mothers with
diabetes or asthma.
– Immediate
onset
of
tachypnea
and
mild
respiratory distress.
– Completely recover by 48
hours.
– Imaging findings of TTN 
lungs hyperinflated, streaky,
perihilar, linear densities, fluid
in the fissures and/or laminar
pleural effusions
fluid in the fissures
streaky, perihilar, linear densities
laminar pleural effusions
• RDS (Hyaline Membran Disease)
– Disease
of
premature
infants, usually <34 weeks
– Numerous risk factors 
perinatal, asphyxia, hypoxia
and maternal diabetes.
– Major cause  surfactant
deficiency  alveolar sacs
have an increased tendency
to collapse  atelectasis.
– Clinical  cyanosis, grunting,
nasal flaring, intercostal and
subcostal retractions, and
tachypnea.
– Findings  a diffuse “groundglass” or finely granular
appearance, air bronchograms, hypoaeration in non-
ventilated lungs.
hypoaeration
ground-glass
• Meconium Aspiration Syndrome
– Meconium is found in the
amniotic fluid.
– Meconium products produce
bronchial obstruction, air
trapping, and a chemical
pneumonitis.
– Occurs in postmature infants.
– Clinical  tachypnea, hypoxia, and hypercapnia.
– Treatment
is
supportive,
consisting of antibiotics and
oxygen, inhaled nitric oxide
– Finding  hyperinflated with
diffuse “ropey”
densities,
patchy areas of atelectasis
and emphysema from air
trapping.
hyperinflated with diffuse
“ropey” densities
• Bronchopulmonary Dysplasia
– Arterial oxygen tensions >50
mm Hg accompanied by
abnormal chest radiographs.
– Clinical  oxygen dependence, hypercapnia, and a
compensatory metabolic alkalosis.
– Findings  usually hyperaerated
overall,
contain
coarse, irregular, rope like,
linear densities, lucent, cyst
like
foci,
spongelike
appearance.
atelectasis
lucent, cyst like foci
• CHILDHOOD LUNG DISEASE
• Reactive
Airways
Disease
Bronchiolitis
– Wheezing,
shortness
of
breath, and coughing.
– Tachypnea, retractions, fever,
and rhinorrhea.
– Findings  peribronchial
thickening, bronchi appear as
small, doughnut like densities, tram track like linear
densities, hyperinflation of the
lungs, atelectasis from mucus
plugging.
doughnut like den-sities
• Asthma
– During or after an acute
attack, the lungs may be
overaerated with flattening of
the diaphragm.
– There may be peribronchial
thickening.
• Pneumonia
– Bacterial  produces lobar
consolidation, or a round
pneumonia,
with
pleural
effusion.
– Viral  interstitial infiltrates or
patchy areas of consolidation.
– Treatment is supportive with
antibiotics, as needed.
• SOFT TISSUES OF THE NECK
• Enlarged Tonsils and Adenoids
– The palatine tonsils and
adenoids frequently enlarge
at the same time.
– Clinical  nasal congestion,
mouth-breathing, chronic or
recurrent otitis media as a
result of their proximity to the
eustachian tubes, painful
swallowing, and sleep apnea.
– Imaging findings of enlarged
adenoids
Narrowing nasopharynx
• Epiglottitis
– The
classical
triad

drooling, severe dysphagia,
and respiratory distress with
inspiratory stridor.
– The imaging study of choice
is the lateral neck radiograph,
upright position only.
– Finding  enlargement of the
epiglottis, thickening of the
aryepiglottic folds, circumferential narrowing of the
subglottic portion of the
trachea during inspiration.
Aryepiglottic fold
• Croup
– A harsh cough described as
barking or brassy, associated
with hoarseness, inspiratory
stridor, low-grade fever, and
respiratory distress.
– The three key findings 
distension
of
the
hypopharynx, distension of
the laryngeal ventricle, and
haziness and/or narrowing of
the subglottic trachea.
– The “steeple sign,”.
distension of the laryngeal ventricle
narrowing of the subglottic trachea
Steeple sign
• Ingested Foreign Body
– The major complications of
ingested foreign bodies are
perforation, obstruction, or
stricture formation.
– Clinical  most commonly
include
dysphagia
and
odynophagia
Thymus gland
Infant normal cardiothoracic ratio may be as large as 65%
• Salter-harris Classification Of
Epiphyseal Plate
• Fractures in Children
• SALTER HARRIS FRACTURE
• Types I and II heal well.
•
• Type III can develop arthritic•
changes or asymmetric growth
plate fusion.
•
• Types IV and V are more likely to
develop early fusion of the
growth plate, with angular
deformities, and/or shortening of
that bone.
• Type I  slipped capital femoral
epiphysis
• Type II  small metaphyseal
fracture fragment  corner sign
• Type III  longitudinal fracture
through the epiphysis itself, 
fracture invariably enters the joint
space and fractures the articular
cartilage.
Type IV  have a poorer
prognosis
Type V  crush-type injuries of
the epiphyseal plate, associated
with vascular injury.
TYPE I
Klein line
slipped capital femoral epiphysis
Corner sign
TYPE iI
longitudinal fracture
epiphyseal plate has fused
TYPE III
TYPE IV
TYPE V
• NECROTIZING ENTEROCOLITIS
• Clinical  feeding intolerance,•
delayed
gastric
emptying,
abdominal distention, and/or
tenderness,
and
decreased
bowel sounds.
• Normal finding  gas in the
stomach by 15 minutes after birth
and air in the rectum by 24 hours
of age, haustra do not develop in
the colon until about 6 months of
age, many air-filled, polygonalshaped loops of bowel
• NEC  pneumatosis intestinalis
 linear radiolucency within the
bowel wall parallels the bowel
lumen andrepresents subserosal
air that has entered from the
lumen
Portal venous gas  linear
branching areas of decreased
density over the periphery of the
liver and represents air in the
portal venous system
small lucencies of air
Abnormal separation
Air in the bowel
Dilated bowel
• ESOPHAGEAL ATRESIA WITH/
WITHOUT TRACHEOESOPHAGEAL FISTULA
• Clinical  choking, drooling,
difficulty handling secretions,
regurgitation, aspiration, and
respiratory distress.
• Imaging findings will depend on
the type
– With esophageal atresia and
no fistula, no air enters the GI
tract, so the abdomen is
airless.
– With a distal fistula between
the esophagus and trachea,
there is gas in the bowel that
has entered via the trachea,
and a radiolucent, blind-
ending, dilated pouch
upper esophagus.
of
INTRACRANIAL PATHOLOGY
• NORMAL ANATOMY
• In the posterior fossa the 4th
ventricle appears as an inverted•
U-shaped structure, it normally•
appears black on CT.
• Posterior to the 4th ventricle are
the cerebellar hemispheres, and
anteriorly lie the pons and
medulla oblongata.
• The interpeduncular cistern lies
in the midbrain and separates
the paired cerebral peduncles.
• The suprasellar cistern is ante-
rior to the interpeduncular
cistern and usually has a five or
six-point starlike appearance.
The
sylvian
fissures
are
bilaterally
symmetrical
and
contain CSF. They separate the
temporal from the frontal and
parietal lobes.
• The
lentiform
nucleus
is
composed of the putamen
(laterally) and globus pallidus•
(medially).
• The third ventricle is slitlike and
midline.
•
• Posterior of the third ventricle is
the pineal gland.
•
• The corpus callosum connects
the right and left cerebral•
hemispheres and forms the roof
of the lateral ventricle.
• The anterior end is called the
genu, and the posterior end is•
called splenium.
• The
basal
ganglia
are
represented by the subthalamic
nucleus, substantia nigra, globus
pallidus, putamen, and caudate
nucleus.
The two frontal horns are
separated by the midline septum
pellucidum.
The temporal horns, more
inferior.
The posterior horns lie in the
occipital lobes.
The surface or cortex of the brain
is made up of gray matter
convolutions composed of sulci
(grooves) and gyri (elevations).
The medullary white matter lies
below the cortex.
• On an unenhanced CT scan of
– Choroid plexus
the brain, anything that appears
– Pituitary gland and stalk
“white” will generally either be• Metallic densities in the head can
bone (calcium) density or blood, cause artifacts on CT scans.
in the absence of a metallic
foreign body
• Calcifications that may be seen
on CT of the brain and nonpathologic
– Pineal gland
– Basal ganglia
– Choroid plexus
– Falx and tentorium
• Normal structures that can
enhance after administration of
iodinated intravenous contrast
– Venous sinuses
Frontal lobe
Suprasellar cistern
Temporal lobe
Temporal horn
Cerebral peduncle
Pons
Interpeduncular cistern
4th ventricle
Cerebellum
Frontal horn
Sylvian fissure
3rd ventricle
Caudatus nucleus
3rd ventricle
Interpeduncular
cistern
Quadrigeminal
plate cistern
Occipital lobe
Genu of corpus callosum
Caudatus nucleus
Lateral ventricle
Lentiform nucleus
Calcified piineal gland
Septum pellucidum
Calcified plexus choroid
Occipital horn
Occipital lobe
Basal ganglia calcification
Falx cerebri calcification
Pineal gland calcification
Corpus callosum
Mammilary body
Midbrain
Pituitary stalk
Cerebellum
Pituritary gland
Pons
4th ventricle
Medulla oblongata
T1
T2
Gray matter
White matter
Caudatus nucleus
CSF
Lentiform nucleus
Thalamus
CSF
• HEAD TRAUMA
• Initial CT evaluation of the brain
in the emergency setting focuses
on whether there is (a) mass
effect and (b) blood.
• Skull Fractures
– Skull fractures are usually
produced by direct impact to
the.
– In order to visualize skull
fractures, you must view the
CT scan using the “bone
window”.
Fracture
EDH
• Linear Skull Fractures
fluid in the mastoid air cells,
or an air–fluid level in the
– Linear skull fractures are the
sphenoid sinus.
most common and most likely
to occur in the temporal and• Facial Fractures
parietal bones.
– The most common  orbital
• Depressed Skull Fractures
fracture  blow-out fracture
 causes a sudden ↑
– They result from a highintraorbital
energy blow to a small area
of the most often in the
– Sometimes inferior rectus
frontoparietal region, and are
muscle can be trapped 
usually comminuted.
restriction of upward gaze
and diplopia.
• Basilar Skull Fractures
– Associated with tears in the
dura mater with subsequent
CSF leak, which can lead to
CSF rhinorrhea and otorrhea.
– They can be suspected if
there is air seen in the brain,
– Clinical  orbital emphysema, fracture through either
the medial wall or floor of the
orbit, entrapment of fat and/or
extraocular muscle, fluid in
the maxillary sinus
– A tripod fracture  result of
blunt force to the cheek
involves separation of the
zygoma, fracture of the floor
of the orbit, and fracture of
the lateral wall of the
ipsilateral maxillary sinus.
Comminuted fracture
Fluid in mastoid air cell
Depessed fracture
Pneumocephalus
Tripod fracture
Orbital emphysema
Orbital emphysema
Sinus maxillaris
Floor orbital fracture
Lateral wall fracture
• INTRACRANIAL HEMORRHAGE
• Epidural Hematoma
– Hemorrhage into the potential
space between the dura
mater and the inner table of
the skull.
– Caused by injury to the
middle meningeal artery or
vein from blunt head trauma.
– Almost have an associated
skull fracture, frequently the
temporal bone.
– Epidural hematomas may
also be caused by disruption
of the dural venous sinuses
adjacent to a skull fracture.
– Imaging  high density, ex-
traaxial,
biconvex
lensshaped mass often found in
the temporoparietal region of
the brain.
– It is impossible to cross
suture lines.
– Can cross the tentorium.
• Subdural Hematoma (SDH)
– Most commonly a result of
deceleration injuries in motor
accidents (younger patients)
or secondary to falls (older
patients).
– Produced by damage to the
bridging veins that cross from
the cerebral cortex to the
venous sinuses of the brain.
– Hemorrhage into the potential
space between the dura
mater and the arachnoid.
– Clinical

increased
intracranial pressure.
– On CT acute  crescent
shaped, may cross suture
lines
and
enter
the
interhemispheric fissure.
– Subacute  blood is mixed
with lower-attenuating CSF 
isointense.
– Chronic subdural hematoma
 present more than 3 weeks
after injury  low density.
displacement of the
interhemispheric
fissure
Crescent shaped
dilated contralateral
temporal horn
• Intracerebral Hemorrhage/Hematoma
– Trauma

lead
to
intracerebral hemorrhage.
– Ruptures
of
aneurysms,
atheromatous or vasculitis 
intracerebral hematomas
– Injuries occurring at the point
of impact (called coup
injuries) and injuries occurring
opposite the point of impact
(called contrecoup injuries).
– Coup  shearing of small
intracerebral vessels.
– Contrecoup injuries  acceleration/deceleration injuries
that occur when the brain is
propelled in the opposite
direction and strikes the inner
surface of the skull.
– Hemorrhagic contusions are
hemorrhages, with associated
edema.
– Finding  multiple, small,
well-demarcated areas of
high attenuation within the
brain parenchyma, may be
surrounded by a hypodense
rim from edema, intraventricular blood, mass effect
is common, herniations.
high-attenuation
hemorrhage
contusio
Midline displacement
hypodense rim from
edema
Intraventricular
hemorrhage
Subfalcine herniation
Transtentorial herniation
Cytotoxic edema
• DIFFUSE AXONAL INJURY
• Diffuse
axonal
injury
is
responsible for the prolonged
coma following head trauma.
• Acceleration/deceleration forces
diffusely injure axons deep to the
cortex, producing unconsciousness.
• The corpus callosum is most
commonly affected.
• MRI  small petechial hemorrhages may be bright on T1weighted images, multiple bright
areas on T2-weighted images at
the
temporal
or
parietal
cervicomedullary junction or in
the corpus callosum.
Cytotoxic edema
Vasogenic edema
• INCREASED INTRACRANIAL
PRESSURE
• Clinical  papilledema, headache, and diplopia.
• Caused by cerebral edema, or
hydrocephalus.
• Cerebral Edema
– Trauma, hypertension, and
masses are the most causes.
– Vasogenic edema represents
extracellular accumulation of
fluid and is the type that is
associated with malignancy
and infection. Caused by
abnormal permea-bility of the
blood-brain barrier♦
– Cytotoxic edema represents
cellular
edema
and
is
associated
with
cerebral
ischemia. Finding  loss of
the normal differentiation
between gray and white
matter in cytotoxic edema,
ventricles may compressed,
narrowing of sulci.
• STROKE
• Acute loss of neurologic function
that occurs when the blood
supply to an area of the brain is
lost or compromised.
• Ischemic Stroke
– 12 to 24 hours, indistinct area
of low attenuation in a
vascular distribution.
– >24 hours, circumscribed
lesion with mass effect,
dissappeared 2-4 weeks.
– 72 hours, contrast enhancement disappeared.
– >4 weeks, mass effect disappearswell-circumscribed,
low-attenuation lesion with no
contrast enhancement.
24 hour
Mature
• Haemorrhage Stroke
– Freshly extravasated whole
blood
with
a
normal
hematocrit will be visible as
increased
density
on
nonenhanced CT scans of the
brain immediately after the
event
– Dissection of blood into the
ventricular system can occur
in hypertensive intracerebral
bleeds.
– As the clot begins to form, the
blood becomes denser for
about 3 days because of
dehydration of the clot.
– After day 3, the clot
decreases in density and
becomes invisible over the
next several weeks.
– After about 2 months, only a
small
hypodensity
may
remain.
ICH acute
Lacunar infarct
• RUPTURED ANEURYSMS
• Berry aneurysm, which develops
from a congenital weakening in•
the arterial wall, usually at the
sites of vessel branching in the
circle of Willis at the base of the
brain.
• Hypertension and aging play a
role in the growth of aneurysms.
• The classical history of a patient
who has had a ruptured
aneurysm describes it as “the
worst headache of my life.”
• When aneurysms rupture, the
blood
usually
enters
the
subarachnoid space.
• On
CT,
acute
blood
is
hyperdense and may be visu-
alized within the sulci and basal
cisterns.
The region of the falx may
become hyperdense, widened,
and irregularly marginated.
• HYDROCEPHALUS
• Expansion of the ventricular
system on the basis of an•
increase in the volume of
cerebrospinal fluid contained
within it.
• Hydrocephalus may be due to
several factors:
– Underabsorption of cerebrospinal fluid (communicating
hydroce-phalus)
– Restriction of the outflow of
cerebrospinal fluid from the
ventricles (noncommunicating
hydrocephalus)
– Overproduction of cerebrospinal fluid
• In hydrocephalus the ventricles
are usually disproportionately
dilated.
Temporal horns may be greater
than 2 mm in size.
• Obstructive Hydrocephalus
• Communicating (extraventricular
obstruction) and noncommunicating (intraventricular obstruction).
• Communicating hydrocephalus is
caused by abnormalities that
inhibit
the
resorption
of
cerebrospinal fluid.
– CSF
flow
through
the
ventricles and over the
convexities normally occurs
unimpeded.
Reabsorption
through the arachnoid villi can
become restricted by such
things as SAH or meningitis.
• Noncommunicating occurs as a
result of tumors, cysts, or other
physically obstructing lesions that
do not allow cerebrospinal fluid to
exit from the ventricles.
Dilatation of temporal horn
4th ventricle is compressed
and nearly invisible
hemorrhagic metastatic lesion
A, There is dilatation of the temporal horns (solid white arrows), and the 4th ventricle is compressed and nearly
invisible (dotted white arrow). There is a hemorrhagic metastatic lesion (black arrow) that is obstructing the 4th
ventricle.
B, The frontal horns of the lateral ventricles (L) and 3rd ventricle (3) are dilated, but note that the sulci are not
dilated. This form of hydrocephalus is the result of obstruction to the outflow of cerebrospinal fluid from the
ventricles.
A, Classically, the 4th ventricle is dilated in communicating hydrocephalus (4) but normal in size in
noncommunicating hydrocephalus. The temporal horns (T) are particularly sensitive to increases in intraventricular
volume or pressure and are dilated here.
B, The frontal horns (F), occipital horns (O), and 3rd ventricle (3) are markedly dilated. There is a disproportionate
dilatation of the ventricles compared with the sulci (which are normal to small here). Communicating
hydrocephalus is usually treated with a ventricular shunt.
• Normal Pressure Hydrocephalus
• Characterized by a classical triad
of clinical symptoms: abnormalities of gait, dementia, and
urinary incontinence.
• Imaging findings are similar to
other forms of communicating
hydrocephalus
and
include
enlarged ventricles, particularly
the temporal horns, with normal
or flattened sulci.
A, The ventricles are
enlarged, particularly
the temporal horns (T)
and the 4th ventricle.
B, The bodies of the
lateral ventricles (L)
are also markedly
enlarged, but the sulci
are
normal
or
flattened.
• CEREBRAL ATROPHY
• Atrophy implies a loss of both
gray and white matter.
• The ventricles dilate in cerebral
atrophy, but do so because a loss
of
normal
cerebral
tissue
produces a vacant space that is
filled passively with the CSF-filled
ventricles.
• Unlike
hydrocephalus,
the
dynamics of CSF production and
absorption are normal.
A, Lateral ventricles
are enlarged.
B,, Sulci are also
enlarged
• BRAIN TUMOR
• Gliomas of the Brain
– Most
common
primary,
supratentorial, intraaxial mass
in an adult.
– Glioblastoma multiforme infiltrates adjacent areas of the
brain along white matter
tracts, making it difficult to
resect.
– Producing a necrosis and
pattern called a butterfly
glioma.
– It
tends
to
produce
considerable vasogenic edema and mass effect.
• Metastases
– Frequently
well
defined,
round masses near the graywhite junction.
– They are usually multiple but
can be solitary.
– They are typically hypodense
or isodense on nonenhanced
CT.
– With intravenous contrast
they can enhance, sometimes
with a pattern of ring
enhancement.
Ring enhancement
• Meningioma
– Most
common
extraaxial
mass, usually occurring in
middle-aged women.
– They tend to be slow-growing
with an excellent prognosis if
surgically excised.
– On unenhanced CT, over half
are hyperdense to normal
brain and about 20% contain
calcification.
• Vestibular Schwannoma
– Their most common symptom
is hearing loss, but they also
produce tinnitus and disturbances in equilibrium.
• OTHER DISEASE
• Multiple Sclerosis
– Autoimmune and common
demyelinating disease.
– It characteristically affects
myelinated (white matter)
tracks with lesions known as
plaques.
– The lesions produce discrete,
globular foci of high signal
intensity (white) on T2weighted images.
– On T1-weighted, nonenhanced images, they are isointense to hypointense.
discrete, globular foci
Dawson finger
NUCLEAR MEDICINE
• A radioisotope  an unstable•
form of an element that emits
radiation from its nucleus as it•
decays.
• The end product is a stable,•
nonradioactive
isotope
of
another element.
• Radiopharmaceuticals  com-•
binations of radioisotopes to a
pharmaceutical that has binding
to concentrate in certain body
tissues (e.g., the lungs, thyroid,
or bones).
Various body organs have a
specific affinity for, or absorption
of, different biologically active
chemicals.
For example, the thyroid takes
iodine, the brain utilizes glucose,
bones utilize phosphates.
After the radiopharmaceutical is
carried to a tissue or organ 
radioactive emissions allow it to
be measured and imaged using
gamma camera.
• RADIOACTIVE DECAY
• Gamma rays are identical to “x• Unstable isotopes attempt to rays” except that gamma rays
reach stability by one or more of originate from nuclei.
several processes.
• Fission  destructive process
that occurs in nuclear reactors.
• Alpha particles have high energy,
strongly absorbed by adjacent
tissue, can cause substantial
damage to nearby molecules..
• Beta particles are high energy,
high-speed electrons or positrons
that have a penetrating power
between alpha and gamma rays..
• Gamma decay involves the
emission of energy from an
unstable nucleus in the form of
electromagnetic radiation.
• HALF-LIFE
• A radioisotope be useful for
medical diagnosis if it capable of
emitting gamma rays to be
measurable outside of the body.
• It must have a half-life that is long
enough for it to still be radioactive
after shipping and preparation,
but short to decay soon after it is
used for imaging.
• EQUIPMENT
• The most used radioisotope is
technitium- 99m.
• Geiger counters
– To detect contaminations and
detecting low levels of
radioactivity.
• Scintillation detectors
– Scintillation  process by
which a material called a
scintillator luminesces when
excited by ionizing radiation.
• Gamma cameras
– Uses one or more scintillation
scintillate in response to
gamma rays emitted from the
patient.
– A computer reconstructs an
image
based
on
the
distribution and concentration
of the radioisotope deposited
in the target organ.
• SPECT imaging is a nuclear
medicine study that is performed
by using a gamma camera to
acquire 2D images from multiple
angles, which are reconstructed
into 3D that can be manipulated.
• Radiofarmaka  radioaktif dan
untuk jantung
pembawa materi
– Pengasingan sel  sel darah
• Cara penempatan
merah yang ditandai Cr51
akan
dipanaskan
dan
– Fagositosis  mikrokoloid
dimasukkan secara IV 
difagosit di RES untuk hati,
untuk limpa, Ti201 untuk
limpa, sumsum tulang dan
miokard jantung.
KGB regional.
– Transportasi aktif  sel tubuh• Syarat radiofarmaka
memindahkan radiofarmaka
– T1/2 singkat, radiasi minmal
dari plasma darah ke organ.
– Sebaiknya monoenergi foton
– Penghalang
kapiler

– Tidak menganggu fungsi
makrokoloid untuk perfusi
fisiologis dan metaboliems
paru  deteksi emboli
– Tidak toksik
– Pertukaran difus  pembawa
– Cepat diekskresi
materi
bertukar
tempat
dengan senyawa yang sama
dari organ.
– Komparmental  Blood pool
• NUCLEAR MEDICINE SAFETY
• Radiopharmaceuticals are prescription drugs that require
dispensing by a physician.
• Dose calibration is essential in
ensuring that a safe and effective•
amount of radiopharmaceutical is
given.
• A locked and controlled area is
needed for the storage and•
preparation of radiopharmaceu-•
ticals.
• Techniques need to be in place to
ensure the material being
injected is sterile and free of
pyrogens.
• Spills have prescribed methods
for containing and cleaning as
well as disposing of the material
used for the cleanup. The area in
which the spill has occurred may
be monitored by using Geiger
counters.
Some radioisotopes can cross
the placenta and be concentrated
in the fetal thyroid, pass through
breast milk to the child.
Adverse effect extremely rare.
Patients may be assigned to
private rooms without outside
visitors for 24 hours.
• BONE SCANNING
• Body is imaged about 2 to 4
• Screening method of choice for hours after injection.
the
detection
of
osseous• Metastases to Bone
metastatic disease and for
– Tc-99m MDP deposits in the
diagnosing fractures.
greatest concentration in
• The disadvantages of bone
those areas of greatest bone
scanning are poor spatial and
turnover.
contrast resolution.
– Pattern  multiple, asymme• Technetium-99m methylene ditric focal areas of increased
phosphonate most used for bone
uptake (“hot spots”) on bone
scanning.
scans.
• Diphosphonates
are
rapidly
removed from the circulation and
produce little background noise
from uptake in soft tissues.
• After the intravenous injection
most of the dose is quickly
extracted by the bone.
Normal
Metastase
Hot spot
– Photopenic lesion (cold spot)
 area of abnormally diminished or absent radiotracer
uptake on the bone scan.
Caused by an interruption of
the blood supply so that no
radiopharmaceutical
can
reach the area or when a
process is so destructive that
no bone-forming elements
remain.
– Superscans  diffuse and
relatively uniform uptake of
radioisotope in bones. Occurs
when there is extensive
involvement with metastatic
disease but can also be seen
in bones with diffusely high
turnover rates such as in
hyperparathyroidism.
– The clue to this abnormality is
decreased or absent uptake
in the kidneys, because so
much is extracted by the
bone.
– Bone scans may be positive
within 24 hours after a
fracture.
• Osteomyelitis
• A triple-phase bone scan  first
minute after injection (flow
phase), about 5 minutes after
injection (blood pool or tissue
phase), and then 2 to 4 hours
after injection (delayed or skeletal
phase)
• Cellulitis
will
demonstrate
increased uptake in the soft
tissue on both the tissue phase
and the skeletal phase.
• Osteomyelitis
will
show
clearance of the tracer from the
soft tissues with progressive
uptake in the bone on the
skeletal phase.
• LIVER AND LIEN SCANNING
dan non obstruksi
• Memakai cara fagositosis
• Penilaian
• RES ada banyak di hati dan
– Scan I 5 menit setelah injeksi
limpa, bila ada lesi  sel RES
 menilai bentuk, besar dan
gagal menangkap radiofarmaka
posisi hati, bila ada lesi akan
 cold spot atau hole
tampak hole
• Variasi normal  penurunan
– Scan II 15-30 menit setelah
aktivitas fokal di hilus, tempat
injeksi  menilai saluran dan
keluar vena hepatika, akibat
kandung empedu
penekanan ginjal, tertutupnya
– Scan III 60 menit setelah
kaudaventral hati oleh kandung
injeksi  aktvitas kandung
empedu.
empedu dan usus, bila tidak
• GALL BLADDER SCANNING
ada  scan IV 20 jam setelah
injeksi  tetap tidak ada 
• BSP, Rose bengal, IDA 
obstruksi total.
dikeluarkan dari darah oleh sel
poligonal hati  ekskresi ke
saluran cerna lewat empedu
• Untuk bedain ikterik obstruksi
• THYROID SCANNING
• Sel kelenjar gondok menangkap
ion I untuk sintesis T3 dan T4
• Indikasi

menilai
besar,
anatomi dan letak, evaluasi
nodul, efek terapi, massa leher
dan mesdiatinum serta uptake
tiroid
• Keterbatasan  kelenjar gondok
normal dengan fungsi rendh
menunjukkan cold
• KIDNEY SCANNING
• Renogram
– Evaluasi semikuantitatif fungsi ginjal
– Indikasi  menilai kelainan
unilateral ginjal dan untuk
penderita yang sensitif media
–
–
–
–
–
–
kontras
Fase vaskuler  keadaan
perfusi ke ginjal, normlanya
45 detik
Fase sekresi  fungsi
absorpsi sampai sekresi, 3-5
menit
Fase ekskresi  funsgsi
bersihan, 7-15 menit  bila
memanjang  obstruksi
Obstruksi non mekanik <10
menit
Obstruksi mekanik >10 menit
10-20 menit obstriksi parsial
• Scan ginjal
•
– Indikasi  menilai besar,•
bentuk, letak ginjal, fungsi
secara kuantitatif, evaluasi•
trauma, tumor, kista
• LUNG SCANNING
• Makrokoloid

menghalangi kapiler paru,
mendeteksi
emboli

tampak cold
• Keterbatasan  KI pada
penyakit jantung bawaan
dan hipoksia berat
• HEART SCANNING
• Ventrikulografi
Infark miokard  cold
BRAIN SCANNING
Kerusakan BBB, iskemi 
materi
masuk
ke
ekstraseluler otak  hot
spot
PAYUDARA DAN TIROID
• MAMMOGRAFI
gakan dan metastasis
• Mengenal secara dini kegana-• Tanda primer
san payudara
– Kepadatan tumor  ↑ densi• > berperan pada payudara detas, batas tidak teratur,
ngan jaringan lemak yang domispikula, ekor seperti komet
nan serta jaringan fibroglandular
– Perbedaan besar tumor
sedikit (>40 tahun)
– Mikrokalsifikasi
• Indikasi
– Ada benjolan pada payudara
– Rasa tidak enak pada
payudara
– Risiko tinggi Ca
– Pembesaran KGB mencuri-
GI ABNORMALITIES
• ESOPHAGUS
• Patient drinking liquid barium •
single contrast, or accompanied
by a gas producing agent that
provides the “air”  doublecontrast.
• Video esophagography  study
of the swallowing mechanism,
performed with fluoroscopy.
• Choice for diagnosing and
documenting
aspiration,
in
which ingested substances pass
into the trachea below the level
of the vocal cords.
Fluoroscopic can also reveal
abnormalities in esophageal
motility.
– Example  tertiary waves
are common but abnormality
representing disordered and
nonpropulsive contractions
of the esophagus.
Tertiary waves
• Esophageal Diverticula
• Diverticula of the GI tract are
usually produced when the
mucosal and submucosal layers
herniate through a defect in the
muscular layer of the bowel wall.
• Diverticula produce an outpouching that projects beyond
the borders of the lumen.
• 3 locations
– In the neck, the diverticulum
is posteriorlylocated and is
called a Zenker diverticulum.
– Diverticula at the level of the
carina may be caused by
extrinsic inflammatory such
as
tuberculosis
(traction
diverticula)
– Diverticula just above the
esophagogastric junction are
called epiphrenic diverticula.
weakness in the posterior wall of the hypopharynx
(Zenker diverticulum)
fibrosis, which pulls on the esophagus, forming
a traction diverticulum
above the diaphragm in the distal esophagus
(epiphrenic diverticulum) (
Pseudodiverticula
True
Pseudodiverticula
• Esophageal Carcinoma
• The lack of an esophageal
serosa and a rich supply of
lymphatics  extension and
dissemination of esophageal
carcinoma.
• Adenocarcinomas
arise
in
esophageal epithelium  metaplasia from squamous to columnar epithelium (Barrett esophagus.
• Barium esophagrams suggest
this diagnosis.
• Appear in 1/> of several forms 
annular
constricting
lesion,
polypoid mass, a superficial,
infiltrating lesion or ulceration;
and irregularity of the wall.
Ulceration
annular constricting
polypoid mass
Irregular and rigid
• Hiatal Hernia and Gastroesophageal Reflux
• Hiatal hernias divided into the
sliding type  esophagogastric
junction
lies
above
the
diaphragm, or the paraesophageal type  portion of the•
stomach herniates through the
esophageal hiatus, but the EG
junction remains below the
diaphragm.
• Gastroesophageal reflux usually
result of dysfunction of the lower
esophageal sphincter, which
normally prevent gastric acid
refluxing into the esophagus.
• Findings  bulbous area of the
distal esophagus with failure of
the esophagus to narrow on,
extension of multiple gastric folds
above the diaphragm; and a thin,
circumferential filling defect in the
distal esophagus called a
Schatzki ring.
Gastroesophageal
reflux

barium is seen to move from the
stomach retrograde into the
esophagus.
narrowing
a Schatzki ring
bulbous collection of
contrast
stomach herniated above the
diaphragm
hiatal hernia
• STOMACH AND DUODENUM
• Lumen of the stomach  upper
endoscopy
• Wall thickness and structures
outside of the stomach  CT
with oral contrast.
• Gastric Ulcers
• Helicobacter pylori, NSAID
• Most ulcers occur on the less
curvature or posterior wall in the
region of the body or antrum.
• Gastric Carcinoma
• Gastric carcinomas may be
polypoid, infiltrating or ulcerative
in form.
mound of edematous tissue
gastric ulcer
gastric folds
gastric ulcer
walls of the stomach are concave and rigid
polypoid filling defect
ulceration in the mass
• DUODENAL ULCER
• Almost all duodenal ulcers occur
in the duodenal bulb.
• Double-contrast
UGI
series
detecting duodenal ulcers.
• Complications
of
duodenal
ulcers, best demonstrated by CT,
include obstruction, perforation
(into the peritoneal cavity),
penetration (such as into the
pancreas), or hemorrhage.
Zone of edema
Collection of barium
Peritoneal cavity
• SMALL AND LARGE BOWEL
• Oral contrast used for CT•
examinations is either a dilute
solution containing barium or•
iodinated contrast.
• Thickening of the bowel wall 
normal small bowel <2.5 cm in
diameter, and no thicker than 3
mm, colonic wall does not
exceed 3 mm with the lumen
distended.
• Submucosal
edema
or
hemorrhage  varying degrees
of thumbprinting, nodular indentations into the bowel lumen
representing focal areas of
submucosal infiltration by edema,
hemorrhage, inflammatory cells,
tumor (lymphoma), or amyloid.
Hazy or strandlike infiltration of
the surrounding fat.
Extraluminal
contrast
or
extraluminal air  indicates the
presence of a bowel perforation.
• Small Bowel—Crohn Disease
• A chronic, relapsing, granulomatous inflammation of the small
bowel and colon resulting in
ulceration, obstruction, and fistula
formation.
• Crohn disease typically involves
the ileum and right colon,
presents with skip areas, is prone
to fistula formation, and has a
propensity for recurring.
• May be imaged with a barium
small
bowel
follow-through
(series) or CT of the abdomen
and pelvis.
• Findings  narrowing, irregularity, and ulceration of the terminal
ileum with proximal small bowel
dilatation, infiltration of the
mesentery surrounding the ileum,
the string sign.
Fistula
String sign
Multiple streaks of barium
Multiple streaks of barium
• LARGE BOWEL
• Studied with optical colonoscopy
or CT colonography and/or
double-contrast barium enema
examination.
• Diverticulosis
• Represent herniation of the
mucosa and submucosa through
a defect in the muscular layer
(false diverticula).
• Most common cause of massive
lower GI bleeding.
• They occur most often in the
sigmoid colon and are readily
identified on either barium enema
or CT examination as small
spikes or smoothly contoured
collections of air and/or contrast
attached to the colon.
diverticula contain air and appear as
small, usually round outpouchings
Circular density
diverticula are filled with barium
contain air and are outlined with
barium
• Diverticulitis
• Diverticula become inflamed and
perforate, most often secondary
to mechanical irritation and/or
obstruction.
• CT is the modality of choice for•
the diagnosis.
•
• CT findings  presence of
diverticula, thickening of colonic
wall
(>4
mm),
pericolonic
inflammation, increased attenuation
and/or
streaky
and
disorganized
linear
and
amorphous densities in the
pericolonic fat, abscess formation, multiple small bubbles of air
or pockets of fluid contained
within a pericolonic soft tissue,
masslike density, and perforation
of the colom extraluminal air or
contrast either around the site of
the perforation, or less likely, free
air in the peritoneal cavity.
Colonic Polyps
Patients
with
polyposis
syndromes, have a much higher
risk of developing a colonic
malignancy.
Hazy increase in attenuation
Small bubble
Large cavity
Polyp
Normal haustra
• Colonic polyps can be visualized
using either barium enema
examination, CT colonography,•
or optical colonoscopy.
• Polyps may be sessile (attach
directly
to
the
wall)
or
pedunculated (attach to the wall
by a stalk).
• A polyp may contain numerous
fronds that produce an irregular,
wormlike surface with numerous
crypts that may collect barium
(villous polyp).
• Villous polyps tend to be larger
and have more of a malignant
potential than other adenomatous
polyps.
• Occasionally, a polyp may serve
as a lead point for an
intussusception.
Intussusception may produce a
characteristic coiled-spring appearance on barium enema or CT.
Polypoid mass in cecum
pedunculated polyps.
sessile filling defect
filling defect
coiled-spring
MEDIA KONTRAS
• Bahan yang sangat radioopak/
– Tekanan osmotik rendah
radiolusen  membedakan or– Tidak mengalami degradasi
gan dengan jaringan sekitarnya.
– Minimum protein binding
• 2 jenis 
– Stabil terhadap panas
– Kontras (-) = udara O2 dan• Komplikasi
CO2
– Ringan  Panas, bersin,
– Kontras (+) = barium dan
gatal, mual
iodium
– Sedang

Urtikaria,
• Media kontras iodium  ionik
kemerahan, muntah, sesak,
dan non ionik
hipotensi
• Media ideal
– Berat  Edema laring,
– Konesntrasi tinggi
trombosis PD, henti jantung,
– Larut air
kematian
– Viskositas minimal
MRI
• Memakai medan magnet
– Pasien claustrophobia harus
dianestesi
• Keuntungan
• Intensitas  hipointens, isoin– Tidak memakai sinar X
tens, hiperintens
– Tidak merusak kesehatan
– Air  Hipointens T1, hiperin– Jarang memakai kontras
tens T2
– Dapat menunjukkan parame– Lemak atau darah 
ter biologik
Hiperintens T1 dan T2
– Potongan dapat 3D
– Kalsifikasi  Hipointens T1
• Kerugian
dan T2
– Mahal
– Waktu pemeriksaan lama
– Pasien mengandung metal
tidak bisa diperiksa
• Kepala
•
• T1  Gray matter sinyal lebih•
sedikit, CSF tidak memiliki sinyal•
 hipointens
•
• T2  Gray matter sinyal tinggi,•
CSF juga  hiperintens
•
• Membedakan lemak dengan
darah  fat supression  lemak
akan menjadi hipointens, jika
darah akan tetap hiperintens
• Jantung
• Dinding tampak abu-abu, atrium
dan ventrikel tampak hitam,
lemak tampak putih
• Kandung empedu dan Saluran
• Cairan pekat  periintensif,
encer  hipointensif
Batu  hipointensif
Limpa
Sinyal T2 tinggi
Pankreas
Lebih butuh kontras
Pankreatitis akut  organ
membesar,
jaringan
sekitar
menyempit  hiperintens
• Ginjal
• Pengamanan Khusus
• Bedakan korteks dan parenkim di
– Pasien dengan alat pacu
T1
jantung tidak boleh MRI
• Sumbatan ureter  pielum
– Protase, klips dan lainnya
melebar, ureter melebar, urin
boleh di MRI tapi akan
banyak  T1 hipointens, T2
menimbulkan artefak
hiperintens
– Hamil trimester I tidak boleh
• Fibrolipomatosis

lemak
– Sakit jantung dan epilepsi
hiperintens
harus diawasi
• Tulang Belakang
– Claustrophobia
harus
• T1 intensitas sedang, likuor hitam
dianestesi
T2 jadi hiperintens
• Degeneratif  isointens pada T1,
hipointens pada T2 (normalnya
T2 hiperintens)