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Atlas on X-ray and

Angiographic Anatomy

Atlas on X-ray and


Angiographic Anatomy

Hariqbal Singh MD DMRD

Professor and Head


Department of Radiology
Shrimati Kashibai Navale Medical College
Pune, Maharashtra, India

Parvez Sheik MBBS DMRE

Consultant Radiology
Shrimati Kashibai Navale Medical College
Pune, Maharashtra, India

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Atlas on X-ray and Angiographic Anatomy
First Edition: 2013
ISBN978-93-5090-432-9
Printed at

Dedicated to
Our dear consorts
Arvind Hariqbal
and
Naasiya Musthafa

Saying
Anatomy is a nursery
offers framework to enter the infirmary,
clasp it firmly
it will help analyze the pathology rightly
with foundation in place
all is well
the value of radiology cannot be measured
it can only be treasured.

Hariqbal Singh

Preface
Human anatomy has not transformed over the years but the advance in imaging has changed the perception
of structural details. Thorough understanding of the normal anatomy is an essential prerequisite to precise
diagnosis of pathology.
Atlas on X-ray and Angiographic Anatomy is loaded with meticulously labeled illustrations. This book is
steal a look into the anatomy in an easy and understandable manner.
This atlas is meant for undergraduates, residents in orthopedics and radiology, orthopedic surgeons,
radiologists, general practitioners and other specialists. It is meant for medical colleges, institutional and
departmental libraries and for stand-alone X-ray and orthopedic establishments. They will find the book
useful.

Hariqbal Singh
Parvez Sheik

Acknowledgments
We thank Professor MN Navale, Founder President, Sinhgad Technical Educational Society and Dr Arvind V
Bhore, Dean, Shrimati Kashibai Navale Medical College, Pune, Maharashtra, India, for their kind acquiescence
in this endeavor.
Our special thanks to the consultants Dr Sasane Amol, Roshan Lodha, Santosh Konde, Shishir Zargad,
Yasmeen Khan, Shivrudra Shette, Anand Kamat, Varsha Rangankar, Prashant Naik, Abhijit Pawar, Aditi
Dongre, Rajlaxmi Sharma, Manisha Hadgaonkar, Subodh Laul, Sumeet Patrikar, Ronaklaxmi, Shrikant Nagare
and Vikash Ojha, who have helped in congregation of this imagery and for their indisputable help in assembly
of this educational entity.
Our special appreciation to the technicians Mritunjoy Srivastava, Premswarup, Sudhir Mane, Sonawane
Adinath, Deepak Shinde, Vinod Shinde, Yogesh Kulkarni, Pravin Adlinge, Parameshwar and Amit Nalawade,
for their untiring help in retrieving the data.
Our gratitude to Sachin Babar, Anna Bansode, Sunanda Jangalagi and Shankar Gopale, for their clerical
help.
We are grateful to God and mankind who have allowed us to have this wonderful experience.
Last but not least, we would like to thank M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi,
India, who took keen interest in publishing the book.

Contents
1. Skull

2. Spine

13

3. X- ray Chest

28

4. Abdominal Radiograph

34

5. Upper Limb

37

6. Lower Limb

49

7. Angiograms

67

8. Radiological Procedures

103

9. Ossification Centers

127

10. Production of X-rays

133

11. Digital Subtraction Angiography

135

12. Computed and Digital Radiography

137

13. Picture Archiving and Communications System

140

14. Computed Tomography Contrast Media

142


Index

145

1
CHAPTER

INTRODUCTION
The term Skull includes the mandible, likewise
the term Cranium is the Skull without the
mandible (Figs 1.1 and 1.2). The cranial cavity has
a roof (cranial vault) and floor (base of the skull).
The frontal bone occupies the upper third of
the anterior view of the skull; the rest is formed
by the maxillae and mandible. The frontal bone
extends downwards to form the upper margins
of the orbits. Medially the frontal bone articulates
with the frontal process of each maxilla. Laterally
the frontal bone projects as the zygomatic process
to make the frontozygomatic suture with the
zygomatic bone at the lateral margin of orbit (Figs
1.3 to 1.6). The frontal bone articulates with the
parietal bones at the coronal sutures (which run
transversely).
The temporal bone consists of five parts
Squamous, mastoid, petrous, tympanic and
styloid process. The squamous portion forms
part of wall of temporal fossa and gives rise to
zygomatic process. The mastoid portion contains
the mastoid antrum, in adults it elongates
into mastoid process. The mastoid antrum
communicates with the remainder of mastoid air
cells and with the epitympanum via the aditus ad
antrum. The petrous portion is wedge-shaped and
lies between the sphenoid bone anteriorly and
occipital bone posteriorly. The tympanic portion
lies below the squamous part and in front of the

Skull

mastoid process. The styloid portion forms the


styloid process.
The temporal fossa is the area bounded by
the superior temporal line, zygomatic arch and
the frontal process of the zygomatic bone. The
zygomatic arch is formed by the zygomatic process
of the temporal bone and the temporal process of
the zygomatic bone. The zygomatic process of the
maxilla articulates with the zygomatic bone. The
zygomatic bone forms the bony prominence of
the cheek (Figs 1.7 to 1.10).
The styloid process is a part of the temporal
bone, from its tip the stylohyoid ligament passes
to the lesser horn of hyoid bone. At the base of
the skull medial to the styloid process the petrous
bone is deeply hollowed out to form the jugular
fossa with an opening called as jugular foramen
through which the internal jugular vein passes.
Anterior to the jugular foramen the petrous part
of the temporal bone is perforated by the carotid
canal, allows the internal carotid artery to pass
through it (Fig. 1.11). Between the basiocciput
and the body of sphenoid bone lies the foramen
lacerum, it allows the small emissary vein and
meningeal branch of ascending pharyngeal artery
to pass through it. The roof of the infratemporal
fossa is pierced medially by the foramen ovale,
through which passes the mandibular nerve,
lesser petrosal nerve, accessory meningeal artery
and emissary veins. The base of the spine of
sphenoid is perforated by the foramen spinosum

Atlas on X-ray and Angiographic Anatomy

Figs 1.1A to D: CT scan multiplanar reconstruction images of skull: (A) Frontal view; (B) View from back;
(C) Lateral view; (D) View from below

which allows the middle meningeal vessels to


pass through it. The stylomastoid foramen lies
behind the base of styloid process. Medial to the
third molar tooth on either side is the greater
palatine, foramen between the horizontal plate

of palatine bone and the palatine process of the


maxilla, the greater palatine vessels and nerves
pass through it. Behind the greater palatine, there
are numerous small openings called the lesser
palatine foramina in the pyramidal process of

Skull

B
Figs 1.2A and B: X-ray skullAP view

Atlas on X-ray and Angiographic Anatomy

B
Figs 1.3A and B: X-ray skullLateral view

Skull

Fig. 1.4: X-ray skullMastoid view (Schullers view)

Fig. 1.5: X-ray skullLateral view (close-up view to show the pituitary fossa)

palatine bone through which the lesser palatine


vessels and nerves pass.
There are two parietal bones on either side of
skull. They are seen better on lateral views of skull
and they articulate with the frontal bone anteriorly
at the coronal sutures. Posteriorly, the parietal
bones articulate with occipital bone and temporal

bone mastoid process at lambdoid suture. The


bregma is the area in midline where the coronal
sutures and the two parietal bones meet. Behind
the bregma, the parietal bones articulate in the
midline sagittal suture. This midline sagittal suture
ends at the lambda in posteriorly. The lambda is
the area posterior where the sagittal suture ends

Atlas on X-ray and Angiographic Anatomy

Fig. 1.6: X-ray skullPA view (Caldwell view for paranasal sinuses)

Fig. 1.7: X-ray skullWaters view (for paranasal sinuses)

Skull

Fig. 1.8: X-ray skullReverse Waters view

Fig. 1.9: X-ray skullTownes view (30o fronto-occipital view)

Atlas on X-ray and Angiographic Anatomy

Fig. 1.10: X-ray skullSubmentovertical view

Fig. 1.11: X-ray skull showing base of skull

Skull
in midline and the apex of occipital bone reaches
out to join it in midline. The mastoid region of the
temporal bone articulates with the parietal and
occipital bones posteriorly, the mastoid process
projects down at the sides. Inferiorly the parietal
bones articulate with the squamous portion of
temporal bone on either side.
The occipital bone on its lower surface has
a ridge which is pointing towards the base of
the mastoid process; this is called the external
occipital protuberance. The basiocciput extends
forward from the foramen magnum and fuses
with the basis
phenoid. The foramen magnum
is located in the basilar part of the occipital
bone (basiocciput). The pharyngeal tubercle is a
slight bony prominence in front of the foramen
magnum. One-third of the foramen magnum lies
in front and two-thirds behind an imaginary line
joining the tips of the mastoid processes. This is
contrary to the occipital condyles, where twothirds of the condyles lie in front of this imaginary
line.
The internal surface of the base of skull is
divided into the anterior, middle and posterior
cranial fossa. The orbital part of the frontal bone
forms a large part of anterior cranial fossa. The
anterior cranial fossa extends up to the posterior
edge of the lesser wing of sphenoid. The anterior
cranial fossa articulates with the cribriform plate
medially. The crista galli is a sharp projection of
the cribriform plate.
The sphenoid bone contributes to the
middle cranial fossa. The small midline body of
sphenoid bone contains the sella turcica (means
Turkish saddle), a small elevation in front of
sella turcica is called tuberculum sellae (Fig. 1.5).
The tuberculum sellae has three small spikes,
the middle spike is called the middle clinoid
process, the two lateral spikes are called anterior
clinoid process. At the posterior edge of the sella
turcica is an elevation called the dorsum sellae,
which has two lateral spikes called the posterior
clinoid process. A fibrous portion of the dura
forms the roof of the sella turcica extending from

9
the tuberculum sellae to the dorsum sellae and is
called the diaphragm sellae. The diaphragm sellae
has a central opening to allow the pituitary stalk
and vessels to pass through it.
The posterior cranial fossa extends from the
petrous temporal bone anteriorly to the internal
occipital protuberance in the midline. The floor
is formed by the foramen magnum, basiocciput
and posterior part of sphenoid bone. The dorsum
sellae slopes downwards in front of foramen
magnum, this slope is called the clivus.
The mandible or the jaw bone is a Ushaped, a
horizontal central part with two lateral ramus on
each side. The posterior border of each ramus has
a condyle with a neck which articulates with the
temporal bone forming the temporomandibular
joint, while the anterior border of each ramus is
sharp and is called the coronoid process (Figs 1.1
to 1.4).
The temporormandibular joint is a synovial
joint between the head (condyle) of the mandible
and mandibular fossa on the undersurface of the
squamous part of the temporal bone. The joint
is separated into the upper and lower cavities
by a fibrocartilaginous disc within it. There
is no hyaline cartilage within the joint which
makes it an atypical synovial joint. The synovial
membrane lines the inside of the capsule and
the intracapsular posterior aspect of the neck
of the mandible. The articular disc is attached
around its periphery to the inside of the capsule
and to the medial and lateral poles of the head
of the mandible. The joint is more stable with the
teeth in occlusion than when the jaw is open. The
movements at the temporomandibular joint are
depression and elevation (opening and closing
of the jaws), side to side grinding movements,
retraction and protaction movements (retrusion
and protrusion).
THE NASAL CAVITY AND NASAL SEPTUM
The nasal cavity is pear-shaped, broader below
and narrower at the top. From its lateral walls the

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Atlas on X-ray and Angiographic Anatomy

conchae project into the nasal cavity. There are


three conchaeSuperior, middle and inferior
conchae. The superior concha is small and is
found high in nasal cavity, its lower edge overlies
the superior meatus. The sphenoethmoidal recess
lies above and behind the superior concha and
receives the ostia of sphenoidal sinus. The middle
concha lies between the superior and inferior
concha. The area in front of the middle meatus
is the atrium of nose. Posteriorly, the middle
meatus is related to the splenopalatine foramen.
The inferior concha lies below the middle
concha articulates anteriorly with the maxilla
and posteriorly with the palatine bone. The nasal
septum (Fig. 1.12) is normally in the midline, it
consists of bone (vomer) and cartilage. It has a
lower free margin, superiorly it articulates with the
medial ends of frontal bone and also the frontal
process of maxilla. The two maxillae on either side
meet in the midline and project forwards as the
anterior nasal spine at the lower margin of the
nasal aperture. The vomer articulates with the
sphenoid body and forms the posterior border
of the septum. The septal cartilage forms the
anterosuperior part of the septum. The floor of the
nose is formed by the upper surface of the hard
palate. The central part of the roof of nose is the
cribriform plate of the ethmoid.
THE PARANASAL SINUSES
The paranasal sinuses all arise as evaginations
from the nasal fossa. It comprises of frontal
sinuses, maxillary sinuses, sphenoid sinuses and
ethmoidal sinuses. The nasal cavity contains
the superior meatus, middle meatus and the
inferior meatus. The superior meatus drains the
posterior ethmoidal air cells and sphenoidal
sinuses. The middle meatus drains the frontal
sinuses, maxillary sinuses and anterior ethmoidal
air cells. The osteomeatal complex comprises of
the uncinate process, ethmoid infundibulum,
maxillary sinus ostium, middle turbinate, frontal
recess and ethmoid bulla. The inferior meatus
has opening for the nasolacrimal duct (Figs 1.8 to
1.12).

The maxillary sinus lies in the body of maxilla,


the sinus is triangular in shape, the apex in
the zygomatic process of maxilla and the base
towards the lateral wall of the nose. The roof of
the sinus is the floor of the orbit. The floor of the
sinus is formed by the alveolar part of maxilla. The
infratemporal fossa and pterygopalatine fossa lies
behind the posterior wall of maxillary sinus. The
ostium of maxillary sinus is on the superomedial
aspect of the sinus and opens into the middle
meatus on the same side into the nasal cavity (Figs
1.2B and 1.3B).
The ethmoidal sinus lies between the nasal
cavity and orbit. The sinus is divided by multiple
thin bony septa into the anterior and posterior
group of ethmoidal air cells. The lateral wall of
the ethmoidal sinus forms a part of the medial
wall of orbit; it is paper thin and is called the
lamina papyracea. The ostia of anterior ethmoidal
air cells drain into the middle meatus. The ostia
of posterior ethmoidal air cells drain into the
superior meatus.
The sphenoidal sinus occupies the body
of sphenoid bone. A vertical septum divides
the cavity into two unequal halves. The roof of
sphenoid sinus is formed by pituitary fossa and
middle cranial fossa. Laterally the sphenoid sinus
is related to the cavernous sinus and internal
carotid artery. Posteriorly, the sphenoid sinus is
related to the posterior cranial fossa and pons. The
ostium of sphenoidal sinus is in the anterior wall
of the sinus and opens into the superior meatus or
into the sphenoethmoidal recess.
The frontal sinuses are formed within the
frontal bone on either side near midline. Its floor
forms the roof of orbit medially. Posteriorly the
frontal sinus is related to anterior cranial fossa.
The ostium of frontal sinus is at its lower medial
edge and drains into the middle meatus in nasal
cavity or in some cases into the anterior ethmoidal
air cells.
THE ORBIT
The bony orbit is a cavity, shaped like a pyramid
with its apex posteriorly and the base forming

Skull

11

Fig. 1.12: X-ray skullLateral view (for nasal bones)

Fig. 1.13: X-ray skullAP view in a 2-year-old child

the orbital margins anteriorly. The orbital roof is


formed by the frontal bone, which separates the
orbit from the anterior cranial fossa. The orbital
floor is formed by the orbital plate of the maxilla,

portions of the palatine bone and the zygoma


(Figs 1.10, 1.13 and 1.14). The maxillary portion
of orbital floor is usually involved in blow out
fractures. The medial orbital wall is the thinnest

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Atlas on X-ray and Angiographic Anatomy

Fig. 1.14: X-ray skullLateral view in a 2-year-old child

of all the orbital walls and comprises of frontal


process of the maxilla, lacrimal bone, lamina
papyracea and bony sphenoid. The lateral wall of
orbit is formed by the zygoma and greater wing of
sphenoid. The superior orbital fissure is a space
between the greater and lesser wings of sphenoid.
The inferior orbital fissure is formed by the
maxilla, the palatine bone and the greater wing
of sphenoid. The optic canal lies within the lesser
wing of sphenoid, the optic nerve and ophthalmic
artery encased in the dural sheath pass through it.

Structures passing through the superior orbital


fissure: Superior ophthalmic vein, the rectus
muscles (superior, inferior, medial and lateral),
lacrimal nerve, frontal nerve, trochlear nerve,
oculomotor nerve, abducent nerve, nasociliary
nerve.
Structures passing through the inferior orbital
fissure: Infraorbital artery, inferior ophthalmic
vein, zygomatic nerve, infraorbital nerve.
Structures passing through the optic canal:
Optic nerve, ophthalmic artery.

2
CHAPTER

Two common radiographic views taken for the


spine are the AP view and the lateral view. Most
disease process involving the vertebral body or the
posterior elements can be noted on these views,
however, special views like posterior oblique view
may be necessary in some cases.
The spine is made up of five groups of
vertebrae. The portion of spine around the neck
region is cervical spine. It is formed by first seven
vertebrae which are referred as C1 to C7, followed
by 12 thoracic vertebrae referred as T1 to T12 and
subsequently five lumbar vertebrae L1 to L5 in
the low back area. The sacrum is a big triangular
bone at the base, its broad upper part joins the
L5 vertebra and its narrow lower part joins the
coccyx or tail bone.
CERVICAL SPINE
It starts with first cervical vertebra (C1) attached
to the bottom of the skull, the basiocciput. Atlas is
the name given to C1 vertebra as it supports and
balances the weight of the skull. It has practically
no body or spinous process, it appears as two
thickened bony arches which join anteriorly as
anterior tubercle and posteriorly as posterior
tubercle. These two thickened bony arches join to
form a large hole with two transverse processes.
On its upper surface, the atlas has two facets

Spine

that unite with the occipital condyles of the


skull. Structure of atlas is unique and has a large
opening which accommodates spinal cord (Figs
2.1 and 2.2).
The second vertebra is the axis, it lies directly
beneath the atlas vertebra. It bears large bony
tooth-like protrusion on its summit, the odontoid
process or the dens. This process projects upward
and lies in the ring of the atlas. The joints of the axis
give the neck its ability to turn from side to side,
i.e. left and right, as the head is turned, the atlas
pivots around the odontoid process. The odontoid
process arises from anterior part of C2 vertebrae
and articulates with the C1 vertebrae above to form
the atlanto-occipital joint (Figs 2.2, 2.3 and 2.10).
Special views may be taken on plain
radiographs to demonstrate the atlantoaxial joint
and atlanto-occipital joint.
The transverse processes of the cervical
vertebrae have large transverse foramina to
allow the vertebral arteries into the cranium. The
spinous processes of the second to fifth cervical
vertebrae are forked providing attachments for
various muscles.
C3-C6 vertebrae have a typical structure. C7
vertebra is called vertebra prominens because
of a long prominent thick nearly horizontal not
bifurcated spinous process which is palpable
from the skin (Figs 2.4 to 2.9).

Atlas on X-ray and Angiographic Anatomy

14

Figs 2.1A to D: (A) Cervical spine MRI sagittal section T2WI; (B) Multiplanar reconstructed CT scan images of cervical spine
posterior view; (C) View from above; (D) Lateral view

There are eight cervical spinal nerves and


the neural foramina of cervical spine allow the
cervical spinal nerves to exit out of the spinal
canal.
DORSOLUMBAR SPINE
It consists of twelve vertebrae in the chest area,
the first thoracic vertebra articulates with the
C7 vertebra above and the last thoracic vertebra
articulates with the first lumbar vertebra below.
The thoracic vertebrae are larger in size than
those in the cervical region. They have long,
pointed spinous processes that slope downward,
and have facets on the sides of their bodies that
join with ribs. From the third thoracic vertebra
onwards to the last thoracic vertebra, the bodies
of these bones increases in size gradually (Figs
2.11 to 2.13). This reflects the stress placed on
them by the increasing amounts of body weight
they bear. There are five lumbar vertebrae in the

lower back. They have larger and stronger bodies


to provide support. The transverse processes of
these vertebrae project backward at sharp angles,
while their short, thick spinous processes are
directed nearly horizontally.
LUMBOSACRAL SPINE
The 5 lumbar vertebrae in the lower back are
prone to injuries. On AP views the pedicles and
transverse process need to be examined to rule
out any fracture. On lateral views, the curvature
of lumbar spine needs to be examined, note any
slipping of one lumbar vertebra over the other.
The intervertebral disc spaces should be equal
in size (Figs 2.14 to 2.16). Additional views like
posterior oblique view may be necessary in some
cases. The sacrum is a large triangular bone on
AP view at the base of the lower spine. Its broad
upper part joins the lowest lumbar vertebrae and
its narrow lower part joins the coccyx or tail

Spine

B
Figs 2.2A and B: X-ray cervical spineLateral view

15

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Atlas on X-ray and Angiographic Anatomy

Fig. 2.3: X-ray cervical spineLateral view for C1-C2 vertebrae

bone (Fig. 2.17). The sides are connected to the


iliac bones (the largest bones forming the pelvis).
The sacrum is a strong bone and rarely fractures.
The five vertebrae that make up the sacrum are
separate in early life, but gradually become fused
between the eighteenth and thirtieth years.
The spinous processes of these fused bones are
represented by a ridge of tubercles. The weight
of the body is transmitted to the legs through the
pelvic girdle at these joints.
COCCYX
It is the lowest part of the vertebral column and
is attached by ligaments to the margins of the
sacral hiatus. It is better viewed on lateral views of
sacrum with coccyx (Fig. 2.17). Sometimes bowel
gases may obscure a clear picture of coccyx. When
a person is sitting, pressure is exerted on the
coccyx, and it moves forward, acting like a shock
absorber. Sitting down with force may cause the
coccyx to be fractured or dislocated.
GENERAL FEATURES OF SPINE
The vertebral body is shaped like an hourglass,
thinner in the center with thicker ends. Outer
cortical bone extends above and below the

superior and inferior ends of the vertebrae to


form rims. The superior and inferior endplates
are contained within these rims of bone. The
bodies of adjacent vertebrae are joined on the
front surfaces by anterior ligaments and on the
back by posterior ligaments. A longitudinal row
of the bodies supports the weight of the head and
trunk.
Intervertebral discs are found between each
vertebra. They are better viewed on lateral radio
graphs. Intervertebral discs make up about onethird of the length of the spine and constitute the
largest organ in the body without its own blood
supply. The discs receive their blood supply
through movement. The discs are flat, round
structures about a quarter to three quarters of an
inch thick with tough outer rings of tissue called
the annulus fibrosis that contain a soft, white,
jelly-like center called the nucleus pulposus. Flat,
circular plates of cartilage connect to the vertebrae
above and below each disc. Intervertebral discs
separate the vertebrae, and act as shock absorbers
for the spine.
Projecting from the back of each body of
the vertebra are two short rounded stalks called
pedicles. They form the sides of the vertebral
foramen. They can be viewed on both AP and

Spine

B
Figs 2.4A and B: X-ray cervical spineAP view

17

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Atlas on X-ray and Angiographic Anatomy

Fig. 2.5: X-ray cervicothoracic junctionAP view

Fig. 2.6: X-ray cervical spine swimmers view for cervicothoracic junction

lateral radiographs. Pedicles extend posteriorly


from the lateral margin of the dorsal surface of the
vertebral body.
The laminae are two flattened plates of bone
extending medially from the pedicles to form

the posterior wall of the vertebral foramen.


These laminae are better seen on lateral views
on radiographs. They fuse posteriorly in the
midline to become spinous process. The pars
interarticularis is a special region of the lamina

Spine

Fig. 2.7: X-ray cervical spine right posterior oblique for intervertebral foramina

Fig. 2.8: X-ray cervical spineLateral view in flexion

19

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Atlas on X-ray and Angiographic Anatomy

Fig. 2.9: X-ray cervical spineLateral view in extension

Fig. 2.10: X-ray cervical spine open mouth view for atlantoaxial junction

between the superior and inferior articular


processes. A fracture or congenital anomaly of the
pars may result in a spondylolisthesis.
The pedicles, laminae, and spinous process
together complete a bony vertebral arch around
the vertebral opening, through which the spinal
cord passes. Between the pedicles and laminae

of a typical vertebra is a transverse process


that projects laterally and toward the back.
Various ligaments and muscles are attached
to the transverse process. Projecting upward
and downward from each vertebral arch are
superior and inferior articulating processes.
These processes bear cartilage-covered facets by

Spine

21

Figs 2.11A to C: Multiplanar reconstructed CT scan images of dorsolumbar spine: (A) Posterior view;
(B) Anterior view; (C) Lateral view

which each vertebra is joined to the one above


and the one below it. These facet joints facilitate
smooth gliding movement of one vertebra on
another to produce twisting motions and rotation
of the spine. Facet joints are also called as
zygapophyseal joints.
On the surfaces of the vertebral pedicles are
notches that align to create openings, called
intervertebral foramina. These openings
provide passageways for spinal nerves that exit
out of the spinal cord.
SPINAL CANAL AND SPINAL CORD
The spinal canal is bounded anteriorly by
the vertebral bodies, the intervertebral discs,

posterior longitudinal ligament. Posteriorly it is


related to the lamina and ligamentum flavum.
Laterally on either side, it is related to the
pedicles. The intervertebral foramina contain
the spinal nerves, posterior root ganglia, spinal
arteries and veins. The vertebral canal contains
the spinal cord. The spinal canal encases the
spinal cord. The bones and ligaments of the
spinal column are aligned in such a manner to
create a column that provides protection and
support for the spinal cord. The outermost layer
that surrounds the spinal cord is the dura mater,
which is a tough membrane that encloses the
spinal cord and prevents cerebrospinal fluid from
leaking out. The space between the dura and the
spinal canal is called the epidural space. This

Atlas on X-ray and Angiographic Anatomy

22

B
Figs 2.12A and B: X-ray dorsolumbar spineLateral view

Spine

23

B
Figs 2.13A and B: X-ray dorsolumbar spineAP view

space is filled with tissue, vessels and large veins.


Up to the third month of fetal life, the spinal cord
is about the same length as the canal. The growth
of the canal outpaces that of the cord from the
3rd month onwards. In an adult the lower end of
the spinal cord usually ends at approximately the
first lumbar vertebra, where it divides into many

individual nerve roots that travel to the lower


body and legs. This collection of group of nerve
roots is called the cauda equina. MRI spine
is the modality of choice to examine the spinal
canal and spinal cord. CT spine is preferred in
cases of acute trauma and those who cannot
undergo MRI studies.

Atlas on X-ray and Angiographic Anatomy

24

Figs 2.14A to D: Multiplanar reconstruction CT scan images of lumbosacral spine: (A) Posterior view; (B) Lateral view; (C)
Lateral view showing the intervertebral neural foramina; (D) Oblique view

SOME DIFFERENTIATING FEATURES


BETWEEN CERVICAL, THORACIC AND
LUMBAR VERTEBRAE
C3-C6 vertebrae have atypical features. The body
of these four vertebrae is small and broader from
side-to-side than from front-to-back. The pedicles
are directed laterally and backward. The laminae
are narrow, and thinner above than below. The
vertebral foramen is large and has triangular
shape. The spinous process is short and bifid.
Superior articular facets face backward, upward,
and slightly medially and inferior face forward,
downward, and slightly laterally.
The foramen transversarium is an opening
in the transverse processes of the seven cervical
vertebrae. It gives passage to the vertebral artery,
vein and plexus of sympathetic nerves in each of
the vertebrae except the seventh, which lacks the
artery. C7 has enlarged spinous process called the
vertebral prominence.

The thoracic vertebrae have costal facets for ribs


on either sides of the vertebral body. They increase
in size gradually from T3 vertebra downwards.
The lumbar vertebrae have neither a foramen
in transverse process nor costal facets; they are
larger than the dorsal and cervical vertebrae in
size.
RADIOLOGICAL IMPORTANCE OF
VERTEBRAL COLUMN IN SPINAL INJURIES
The vertebral column can be sub
divided as
anterior column, middle column and the
posterior column. Injuries involving the middle
and posterior columns result in unstable injuries.
Anterior column is formed by anterior longi
tudinal ligament, anterior annulus fibrosus
and anterior part of vertebral body.
Middle column is formed by posterior longi
tudinal ligament, posterior annulus fibrosus
and posterior part of vertebral body.

Spine

B
Figs 2.15A and B: Lumbosacral spine X-rayAP view

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Atlas on X-ray and Angiographic Anatomy

26

B
Figs 2.16A and B: Lumbosacral spine X-rayLateral view

Spine

27

Fig. 2.17: Sacrum and coccyx X-rayLateral view

Posterior column includes posterior elements


and ligaments.
RADIOLOGICAL IMPORTANCE OF
CRANIOVERTEBRAL JUNCTION
Chamberlain line is the line between posterior
part of hard palate and posterior margin of

foramen magnum. Normally the tip of odontoid


process lies at or below this line. Basilar line is the
line along the clivus and it usually falls tangent to
the posterior aspect of the tip of odontoid.
Craniovertebral angle (Clivus-canal angle) is
angle between basilar line and a line along posterior
aspect of odontoid process. If this angle is < 150,
cord compression can occur on the ventral aspect.

3
CHAPTER

X-rayChest

When viewing the chest X-ray, check first for the


technical factors:
Projection AP or PA view, etc.
Orientation (right or left)
Rotation
Penetration
Degree of inspiration.
On posteroanterior (PA) view, the X-ray
beam first enters the patient from the back and
then passes through the patient to the film that
is placed anterior to the patients chest. It uses
80-120 kV and focus film distance of 6 feet. On a
PA film, lung is divided radiologically into three
zones:
1. Upper zone extends from apices to lower
border of 2nd rib anteriorly.
2. Middle zone extends from the lower border
of 2nd rib anteriorly to lower border of 4th rib
anteriorly.
3. Lower zone extends from the lower border of
4th rib anteriorly to lung bases. Please note
that radiological division of lung in upper,
middle and lower zone does not depict
anatomical lobes of the lung.
ANATOMICAL SEGMENTAL
DIVISION OF LUNGS
Right lung has three lobes:
1. Upper lobe which has an apical, anterior and a
posterior segment.

2. Middle lobe has a lateral and a medial segment.


3. Lower lobe has superior segment, medial
basal segment, anterior basal segment, lateral
basal segment and a posterior basal segment.
Left lung has two lobes:
1. Upper lobe which has an apicoposterior,
anterior, superior lingular and an inferior
lingular segment.
2. Lower lobe has superior segment, anterior basal
segment, lateral basal segment and a posterior
basal segment. Left lung has no middle lobe.
When viewing the chest X-ray PA view look for
(Figs 3.1 to 3.4):
Check patients name and date
Lung fields
Hilum Normally left hilum is higher than
right hilum
Cardiac shape and borders
Mediastinum
Diaphragmright diaphragm is higher than
left diaphragm
Costophrenic angles should be well-defined
and acute
Trachea should be slightly deviated to the
right around the aortic knuckle
Look at bones for any lesions and fractures
Look for soft tissue abnormalities
Look at the area under the diaphragm.
When viewing the chest X-ray lateral view (Figs
3.5 and 3.6):

X-rayChest

29

E
Figs 3.1A to E: CT scan multiplanar reconstructed (MPR) images of thorax: (A) View from front; (B) Lateral view;
(C) View from back; (D) CT scan coronal section of thorax; (E) CT scan axial section of thorax

Fig. 3.2: X-ray chestPA view

30

Atlas on X-ray and Angiographic Anatomy

Fig. 3.3: X-ray chestPA view mediastinal borders

Fig. 3.4: X-ray chest PA viewCardiothoracic ratio (Cardiothoracic ratio = a+b


c ; Cardiothoracic ratio is estimated from the PA view
of chest to calculate the size of heart. It is the ratio between the maximum transverse diameter of heart and the maximum width
of thorax above the costophrenic angles. a = Right heart border to midline; b = Left heart border to midline and c = Maximum
thoracic diameter above costophrenic angles from inner borders of ribs

X-rayChest
Check patient name and date
Identify the diaphragms (gastric air bubble
lies under the left hemidiaphragm
Compare the lung fields in retrosternal space,
retrocardiac space and supracardiac space,
they should all have the same density on the
X-ray film
Look carefully at the retrosternal space, a mass
in this space will obliterate this space turning
it white on the X-ray film
Check the position of horizontal fissure and
oblique fissures
Check the density of the hila
Do not forget to carefully examine the vertebral
bodies on the chest X-ray lateral view.
Lung Fissures
They are thickening of the septae in the lung
parenchyma. For a fissure to be seen on a
radiograph, the X-ray beam has to be tangential
to it. The right lung has horizontal and oblique

31

fissures while the left lung has only the oblique


fissure.
The location of these fissures are:
On chest X-ray, PA view the horizontal fissure
appears as a faint white line that runs from
the midpoint of the right hilum to the anterior
chest wall.
On chest X-ray, lateral view the oblique fissure
runs obliquely downwards from the D4/D5
vertebral level, crossing the hilum in front and
continuing downward direction to end near
the anterior 1/3rd of diaphragm.
Locating Lesions of the Lungs
We need to have both PA and lateral views to locate
a lesion on chest X-ray. On PA view locate the lung
zone where the lesion lies, also look at the borders
of the lesion well-defined/ill-defined/silhouette
sign. On lateral view identify the horizontal
fissure and oblique fissure. After this is done try to
localize the lesion carefully:

Fig. 3.5: X-ray chestLateral view

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Atlas on X-ray and Angiographic Anatomy

Fig. 3.6: X-ray chestApicogram

Fig. 3.7: X-ray chestPA view (negative) to visualize bony thorax

X-rayChest
Lesion in right lung field
If the lesion lies posterior to the oblique
fissure it must lie within the lower lobe,
does not matter how high it appears on the
PA view.
If the lesion lies anterior to the oblique
fissure it may be in the upper or middle
lobe.
If the lesion is below the horizontal fissure
it is in the middle lobe
If the lesion lies above the horizontal
fissure it is in the upper lobe.
Lesion in left lung field
If the lesion is behind the oblique fissure it
must be in the lower lobe.
If the lesion is anterior to the oblique
fissure then it must be in upper lobe (there
is no middle lobe in left lung).
IMPORTANT POINTS TO OBSERVE
ON CHEST X-RAYS
In a well-centered chest X-ray, medial ends
of clavicles are equidistant from vertebral
spinous process. Both lung fields are of equal
radiolucency.
Both hila are concave outwards. The
pulmonary arteries, upper lobe veins and
bronchi contribute to the making of hilar
shadows (Fig. 3.7).
The normal length of trachea is 10 cm, it
is central in position and bifurcates at T4T5 vertebral level. Left atrial enlargement
increases the tracheal bifurcation angle
(normal is 60 to 75). An inhaled foreign body
is likely to lodge in the right lung due to the
fact that the right main bronchus is shorter,
straighter and wider than left.
Mediastinum is the space between the lungs. It
is divided into a superior and an inferior com
partment. Superior compartment consists
of the thoracic inlet. Inferior compartment

33

has anterior, middle and posterior


subcompartments.
Retrosternal
region
is included in the anterior compartment,
heart lies in the middle compartment and
descending aorta with esophagus and
paraspinal region is located in the posterior
mediastinal compartment. Thymus is located
in the anterior part of superior as well as
inferior compartment of mediastinum.
Normal heart shadow is uniformly white
with maximum transverse diameter less than
half of the maximum transthoracic diameter.
Cardiothoracic ratio is estimated from the PA
view of chest (Fig. 3.4). It is the ratio between
the maximum transverse diameter of the heart
and the maximum width of thorax above the
costophrenic angles: a = right heart border
to midline, b = left heart border to midline,
c = maximum thoracic diameter above
costophrenic angles from inner borders of
ribs. Cardiothoracic ratio = a + b/ c. Thus on
chest X-ray PA view the cardiothoracic ratio is
less than 1/2 the maximum thoracic diameter,
in children this cardiothoracic ratio may be
increased. In adults the normal cardiothoracic
ratio is 2:1.
Borders of the mediastinum are sharp and
distinct (Fig. 3.3). The right heart border is
formed by superior vena cava superiorly and
right atrium inferiorly, the left heart border is
formed by the aortic knuckle superiorly, left
atrial appendage and left ventricle inferiorly.
The right ventricle lies anteriorly, posterior to
the sternum and the right atrium lies on the
right lateral side. The left ventricle lies on the
entire left side, the outlet of the left ventricle
and the ascending aorta lie in the center of
the heart. The left atrium is the most posterior
chamber of the heart. The inferior vena cava
is seen further caudally just at the section the
diaphragm appears together with the upper
part of liver.

4
C H A PT E R

Abdominal Radiograph

The standard projections requested for abdominal


radiographs are (Figs 4.1 and 4.2):
Supine
Erect
Lateral decubitus
The radiation exposure of an abdominal
radiograph is equivalent to 28 chest radiographs.
Key to densities in abdominal radiographs:
BlackGas
WhiteCalcified structures
GreySoft tissues
Darker grayFat
Intense whiteMetallic objects.
Always view the radiograph using a view box.
The contrast of outlines of structures depends on
the differences between their densities. These
differences are less apparent on the abdominal
radiograph as most structures are of similar
densityMainly soft tissue.
On a routine supine, abdominal radiograph
look for the following:
Dark margins outlining the spleen, liver,
kidneys, bladder and psoas musclesThis
indicates intra-abdominal fat.
Gas inBody of stomach, descending colon,
small intestines.
Fecal matter in cecum gives it a mottled
appearance, seen as a mixture of gray densities
representing a gas-liquid-solid mixture.
Pelvic phleboliths are small round/oval
calcific densities in pelvic cavity

A dark skinfold across the upper abdomen is


normal finding
Check the bony pelvis, spine and visualized
ribs
The heart shadow should be on the left side
above the diaphragm
Check whether the right R marker is placed
on the right side of the abdominal radiograph
Make sure that the abdominal radiograph
covers both the hemidiaphragms to the
inguinal canal regions
Check the lung bases.
On an erect abdominal radiograph the
following changes occurs:
The air rises
Fluid goes down due to gravity
The transverse colon, small bowel loops and
kidneys drop down a bit lower due to gravity
A slight increase in radiographic density in
lower abdomen
The lung bases appear clearer as the
diaphragms move down a little
The liver and spleen become more visible.
The abdominal radiograph is most helpful
in cases of acute abdomen. A normal initial
abdominal radiograph does not exclude intraabdominal trauma, follow up radiographs,
ultrasound, CT scan and MRI (Figs 4.1A to E)
may be necessary. Abnormal air-fluid levels
become easier to visualize on erect abdominal
radiographs. Gas under diaphragm is seen in

Abdominal Radiograph
cases of perforated viscus. Also remember not
to waste any time if the patients condition is
critical, stabilize the patient and shift the patient
to operating theater if needed.
Radiation exposure in early pregnancy can be
disastrous. It is always safer in female patients of
reproductive age group to check the date of their
last menstrual period. Written consent form is
needed confirming that the patient is not pregnant/
unlikely to be pregnant at the time of examination.
Additional points to note while examining
abdominal radiographs:
Maximum diameter of small bowel should not
exceed 3 cm and that of large bowel by more
than 5 cm in diameter.

35

Cecum is said to be dilated if it measures more


than 8 cm.
The haustra of the large bowel extends only a
third of the way across the bowel from each
side, whereas the valvulae conniventes of the
small bowel traverse from wall to wall.
Presence of small amounts of intraluminal gas
throughout the gut is normal, but if found in
excess may be abnormal. Also absence of bowel
gas in one area may indicate bowel pathology.
Presence of extraluminal gas is abnormal
(look for it under the diaphragm, in the bowel
wall, in biliary system).
Metallic objects may appear as bright
densities, so ask for appropriate history of

Figs 4.1A to E: CT scan (A to C) multiplanar reconstructed images of abdomen: (A) Coronal view; (B) Sagittal view; (C) Axial
view; (D) MRI-T2WI coronal section of abdomen; (E) MRI-T2WI axial section of abdomen

36

Atlas on X-ray and Angiographic Anatomy

Fig. 4.2: X-ray abdomenSupine view

operations, trauma, ingestion of foreign body,


therapeutic/diagnostic procedures.
Look for nasogastric tube placements,
catheters, etc. to mention them in the report.
Look for normal calcified structures which
can cause diagnostic difficultyexcessive
costal cartilage calcification, calcified aortic/
splenic arteries, pelvic phleboliths, calcified
mesenteric lymph nodes, etc.
Normal liver has a fairly pointed tip, if this tip
appears more rounded with displacement
of adjacent intra-abdominal structures it is
suggestive of hepatomegaly.
The spleen is not normally seen on abdominal
radiographs, when spleen is enlarged more
than 15 cm, it displaces the adjacent intraabdominal organs and becomes more obvious
on abdominal radiographs.
Normal kidneys extend from the lower margin
of 12th dorsal vertebra to the upper margin of

3rd lumbar vertebra, the left kidney is usually


slightly larger in size and slightly higher placed
as compared to the right kidney. The outline of
kidney visible on abdominal radiograph is due
to perinephric fat.
An abdominal mass can arise anywhere in
abdomen and would produce a dense area
with displacement of bowel loops around it,
calcification may also occur within it, CT scan
maybe required to investigate such masses.
A full bladder appears in the pelvic cavity as a
smooth rounded mass of uniform density, the
outline is due to perivesical fat tissue.
Retroperitoneal masses usually obscure
or displace the psoas muscle outline on
abdominal radiographs.
An erect chest radiograph and not abdominal
radiograph is the best projection to diagnose
a small pneumoperitoneum (gas in the
peritoneal cavity).

5
CHAPTER

Upper Limb

SHOULDER JOINT
It is a ball and socket joint and can produce
a range of movement such as adduction,
abduction, extension and flexion. The head of
humerus articulates with the shallow glenoid
cavity of scapula thus connecting the upper
limb to the chest (Figs 5.1A and B). The joint
is made more stable by the articular capsule,
ligaments, glenoid labrum and the rotator cuff.
The labrum is a fibrocartilaginous rim attached

around the margin of the glenoid cavity. It


deepens the articular cavity, cushions and
stabilizes the humeral head. The articular capsule
completely encircles the joint; it is attached to the
circumference of the glenoid cavity beyond the
labrum. The ligaments of the glenohumeral joint
are coracohumeral ligament and glenohumeral
ligament. The rotator cuff surrounds the shoulder
joint; it is formed by tendons of four muscles
Supraspinatus, infraspinatus, teres minor,
subscapularis and inserts into anatomical neck

B
Figs 5.1A and B: (A) Multiplanar reconstructed CT scan image of shoulder joint;
(B) MRI-T1WI coronal section of shoulder joint

38

Atlas on X-ray and Angiographic Anatomy

and tuberosities of humerus. The rotator interval


is the portion of the joint capsule which lies
between the supraspinatus and subscapularis
tendons. On AP view of shoulder joint (Figs 5.2
and 5.3) the normal acromioclavicular distance is
<8 mm, coraco-clavicular distance is <13 mm, and
the inferior margin of clavicle is in line with the
inferior acromion.
UPPER ARM
Humerus is the long bone of upper arm. The head
of humerus articulates with scapula superiorly
at shoulder joint (Figs 5.4 and 5.5); inferiorly
the humerus articulates with radius and ulna
at elbow joint. The humerus at its upper end
has a head and neck. The head of humerus is
rounded almost like a sphere and is about four
times the size of the glenoid cavity of scapula
with which it articulates. The head of humerus

has two bony projections called the greater and


lesser tuberosities which serve as attachments
for muscles around the shoulder joint (Figs 5.6
and 5.7). The surgical neck of humerus lies at the
junction with the shaft of humerus. The axillary
nerve runs behind this neck and is likely to be
injured in fractures of neck of humerus. The
deltoid tuberosity is a bony prominence at the
middle of the lateral side of shaft; and provides
attachment to the fibers of deltoid muscle. The
lower end of the humerus has articular surfaces
for the elbow joint, capitulum and trochlea. The
capitulum articulates with the head of radius
while the trochlea partly articulates with the ulna.
The olecranon fossa found on the posterior aspect
of humerus at the distal end. Provides articulation
for olecranon process of ulna. The medial and
lateral epicondyles are projections of humerus,
which provide attachment for muscles around the
elbow joint.

Fig. 5.2: X-ray shoulder jointAP view

Upper Limb

39

Fig. 5.3: X-ray shoulder jointAxial view

Fig. 5.4: X-ray shoulder jointTransthoracic view

The soft tissues comprise mainly of muscles,


arteries, veins and nerves and are divided by a
medial intermuscular septum into anterior and
posterior compartments. The biceps brachii,

brachialis and coracobrachialis muscles lie in the


anterior compart
ment. The triceps brachii and
anconeus muscles lie in posterior compartment.
The main action of biceps brachii is to supinate

Atlas on X-ray and Angiographic Anatomy

40

Figs 5.5A and B: (A) Multiplanar reconstructed CT scan image of upper arm; (B) MRI-T1WI sagittal section of upper arm

Fig. 5.6: X-ray upper armAP view

Upper Limb

41

Fig. 5.7: X-ray upper armLateral view

the forearm. The main action of brachialis


muscle is to flex the forearm. Both the biceps
brachii and brachialis muscle are innervated
by the musculocutaneous nerve (C5 and C6).
The main action of coracobrachialis muscle is to
flex and abduct the arm. It is innervated also by
musculocutaneous nerve (C5, C6, and C7). The
main action of triceps brachii muscle is extension of
forearm. It is innervated by the radial nerve (C6, C7
and C8). The main action of anconeus is to stabilize
the elbow and assist triceps brachii in extension.
ELBOW JOINT
Elbow joint is a hinge-type of synovial joint
formed by the distal humerus, proximal ulna, and
radius (Fig. 5.8). The distal aspect of the humerus
is flat and the medial third of its articular surface,
the trochlea, articulates with the ulna while the

lateral capitulum articulates with the radius. On


the posterior surface of the humerus is a hollow
area, the olecranon fossa (Figs 5.9 and 5.10). The
posterior capsular attachment of the humerus is
located above the olecranon fossa.
The anterior aspect of the distal humerus
contains two fossae, the coronoid fossa, located
medially, and the radial fossa, located laterally.
The anterior capsular attachment to the humerus
is located above these fossae. The proximal end
of the ulna has the olecranon and the coronoid
process (Fig. 5.11). The radial head has a round
shallow articular surface which articulates with
the capitulum of the humerus.
A fibrous capsule envelops the elbow joint;
and a synovial membrane outlines the deep
surface of this fibrous capsule. A number of fat
pads are located between the fibrous capsule and
the synovium. The muscles around the elbow

Atlas on X-ray and Angiographic Anatomy

42

Figs 5.8A and B: (A) Multiplanar reconstructed CT scan image of elbow joint; (B) MRI-T1WI coronal section of elbow joint

Fig. 5.9: X-ray elbow jointAP view

Upper Limb

43

Fig. 5.10: X-ray elbow jointLateral view (in flexion)

Fig. 5.11: X-ray elbow jointOblique view (in extension)

joint comprise of posterior, anterior, lateral, and


medial groups. The muscles of the posterior
group are the triceps and the anconeus. The
muscles of the anterior group are the biceps and

brachialis. The lateral group of muscles includes


the supinator and brachioradialis muscles and
the extensor muscles of the wrist and hand. The
medial group of muscles includes the pronator

44

Atlas on X-ray and Angiographic Anatomy

teres, the palmaris longus, and the flexors of the


hand and wrist.
FOREARM
The radius is a long bone on the lateral side of
forearm. It has a cylindrical head and articulates
with the capitulum at elbow joint (Figs 5.12 and
5.13). It has a narrow neck below which is the long
shaft of radius. The radius has a bony prominence
on its medial side called the radial tuberosity
(Fig. 5.14). Distally, the radius articulates with
the proximal row of carpal bones, known as
the radiocarpal joint. The styloid process of
radius is bony projection on its lateral side at
the radiocarpal joint. On its medial aspect at the
radiocarpal joint it has a small facet to articulate
with the ulna.
The ulna is the long bone on the medial side of
forearm. It has an olecranon process at the elbow
joint which articulates with the olecranon fossa of
humerus on posterior aspect of elbow joint. The
coronoid process of ulna is a bony prominence on
the anterior aspect of ulna at the elbow joint. The
lower part of coronoid process is called the ulnar
tuberosity, which serves as attachment to the
brachialis muscle. Between the coronoid process
and the olecranon process of ulna there is a
saddle-like depression which articulates with the
trochlea of humerus. The shaft of ulna provides
attachment to the muscles of forearm and wrist.
At the wrist joint the ulna narrows down, it has
a bony projection on its medial side called the
styloid process. The lateral side of ulna at the
wrist has a surface that articulates with the radius,
this is called as distal radioulnar joint. The ulna
articulates with the proximal row of carpal bones
on medial side, called as carpoulnar joint.
The anterior muscle group comprises of:
pronator teres, flexor carpi radialis, palmaris
longus, flexor carpi ulnaris, flexor digitorum
superficialis, flexor digitorum profundus, flexor
pollicis longus and pronator quadratus.
The posterior muscle group comprises of:
brachioradialis, extensor carpi radialis longus,

Figs 5.12A and B: (A) Multiplanar reconstructed CT scan


image of forearm; (B) MRI-T1WI coronal section of forearm

extensor carpi radialis brevis, extensor digitorum,


extensor digiti minimi, extensor carpi ulnaris,
supinator, abductor pollicis longus, extensor
pollicis brevis, extensor pollicis longus and
extensor indicis.
WRIST JOINT AND HAND
The small bones of the hand can be classified into
carpal bones, metacarpal bones and phalanges.
The carpal bones are made up of two rows of eight
carpal bones forming a semicircle (Figs 5.15A and
B). The proximal row lies where the wrist creases
on bending the wrist. From lateral to medial, the

Upper Limb

Fig. 5.13: X-ray forearmAP view

Fig. 5.14: X-ray forearmLateral view

45

Atlas on X-ray and Angiographic Anatomy

46

proximal row of carpal bones is made up of the


scaphoid, lunate, triquetrum and pisiform. The
distal row is made up of the trapezium, trapezoid,
capitate and hamate bones (Figs 5.16 to 5.18).
The distal row of carpal bones articulates with
the bases of metacarpals in hand. All the carpal
bones are surrounded and supported by the joint
capsule containing synovial fluid. The scaphoid is
boat-shaped bone. Its convex surface articulates
with radius, its medial surface articulates with
lunate, laterally it articulates with trapezium and
trapezoid. The waist of scaphoid is narrower and
more likely to fracture in trauma. The lunate has
a semilunar shape and it articulates with radius at
the wrist. It also articulates with the scaphoid and
triquetral bones in proximal row of carpal bones.

The lunate is the most commonly dislocated


carpal bone. The triquetral bone articulates with
the pisiform, hamate and lunate bones. The
pisiform articulates with the triquetral bone. The
trapezium articulates with the trapezoid, scaphoid
and also with the bases of the first and second
metacarpals. The trapezoid is a small bone, it
articulates with the scaphoid, trapezium, capitate
and partly with base of second metacarpal. The
capitate lies between the hamate medially and
trapezoid laterally. It articulates with the base of
third metacarpal and partly with base of fourth
metacarpal. The hamate is wedge-shaped carpal
bone. Proximally it articulates with lunate and
distally it articulates with bases of fourth and
fifth metacarpals. The metacarpal bones are

Figs 5.15A and B: (A) Multiplanar reconstructed CT scan image of hand and wrist joint,
(B) MRI-T1WI coronal section of wrist joint

Upper Limb

Fig. 5.16: X-ray hand and wrist joint oblique view

Fig. 5.17: X-ray hand and wrist jointAP view

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Atlas on X-ray and Angiographic Anatomy

Fig. 5.18: X-ray both wrist joints, AP view in an 18-month-old child

5 in number, they articulate with the carpal


bones proximally, while distally they articulate
with their respective phalanges. The phalanges
articulate with heads of metacarpals proximally
at metacarpophalangeal joint. The first digit has
two phalanges while the rest of digits have three
phalanges.
The wrist joint comprises of bones and joints,
ligaments and tendons. The distal end of ulna
articulates with lunate and triquetrum. The
distal end of radius articulates with scaphoid and
lunate, this is also called as radiocarpal joint. The
distal radioulnar joint is a pivot joint that allows
pronation and supination of wrist joint. It is
formed by the head of ulna and the ulnar notch of
radius; this joint is separated from the radiocarpal
joint by an articular disk lying between the radius

and the styloid process of ulna. The tendons that


cross the wrist begin as muscles that start in the
forearm. The radial and ulnar collateral ligaments
stabilize the wrist joint. Those that cross the
palmar side of the wrist are the flexor tendons.
Those tendons that travel at the back of wrist are
the extensor tendons.
HAND
The metacarpal bones are five in number, its
bases articulate with the distal row of carpal
bones. This articulation is known as
carpometacarpal joints. The head of the
metacarpal bones arti
culate with the base of
phalanx, it is called as metacarpophalangeal joint.
Between the phalanges are the proximal and
distal interphalangeal joints.

6
CHAPTER

Lower Limb

HIP JOINT
On plain X-rays, the hip joint is appreciated on AP,
lateral and postero-oblique views (Figs 6.1 to 6.5).
The hip joint is a multiaxial synovial joint (ball
and socket joint). It comprises of the head of femur
articulating with the acetabular cavity of the hip
bone. The hip joint is supported by muscle and
ligaments which not only provide stability, but
also produce a range of movements at the joint.
The three parts of the hip bone are ilium, ischium
and pubis, they join together at the acetabulum to
form the triradiate synchondrosis. The acetabular
labrum is attached to the acetabular rim and
the transverse acetabular ligament. It forms a
complete ring encircling the head of femur which
fits into the acetabular cavity (Figs 6.2 and 6.3).
Movements at the hip joint include flexion
(normal range 120o), extension (normal range
20o), adduction (normal range 30o), abduction
(normal range 60o), medial and lateral rotation
(normal range along a vertical axis 40o). The fibers
of the capsule become stiffer during movements
like extension and medial rotation of the femur.
The ligament of head of femur connects the head
of femur to the acetabular cavity. The ligament
of the head of femur becomes stiffer during
adduction movement of the hip joint, when the
legs are crossed in front.
Major anastomosis occurs around the femoral
neck involving branches from the femoral

arteries (medial and lateral circumflex branches)


and obtu
rator artery branches. As the medial
circumflex artery supplies a major portion of
blood to the head and neck of femur, in fracture
of femoral neck this blood supply is disrupted
and the head of femur may undergo avascular
necrosis. The obturator artery divides into anterior
and posterior branches. The acetabular artery
is a branch of the posterior branch of obturator
artery. The acetabular branches pass through
the acetabular foramen and enter the acetabular
fossa where they diverge in the fatty tissue. The
nutrient branches radiate to the margins of the
acetabular fossa to enter the nutrient foramina.
Radiological interventions like aspiration or
injections into the hip joint can be done anteriorly
or from the side, laterally. In case of lateral
approach to hip joint the needle passes in front of
the greater trochanter and parallel to the femoral
neck to enter the joint capsule. In the anterior
approach, the needle is inserted just below the
anterior inferior iliac spine and directed upwards
and medially into the joint capsule.
Important Radiologic Lines
of Hip Joint Position
Hilgenreiners line: It is a line connecting the
superolateral margins of triradiate cartilage.
Perkins line: It is a vertical line to the Hilgenreiners
line through the lateral rim of acetabulum.

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Atlas on X-ray and Angiographic Anatomy

Figs 6.1A to D: CT scan multiplanar reconstructed (MPR) images of pelvis with hip joints: (A) Anterior view; (B) As seen from
below; (C) Oblique view; (D) MRI-T1WI hip joint coronal section

Acetabular angle: It is the angle that lies between


Hilgenreiners line and a line drawn from supero
lateral ossified edge of triradiate cartilage.
Acetabular angle > 30o suggest hip joint dysplasia.
Shentons curved line: It is an arc formed by inferior
surface of superior pubic ramus and medial
surface of proximal femur to the level of lesser
trochanter.
Center-edge angle: It is the angle formed by a
line drawn from the acetabular edge to the
center of femoral head, a second line is drawn
perpendicular to the first line thereby connecting

the centers of femoral heads. Radiologically, if this


angle is less than 25o it suggests femoral head
instability.
THIGH
On plain X-rays, the thigh is appreciated on both
AP, lateral and posterior oblique views (Figs 6.6 to
6.9). The thigh comprises of the femur along with
soft tissues (mainly muscle groups).
The femur has a long shaft, the proximal
end of femur has a rounded head and a slender
neck, the distal end of femur at the knee has

Lower Limb

Fig. 6.2: X-ray pelvis with both hip jointsAP view

Fig. 6.3: X-ray right hip jointAP view

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Atlas on X-ray and Angiographic Anatomy

Fig. 6.4: X-ray hip jointPosterior oblique view

Fig. 6.5: X-ray hip joint with pelvisLateral view

Lower Limb
two condyles that articulate with the upper end
of tibia. The head of femur has the fovea on
its medial surface where the ligament of head
attaches to it. The neck of femur has an angle of
around 125 with the shaft of femur and slightly
tilted forwards. The greater trochanter projects
upwards and backwards from the junction of the
neck and shaft of femur, it is slightly pyramidal
in shape with its apex pointed outwards. The
lesser trochanter arises from the lowermost part
of the neck of femur on the posterior aspect of
femur. Between the greater trochanter and lesser
trochanter anteriorly lies the intertrochanteric
line, posteriorly lies the intertrochanteric crest.
The shaft of femur is long and gives attachment

53

to muscles. At the lower end of femur are two


condyles, lateral condyle and medial condyle.
Between these condyles lies the intercondylar
fossa.
The muscle groups of the thigh provide
support to the hip and knee joints and help in
movement. The main muscle groups areThe
anterior, medial, gluteal region, posterior thigh
muscles and iliotibial tract on lateral aspect.
The muscles of the anterior thigh are the
iliopsoas and quadriceps femoris. The iliopsoas
muscle group consists of the psoas major, iliacus,
tensor fascia lata and sartorius.
The main action of this group of muscles at the
hip is flexion and medial rotation.

Figs 6.6A to E: (A) CT scan topogram of thigh with both hip joints; (B to D) CT scan multiplanar reconstructed (MPR) images of
femur with hip joint; (B) Anterior view; (C) Lateral view; (D) Posterior view; (E) MRI-T1WI coronal section of femur with hip joint

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Atlas on X-ray and Angiographic Anatomy

Fig. 6.7: X-ray thigh (femur)AP view

Fig. 6.8: X-ray thigh (femur)Lateral view

Lower Limb

55

Fig. 6.9: X-ray thigh (femur)Postero-oblique view

The quadriceps femoris muscles comprise of


the rectus femoris, vastus lateralis, vastus medialis
and vastus intermedius muscles. The quadriceps
group of tendons fuse together and attach to the
base of the patella. The patella in turn through the
patellar tendon is attached to the tibial tuberosity.
The main action of quadriceps group of muscles is
extension at knee joint.
The muscles of the medial aspect of thigh
are the pectinius, adductor longus, adductor
brevis, adductor magnus, gracialis and obturator
externus muscles. The action at the hip is
adduction and flexion movements.
The muscles of the gluteal region are gluteus
maximus, gluteus medius, gluteus minimus, pyri
formis, obturator internus, gemelli (superior and

inferior), and quadratus femoris. These muscles


assist in extension, abduction, medial and lateral
rotation at the thigh.
The muscles of the posterior thigh are hamstring
musclesSemitendinosus, semimembranosus and
biceps femoris muscles. Their main action is
extension, flexion and medial rotation of the leg.
KNEE JOINT
On plain X-rays, the knee joint is appreciated in
AP and lateral views (Figs 6.10 to 6.12). Additional
views like the patellar (skyline) view may be
necessary to visualize the patellofemoral joint
spaces (Fig. 6.13). The knee joint is a modified
pivotal hinge joint. It is the largest synovial joint

Atlas on X-ray and Angiographic Anatomy

56

in the body. The synovial fluid is around 0.5 ml


normally to prevent friction in joint spaces. The
knee joint consists of two condylar joints between
the femur and the tibia and a saddle joint between
the patella and the femur, the capsule of knee joint
is attached to the articular margins of these bones.
The intercondylar eminence of the tibia prevents
sideway slipping of femur on tibia. The ligaments
and muscles make knee a very stable joint. The
medial and lateral articular surfaces of the femur
and tibia are asymmetrical. The distal surface
of the medial condyle of the femur is narrower

and more curved than the lateral condyle. The


articular surface of lateral tibia is almost circular
whereas the medial surface is oval in shape. The
articular surface of patella has a larger lateral and
a smaller medial surface.
The knee joint is stabilized by the surrounding
muscles and their tendons. Anteriorly, it is the
quadriceps tendon. This broad tendon attaches
to and surrounds the patella and continues
as the patellar ligament, which is attached to
the tuberosity of the tibia. Posteriorly are the
popliteus, plantaris and medial and lateral heads

Figs 6.10A to D: CT scan (A and B) multiplanar reconstructed images of knee joint: (A) Anterior view; (B) Lateral view, MRIT1WI images; (C) Coronal section; (D) Sagittal section

Lower Limb

Fig. 6.11: X-ray knee jointAP view

Fig. 6.12: X-ray knee jointLateral view

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Atlas on X-ray and Angiographic Anatomy

Fig. 6.13: X-ray knee joint skyline, view for patella

of gastrocnemius. Laterally are the tendons of


the biceps femoris and popliteus. Medially are
the sartorius, gracialis, semitendinosus and
semimembranosus muscles.
The ligaments of knee joint include the cruciate
ligaments, arcuate popliteal ligament, the oblique
popliteal ligament, fibular collateral ligament and
the tibial collateral ligament. The patellar ligament
is a central band of the tendon of quadriceps
femoris muscles; it is about 8 cm long. Proximally,
it attaches to the anterior and posterior surfaces of
patella including the apex. Distally it attaches to
the smooth area of tibial tuberosity.
The menisci are called semilunar cartilages.
These are cresenteric disks of fibrocartilage that
act as shock absorbers. The menisci are avascular
structures comprising mainly of collagenous
fibrous tissue attached to the tibial plateau.
There are two menisci, the lateral and the medial
meniscus.
Movements at the knee joint are the flexion
(normal range 150o), extension (normal range
30o), medial and lateral rotation (normal 510o).

Blood supply to knee joint is by anastomosis of


the genicular branches of the popliteal artery. The
middle genicular branches supply the cruciate
ligaments.
Bursae of knee joint reduce the friction
between tendon and bones. The suprapatellar
bursa lies between the femur and the quadriceps
femoris. The prepatellar bursa lies between the
skin and the patella. The infrapatellar bursa
lies between the skin and the tibial tuberosity.
The deep infrapatellar bursa lies between the
patellar ligament and the upper part of the tibia.
The semimembranosus bursa lies between the
medial collateral ligament and the tendon of the
semimembranous.
LEG
On plain X-rays, the tibia and fibula are
appreciated on both AP and lateral views. Either
the ankle joint or the knee joint is included to
provide the radiologist a landmark to assess and
report the abnormality on plain X-rays.

Lower Limb
The tibia is a long bone on the medial aspect
of leg; it has a larger upper end at the knee joint
and a rather smaller lower end at the ankle joint.
At the knee joint the upper end of tibia has a
superior articular surface (plateau-like surface),
and divided by the intercondylar eminence
into two unequal surfaces (medial and lateral
surfaces). The medial surface is larger than the
lateral surface, they articulate with the medial and
lateral condyles of femur. The shaft of tibia is more
triangular in shape and provides attachment
to the muscle of knee joint and leg. The lower
end of tibia has a prominence called the medial
malleolus on its medial side at the ankle joint. The
tibia articulates with the talus at the ankle joint
(talocrural joint).
The fibula is a slender long bone on the lateral
aspect of leg. The head of fibula has a facet to
articulate with the upper end of tibia. The shaft has
surfaces for muscle attachments. The common
peroneal nerve run close to the neck of fibula and
in case of fracture to the neck of fibula the nerve

59

can get injured. The lower end of fibula at ankle


has a prominence on its lateral aspect called as
the lateral malleolus (Figs 6.14 to 6.16).
Soft tissues of the leg are mostly made
of muscles. These muscles are grouped into
compartments for description purposes.
The anterior group of muscles comprises
of tibialis anterior, extensor hallucis longus,
extensor digitorum longus and peroneus tertius
muscles. Their main action is dorsiflexion at
ankle, inversion of foot, eversion of foot, extend
the great toe and the four lateral digits.
The lateral group of muscles comprises
of peroneus longus muscle, peroneus brevis
muscles. Their main action is eversion of the foot
and plantar flexion of the ankle.
The posterior group of muscles are classified
into two subgroupsSuperficial group and deep
group of muscles. The superficial group comprises
of gastrocnemius, soleus and plantaris muscles.
Its main action is to assist in plantar flexion of
ankle and flexion at knee joint. The deep group

Figs 6.14A to E: CT scan multiplanar reconstructed images of lower leg with ankle: (A) Anterior view; (B) Medial view;
(C) Lateral view; (D) Posterior view; (E) MRI-T1WI coronal section of lower leg

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Atlas on X-ray and Angiographic Anatomy

Fig. 6.15: X-ray leg (tibiofibula)AP view

of muscles comprises of popliteus, flexor hallucis


longus, flexor digitorum longus, tibialis posterior
muscles. Its main action is flexion at knee joint,
flexion at great toe, plantar flexion at ankle, flexion
of lateral four digits and inversion of the foot.
ANKLE JOINT
On plain X-rays, the ankle joint (talocrural joint)
is appreciated on AP and oblique views.
The articular surfaces of the lower ends of tibia
and fibula, the upper ends of talus and calcaneus
constitute the ankle joint (Figs 6.17 to 6.21). The
body weight is transmitted through the tibia to the
talus which distributes anteriorly and posteriorly
within the foot. The muscles and ligaments around

the ankle joint provide stability and movements


possible at the ankle joint.
The ankle joint has two groups of ligaments
The lateral collateral ligaments and the medial
collateral ligaments. These ligaments are strong
fibrous bands and they are extremely important
in the stability of the ankle joint. The lateral
collateral ligament prevents excessive inversion
and comprises of anterior talofibular ligament,
calcaneofibular ligament and posterior talofibular
ligament. The medial collateral ligament or
the deltoid ligament is thicker than the lateral
ligament and spreads in a fan shape manner
to cover the distal end of the tibia and the inner
surfaces of the talus, navicular, and calcaneus.

Lower Limb

61

Fig. 6.16: X-ray leg (tibiofibula)Lateral view

Figs 6.17A to C: CT scan multiplanar reconstructed images of ankle joint: (A) Anterior view; (B) Posterior view; (C) MRI-T1WI
coronal section of ankle joint

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Atlas on X-ray and Angiographic Anatomy

Fig. 6.18: X-ray ankle jointAP view

Fig. 6.19: X-ray ankle jointLateral view

Lower Limb

63

Figs 6.20A to F: CT scan multiplanar reconstructed images of foot with ankle: (A) Medial view; (B) Anterior
view; (C)Posterior view; (D) Lateral view; (E) View from below; (F) MRI-T1WI sagittal section of foot with ankle

Fig. 6.21: X-ray ankle and footLateral view

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Atlas on X-ray and Angiographic Anatomy

Fig. 6.22: X-ray foot showing the location of arches of foot

Fig. 6.23: X-ray footAP view

Lower Limb
The medial collateral ligament or deltoid
ligament includes the tibionavicular ligament,
calcaneotibial ligament, anterior talotibial
ligament and the posterior talotibial ligament.
They prevent abduction and limit plantar flexion
and dorsiflexion of the ankle joint.
Tarsal joints at ankle: comprises of the talocal
caneonavicular joint, talocalcaneal joint and the
calcaneocuboid joint. The main action at these
joints is inversion and eversion at ankle joint.
The talocalcaneonavicular joint is a synovial
joint of the ball and socket type. The ball is formed
by the head of talus; the socket is formed by
the navicular, calcaneus and spring ligament.
The posterior surface of navicular is concave
and articulates with the head of talus which is
convex-shaped. The inferior convexity of head

65

of talus articulates with the calcaneus at the


sustentaculum tali. Between the articular surfaces
of talus with the navicular and calcaneus, the
head of talus articulates with the spring ligament.
The talocalcaneonavicular joint is enclosed in a
single capsule.
The talocalcaneal joint lies behind the talocal
caneonavicular joint.
The calcaneocuboid joint is a synovial joint
between the anterior surface of calcaneus
and the back of the cuboid. The talonavicular
part of talocalcaneonavicular joint and the
calcaneocuboid joint form the midtarsal joint.
Radiological interventions like aspiration of
the ankle joint is possible - from lateral side of
ankle joint, directing the needle in front of the
lateral malleolus and lateral to the tendon of

Fig. 6.24: X-ray footOblique view

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Atlas on X-ray and Angiographic Anatomy

peroneus tertius muscle to enter the joint capsule.


It is also possible to direct the needle from the
medial side of ankle, in front of the medial
malleolus and medial to tibialis anterior muscle
to enter the joint capsule.
FOOT
On plain radiographs, the foot is appreciated on
AP, oblique and lateral views. The tarsal bones
are Navicular, cuboid, cuneiform bones (medial,
intermediate and lateral). The metatarsal bones
articulate with the tarsal bones proximally and
distally they articulate with the phalanges. The
interphalangeal joints are similar to the joints of
hand with capsules and collateral ligaments. The
first tarsometatarsal joint has its own capsule and
synovial membrane, some movements in vertical
plane possible along with the medial longitudinal
arch of foot. The second tarsometatarsal joint

is immobile, in addition its slender metatarsal


shaft makes it prone for injury, it is a commonly
involved site in March fractures. Supporting
mechanisms of the foot are the arches of the
foot namely, medial longitudinal arch, lateral
longitudinal arch and the transverse arch. The
arches are formed by the bony undersurfaces of
the bones of foot with the ligaments and muscles.
Due to the upright posture and bodyweight
transmitted to the foot, these arches help to act
as shock absorbing mechanism and propulsion
to some extent. The medial longitudinal arch is
formed by the undersurfaces of the calcaneus,
talus, navicular, three cuneiform bones and
their three metatarsal bones (Figs 6.20 to 6.24).
The lateral longitudinal arch is formed by
undersurfaces of calcaneus, cuboid, and the two
lateral metatarsal bones. The transverse arch
is formed by the undersurfaces of bases of five
metatarsal bones, cuboid and cuneiform bones.

7
CHAPTER

Angiograms

CEREBRAL CIRCULATION
Normal Intracranial Arterial System
Branches of the aortic arch: Brachiocephalic
artery, the left common carotid artery, and left
subclavian artery (Flow chart 7.1).
The extracranial carotid arteries: The right
common carotid artery usually arises from the
bifurcation of the brachiocephalic artery. The
left common carotid artery arises from the aortic
arch distal to the origin of brachiocephalic artery.
Both the right and left common carotid arteries
bifurcate into the external and internal carotid
arteries on either side at C4- C5 level.
Branches of the external carotid artery: Superior
thyroidal artery, ascending pharyngeal artery,
lingual artery, occipital artery, facial artery,
posterior auricular artery, internal maxillary
artery and superficial temporal artery.
The internal maxillary artery branches are
superficial temporal artery, middle meningeal
artery, accessory meningeal artery and anterior
deep temporal artery.
The superior thyroid artery supplies the thyroid
and larynx. The ascending pharyngeal artery
supplies the nasopharynx and tympanic cavity. The
lingual artery supplies the tongue, floor of the mouth
and submandibular gland. The occipital artery
supplies the scalp and upper cervical musculature.

Facial artery branches supply the palate, pharynx,


orbit, face and important anastomosis with other
external carotid artery branches.
The superficial temporal artery and posterior
auricular arteries supply the scalp, buccal region
and ear structures. The internal maxillary artery
gives vascular supply to temporalis muscles,
meninges, paranasal sinuses and mandible.
While traversing the foramen spinosum, the
middle meningeal artery may supply a branch,
through the petrous bone, to the facial nerve.
Internal carotid artery: The intracranial portions
are petrous and cavernous portions.
Petrous portion of internal carotid artery: The ICA
while passing through the carotid canal, gives of
the Vidian artery which anastomoses with the
basilar artery of posterior circulation.
Cavernous
portion
of
internal
carotid
artery: It gives off the following branches
Meningohypophyseal trunk, inferolateral trunk,
ophthalmic artery, posterior communicating
artery, anterior choroidal artery, anterior and
middle cerebral arteries.
The ophthalmic artery is the first branch of the
supraclinoid portion of the ICA and thus serves as
a demarcation between the intracavernous and
subarachnoid segments of the ICA.
The posterior communicating artery (PCOM)
connects the ICA with vertebrobasilar circulation

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Atlas on X-ray and Angiographic Anatomy


Flow chart 7.1: Cerebral circulation

Flow chart 7.2: Internal carotid artery branches

(P1 segment of ipsilateral posterior cerebral


artery). The posterior communicating artery
supplies the thalamus, hypothalamus and optic
chiasm.
The anterior choroidal artery originates
from ICA, it supplies the choroid plexus of
lateral ventricle and anastomoses with lateral
posterior choroidal artery. The occlusion of
anterior choroidal artery can cause hemiplegia,

hemiparesis, homonymous hemianopia as its


minute perforators supply the internal capsule,
thalamus, basal ganglia (Flow chart 7.2).
Circle of Willis: It is an important collateral
system at the base of the brain surrounding the
optic chiasm and pituitary stalk. It comprises
ofthe basilar artery bifurcation (basilar tip), P1
segments of posterior cerebral artery proximal

Angiograms
segments, paired distal ICAs, paired posterior
communicating arteries (PCOM), paired
proximal A1 segments of ACAs and the anterior
communicating artery (ACOM). This vascular ring
is complete only in about 25 percent of cases (Fig.
7.1). Perforating vessels arising from the circle of
Willis include branches to the thalamus, limbic
system, reticular activating system, cerebral
peduncles, posterior limb of internal capsule
and oculomotor nerve nucleus. The recurrent
artery of Heubner originates from the A1 segment
to supply the anterior limb of internal capsule,
portion of the globus pallidus and head of the
caudate nucleus.
The anterior cerebral artery: The most proximal
segment is the A1 segment, its origin at the
terminal ICA to the anterior communicating
artery (ACOM). A2 segment is the portion distal

69

to the ACOM and extends into the distal ACA.


The A2 segment supplies the head of the caudate
nucleus, portions of the globus pallidus, anterior
limb of the internal capsule, anterior two-thirds of
medial cerebral cortex. The main branches of the
A2 segment are the orbitofrontal and frontopolar
arteries. The ACA bifurcates into the pericallosal
and callosomarginal arteries (Figs 7.2 to 7.6).
The middle cerebral artery: The most proximal
segment is M1 segment. It extends from ICA
bifurcation to the insular cortex (island of Reil).
M2 segment is the course of the artery in the
insular cortex and sylvian fissure and it bifurcates
into anterior and posterior cortical branches. The
branches of the anterior cortical M2 segment
are lateral orbitofrontal, operculofrontal and
central sulcus arteries. The central sulcus arteries
are called precentral (prerolandic) and central
(rolandic) branches which supply motor and
sensory cortical strips. The branches of posterior
cortical M2 segment are the anterior and posterior
parietal, angular and posterior temporal arteries
(Figs 7.2 to 7.6).
The Vertebrobasilar Circulation

Fig. 7.1: Circle of Willis


Abbreviations: ACA: Anterior cerebral artery; ACom: Anterior
communicating artery; MCA: Middle cerebral artery; ICA:
Internal carotid artery; PCom: Posterior communicating
artery; PCA: Posterior cerebral artery; SCA: Superior- internal
carotid artery; Basilar: Basilar artery; AICA: Anterior cerebral
artery; VA: Vertebral artery; ASA: Anterior spinal artery

Vertebral arteries: The vertebral arteries originate


from the subclavian arteries. One of the vertebral
arteries may be dominant in size as compared to
the other. Each vertebral artery passes through the
transverse foramen of C6 and passes superiorly
through the transverse foramina of C5 to C1, then
it courses posteriorly around the atlanto-occipital
joint and ascends through the foramen magnum,
penetrating the atlanto-occipital membrane and
dura. It gives off the posterior-inferior cerebellar
artery and the anterior spinal arteries. It then
travels superiorly around the lateral aspect of
medulla to join with the contralateral vertebral
artery to form the basilar artery at pontomedullary
junction.
The posterior inferior cerebellar artery (PICA)
provides branches to the medulla, the occlusion of
which can cause the lateral medullary syndrome
or pyramidal tract ischemia. Lateral medullary

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Atlas on X-ray and Angiographic Anatomy

Fig. 7.2: Angiogram of right anterior cerebral circulation arterial phaseAP view

Fig. 7.3: Angiogram of right anterior cerebral circulation arterial phaseLateral view

Angiograms

Fig. 7.4: Angiogram of right anterior cerebral circulation arterial phaseLateral view

Fig. 7.5: Angiogram right anterior cerebral circulation capillary phaseAP view

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Atlas on X-ray and Angiographic Anatomy

Fig. 7.6: Angiogram of right anterior cerebral circulation capillary phaseLateral view

Fig. 7.7: Angiogram of right anterior cerebral circulation venous phaseAP view

Angiograms

73

Fig. 7.8: Angiogram of right anterior cerebral circulation venous phaseLateral view

syndrome consists of ipsilateral Horners


syndrome, facial sensory loss, pharyngeal/
laryngeal paralysis, contralateral pain and
temperature sensory loss in the limbs and trunk.

Superior cerebellar artery provides vascular


supply to the cerebellar peduncles, vermis,
dentate nucleus, lateral pontine structures,
spinothalamic tracts and sympathetic.

Anterior spinal arteries: It originates from the


vertebral arteries distal to the posteroinferior
cerebellar artery origin, they course inferomedially
to join with their contralateral artery along the
anterior cord.

Posterior cerebral arteries: Arise from the basilar


artery at the level of pontomesencephalic junction, superior to the oculomotor nerve and
tentorium. The proximal PCA is divided into P1
and P2 segments at the junction of the PCA with the
posterior communicating artery. A filling defect is
frequently seen at the transition between P1 and
P2 during frontal vertebral artery angiograms
due to the inflow of unopacified blood from the
ipsilateral posterior communicating artery. The
proximal P2 segment gives rise to the posterior
thalamoperforating and thalamogeniculate
arteries which supply the posterior portions
of the thalamus, geniculate bodies, choroid
plexus of third and lateral ventricles, posterior
limb of internal capsule, optic tract and small

Basilar artery: The two vertebral arteries


join together to form the basilar artery at the
pontomedullary junction. The basilar artery
courses anterosuperiorly over the ventral pons. It
gives off small pontine perforating branches which
supply the pyramidal tracts, medial lemnisci, red
nuclei, respiratory centers and nuclei for cranial
nerves (III, VI, XII). The basilar artery gives off the
anterior inferior cerebellar artery and the superior
cerebellar artery. The labyrinthine artery is a
branch of the anterior inferior cerebellar artery.

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branches to the cerebral peduncles. The other


branches of posterior cerebral artery are the
splenial artery, anterior and posterior temporal
branches, parietooccipital artery. The distal PCA
courses posteriorly around the brainstem in the
ambient cistern, travelling more medially in the
quadrigeminal plate cistern. The distal calcarine
cortical branches converge towards the midline
but are separated by falx, on Townes projection
vertebral angiogram (Figs 7.9 to 7.12).
NORMAL INTRACRANIAL
VENOUS SYSTEM
Cerebral cortical veins: Multiple cortical veins
drain towards the superior sagittal sinus. The
superficial middle cerebral vein which lies
in the sylvian fissure may have anastomotic
communication with the deep cerebral venous
system, the facial veins and the extracranial
pterygoid venous plexus. Posteriorly the
superficial middle cerebral vein communicates
with the veins of Trolard and Labbe towards the
ipsilateral transverse sinus. The veins of Trolard

and Labbe cross the subdural space to enter the


dural sinuses.
Deep cerebral veins: These are the paired septal
veins which run close to midline beside septum
pellucidum. The paired thalamostriate veins pass
along the floor of the lateral ventricles between
the body of caudate nucleus and thalamus. The
internal cerebral veins run posteriorly in the
roof of third ventricle. The paired basal veins of
Rosenthal are formed by the confluence of deep
middle and anterior cerebral veins on the ventral
surface of brain. The basal veins then coalese
posteriorly with the internal cerebral veins to
form the vein of Galen (Figs 7.7 and 7.8). This vein
of Galen travels in the midline for about 12 cm
under the splenium of corpus callosum, it then
joins the inferior sagittal sinus in the posterior
fossa to form the straight sinus at the junction of
falx and tentorial incisura (Flow chart 7.3).
The posterior fossa veins: These are the anterior
pontomesencephalic veins, the precentral veins,
superior and inferior vermian veins. The anterior

Fig. 7.9: Angiogram of posterior cerebral circulation arterial phaseAP view

Angiograms

Fig. 7.10: Angiogram of posterior cerebral circulation arterial phaseLateral view

Fig. 7.11: Angiogram of posterior cerebral circulation capillary phaseAP view

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Fig. 7.12: Angiogram of posterior cerebral circulation capillary phaseLateral view

pontomesencephalic vein runs along the ventral


surface of pons, it drains either into the basal
vein of Rosenthal or posterior mesencephalic
vein (Figs 7.13 and 7.14). The precentral veins run
along the posteriorly in the roof of fourth ventricle
and drains into the vein of Galen (Flow chart 7.4).
Dural sinuses: The dura mater which envelops the
central nervous system has two layers that form
the reflections like the falx cerebri, tentorium and
falx cerebelli. The layers of dura separate to form
venous drainage channels or dural sinuses for the
brain. Some of them anastomose with the veins of
scalp through the emissary veins. The main dural
sinuses found are the superior sagittal sinus,
inferior sagittal sinus, occipital sinuses, paired
transverse sinuses and paired cavernous sinuses
(Figs 7.7 and 7.8).
The superior sagittal sinus travels along the
superior margin of falx cerebri, it continues

posteriorly and inferiorly in a cresenteric course to


the junction point between the falx and tentorium
containing the confluence of sinusesThe torcular
Herophili near the occipital protuberance.
The inferior sagittal sinus is found within
the lower edge of falx between the cerebral
hemispheres. It drains posteriorly to join with
the vein of Galen forming the straight sinus. The
straight sinus drains posteriorly in midline into
the torcular herophili.
The occipital sinuses are of variable size, are
seen to course superomedially within the dura of
the posterior fossa, just lateral to foramen magnum
and drains towards the torcular herophili.
The paired transverse sinus follows a
cresenteric course within the periphery of the
tentorium, laterally and anteriorly from the
torcula. The transverse sinuses receive drainage
from the inferior cerebral veins and vein of Labbe,
it communicates with the cavernous sinuses via

Angiograms

77

Fig. 7.13: Angiogram of posterior cerebral circulation venous phaseAP view

Fig. 7.14: Angiogram of posterior cerebral circulation venous phaseLateral view

the superior petrosal sinuses, which run along the


petrous bone and as it nears the tentorium it is

called the sigmoid sinus which later empties into


the internal jugular vein (Flow chart 7.5).

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Flow chart 7.3: Normal venous anatomy of the brain

Flow chart 7.4: Posterior fossa veins and jugular bulb

Angiograms

79

Flow chart 7.5: Dural sinuses

The paired cavernous sinuses receive venous


drainage from the orbits through the superior
and inferior ophthalmic veins. The jugular bulbs
communicate with the cavernous sinuses by

means of the paired inferior petrosal sinuses. The


inferior petrosal sinuses also interconnect with
those on the opposite side through a clival venous
plexus.

THE THORACIC AORTA


The ascending aorta arises at the aortic root,
from the left ventricle. Immediately above the
aortic root, the ascending aorta bulges to form
the aortic sinuses, the aortic sinuses give rise
to right and left coronary arteries to supply the
heart. The ascending aorta the courses upwards
and continues as the aortic arch. The main
branches of the aortic arch (arch of aorta) are
the brachiocephalic trunk, left common carotid
artery and the left subclavian artery (Figs 7.15

and 7.16). Sometimes the thyroidea ima artery


may arise from the aortic arch. These branches
of aortic arch supply the head, neck, brain and
upper limbs (Flow chart 7.6).
The aortic arch on plain chest X-ray appears
behind the mediastinal structures in midline.
The aortic knuckle or arch at the level of sternal
angle (angle of Louis). Sometimes age-related
calcification may be noted at this site. The arch
of aorta passes above the left bronchus and to

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Fig. 7.15: Outline of the thoracic aorta on chest X-rayPA view. (A) Ascending thoracic aorta curves upwards and at the level
of sternal angle continues as arch of aorta; (B) Arch of aorta curves above the left main bronchus and descends into posterior
mediastinum. It gives off the: 1. Brachiocephalic trunk; 2. Left common carotid artery; 3. Left subclavian artery; (C) At the level
of 4th thoracic vertebra, the arch of aorta becomes the descending thoracic aorta; (D) Descending thoracic aorta in posterior
mediastinum enters the abdominal cavity through the aortic hiatus (12th dorsal vertebra level)

Fig. 7.16: Angiogram showing the thoracic aorta

Angiograms

81

Flow chart 7.6: Thoracic aorta

the left of trachea and esophagus. At the level of


4th thoracic vertebra the arch of aorta courses
downwards as the descending thoracic aorta in
the posterior mediastinum.
The descending thoracic aorta gives off posterior intercostal arteries, 9 in number on either

side. These intercostal arteries pass laterally into


the intercostal spaces. At the level of the aortic
hiatus in diaphragm (at 12th thoracic vertebra),
the descending aorta passes into the abdominal
cavity and continues in the abdomen as the
abdominal aorta.

ABDOMINAL ANGIOGRAPHY
ABDOMINAL AORTA
The abdominal aorta is the continuation of the
thoracic aorta below the diaphragm at T12 vertebral
level. In the abdomen aorta is retroperitoneal in its
course and travels downwards to its bifurcation
at the level of L4 vertebral body. The abdominal
aorta supplies the viscera, peritoneum, gonads
and spine during its course. Its anterior branches
are the celiac arterial trunk, superior mesenteric
artery, inferior mesenteric artery (Fig. 7.17).
Its lateral branches are inferior phrenic artery,
suprarenal arteries, gonadal arteries, lumbar
arteries. Its terminal branches at L4 vertebral level
are the common iliac arteries and the median
sacral artery (Flow chart 7.7).
CELIAC TRUNK
The celiac trunk is the main vascular supply
of the foregut supplying the lower part of the
esophagus to the duodenum; it also supplies the
liver, pancreas and spleen. The celiac trunk arises
at the level of T12 vertebra from the abdominal

aorta and courses forwards until the upper border


of pancreas and terminates into: the left gastric
artery, splenic artery, common hepatic artery (Fig.
7.18). The left gastric artery gives off esophageal
branches, then courses to the right along the lesser
curvature of stomach and gives of branches to the
stomach. The splenic artery courses to the left, is
tortuous and runs in the splenorenal ligament to
the hilum of the spleen. Before giving off terminal
splenic branches it gives off 6-7 short gastric arteries
which course in gastrosplenic ligament and the left
gastroepiploic artery (which supplies the stomach
and omentum).The splenic artery also gives off the
posterior gastric artery during its course to splenic
hilum. The common hepatic artery courses
over the upper border of the pancreas, the main
branches are: right gastric artery, gastroduodenal
artery, small supraduodenal arteries and terminal
branchThe hepatic artery. The right gastric artery
runs forwards in the lesser omentum and to the
left in lesser curvature of stomach to anastomose
with the left gastric artery. The gastroduodenal
artery passes behind the 1st part of duodenum

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Fig. 7.17: Angiogram of abdominal aorta

Flow chart 7.7: Abdominal aorta branches

and at the lower border of duodenum divides


into the right gastroepiploic artery and superior
pancreaticoduodenal arteries. The supraduodenal
arteries are smaller branches arise from the

common hepatic artery. The common hepatic


artery at the porta hepatis divides into the right
and left hepatic arteries to supply the liver (Flow
chart 7.8).

Angiograms

83

Fig. 7.18: Angiogram of celiac arterial trunk

Flow chart 7.8: Celiac arterial trunk (artery of foregut)

SUPERIOR MESENTERIC ARTERY


The superior mesenteric artery is the artery of
mid- gut and supplies the gut from the bile duct
entrance to the splenic flexure of colon. This

artery arises from the abdominal aorta at the level


of lower border of L1 vertebra. It courses behind
the body of pancreas, later it lies anterior to the
left renal vein, uncinate process of pancreas and
third part of duodenum. Its main branches are

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Fig. 7.19: Angiogram of superior mesenteric artery

the inferior pancreaticoduodenal artery, jejunal


and ileal branches, ileocolic artery, right colic
artery, middle colic artery (Fig. 7.19). The inferior
pancreaticoduodenal artery is the first branch of
superior mesenteric artery. It further divides into
anterior and posterior branches to supply the
head of pancreas and adjacent duodenum. The
jejunal and ileal branches pass between the two
layers of the mesentery and create a network of
arteries along the jejunum and ileum to supply
the same. The ileocolic artery courses down to
the base of mesentery into the right iliac fossa
and divides into superior and inferior branches.
The superior branch courses along the ascending
colon to anastomose with the right colic artery.
The inferior branch courses down to the ileocolic
junction and gives off the anterior and posterior
cecal arteries, an appendicular artery and an
ileal artery that anastomoses with the terminal
branches of superior mesenteric artery. The
right colic artery course downwards into the
right infracolic compartment and divides into

the ascending and descending branches. The


ascending branch courses along the ascending
colon upwards to anastomose with a branch from
middle colic artery at hepatic flexure of colon. The
descending branch courses downwards along the
ascending colon to anastomose with a branch
from the ileocolic artery. The middle colic artery
arises from the superior mesenteric artery at the
lower border of neck of pancreas. It courses into
the transverse mesocolon and on the right side
of transverse colon divides into two branches
The right and left branches. The right branch
anastomoses with the ascending branch of right
colic artery. The left branch anastomoses with a
branch of the left colic artery (Flow chart 7.9).
INFERIOR MESENTERIC ARTERY
It is also called as the artery of hindgut. It arises as
an anterior branch of abdominal aorta at the level
of L3 vertebra and courses downwards in lower
abdomen. Its branches are the left colic artery,

Angiograms
sigmoidal arteries and superior rectal artery. These
branches supply the descending colon, sigmoid
colon and upper rectum. The marginal artery

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of Drummond is formed by an interconnecting


anastomotic network of the branches along the
mesenteric border of large bowel. The marginal

Flow chart 7.9: Superior mesenteric arteriogram (artery of midgut)

Fig. 7.20: Angiogram of right renal artery early arterial phase

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Atlas on X-ray and Angiographic Anatomy

Fig. 7.21: Angiogram of right renal artery late arterial phase

Fig. 7.22: Angiogram of right renal artery nephrogram phase

Angiograms

Fig. 7.23: Angiogram of renal arteries in pyeloureterogram phase

Flow chart 7.10: Renal artery angiogram

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artery of Drummond is crucial to maintain the


vascular supply of large bowel.
RENAL ARTERY
Both the renal arteries arise at right angles to the
abdominal aorta at the level of L2 vertebra. The left
artery is shorter than the right. Each renal artery gives
off small suprarenal and ureteric branches. The renal
arteries course behind the pancreas and the renal vein
to reach the hilum of the kidney on either side (Figs
7.20 to 7.23). At the hilum the renal artery branches
into anterior and posterior divisions. Each kidney is

subdivided into five segments based on arterial supply.


The anterior arterial division supplies the apical,
upper, middle and lower segments while the posterior
arterial division supplies the posterior segment (Flow
chart 7.10). There is no collateral circulation between
these segmental arteries. The segmental arteries are
accompanied by their corresponding veins. Each
segmental artery divides into lobar artery, interlobar
artery, arcuate artery and finally into interlobular
arteries. The segmental veins communicate with each
other and at the hilum they join to form the renal vein.
At the hilum of each kidney the structures from front
to back are vein, artery and ureter.

UPPER LIMB ANGIOGRAPHY


ARTERIAL SYSTEM
The axillary artery is the main artery supplying the
upper extremity. It is a continuation of the third part
of the subclavian artery. The axillary artery begins
at the outer border of the first rib and continues
until the lower border of teres major muscle (Fig.
7.24). Beyond the teres major muscle the axillary
artery continues into the arm as the brachial
artery (Flow chart 7.11 and 7.12). The axillary
artery for description purposes is subdivided into
three parts by the pectoralis minor muscle which
crosses middle 1/3rd the axillary artery. The 1st
part of axillary is proximal to pectoralis muscle; it
gives off the superior thoracic artery. The 2nd part
of axillary artery is beneath the pectoralis minor
muscle, it gives off the lateral thoracic artery and
the thoracoacromial artery. The 3rd part of axillary
artery is distal to the pectoralis minor muscle; it
gives off the subscapular artery, anterior humeral
circumflex artery and the posterior circumflex
artery.
The brachial artery is continuation of axillary
artery in arm. The artery is superficial in its
course and lies beneath the deep fascia in the
anteromedial aspect of arm. Its branches are: the

profunda brachii artery, middle collateral artery,


radial collateral artery, superior ulnar collateral
artery, inferior ulnar collateral artery, muscular
branches to flexor muscles and nutrient artery to
humerus (Figs 7.25 and 7.26).
The radial artery originates as a terminal
branch of the brachial artery at the cubital fossa.
It runs deep to the brachioradialis muscle on the
lateral aspect of forearm and at the wrist joint it
courses in the anatomical snuff box and forms
the deep palmar arch. The radial artery gives
small muscular branches in forearm, the radial
recurrent artery and a superficial branch near the
radiocarpal joint (Flow chart 7.13). The princeps
pollicis artery is a branch of radial artery in hand,
it divides into two smaller branches that run
laterally along the thumb (Figs 7.27 and 7.28).
The ulnar artery arises as a terminal branch of
the brachial artery at cubital fossa. It courses on
the medial aspect of forearm deep to the flexor
muscles. The ulnar artery gives off the anterior
and posterior ulnar recurrent arteries in proximal
forearm and also a few muscular branches along
its course in forearm. The ulnar artery passes
superficial to the flexor retinaculum at the wrist
joint and continues as the superficial palmar arch

Angiograms

Fig. 7.24: Angiogram showing subclavian artery and axillary artery

Fig. 7.25: Angiogram showing brachial artery

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Fig. 7.26: Angiogram showing radial and ulnar arteries

Fig. 7.27: Angiogram showing ulnar artery and anterior interosseous artery

Angiograms
in the hand. A deep branch of the ulnar artery in
hand anastomoses with the deep palmar arch to
maintain collateral circulation.
The common interosseous artery is a branch
of the ulnar artery close to cubital fossa. It divides
into the anterior and posterior interosseous
branches distal to the radial tubercle and supplies
the muscles of the forearm (Figs 7.27 and 7.28).
The superficial palmar arch is a direct continuation of the ulnar artery in the hand, it is joined
on its lateral side by the superficial branch of
radial artery to complete the superficial palmar
arch.
The deep palmar arch is a direct continuation
of the radial artery, it is joined on its medial side
by the deep branch of ulnar artery to complete the
deep palmar arch (Fig. 7.29).
The dorsal carpal arch is formed by both the
radial and ulnar arteries within the fascia on
dorsum of hand.

91

Venous System
The veins of the upper extremity can be classified
into the superficial veins and the deep veins. The
superficial veins are digital veins, metacarpal
veins, cephalic veins, basilic vein and median
vein. The deep veins are the venae comitantes of
radial and ulnar arteries, volar arches of hand,
brachial vein, axillary vein and subclavian vein.
Superficial Veins
The digital veins are subclassified into dorsal and
volar digital veins. The dorsal digital veins pass
along the sides of the fingers and are joined to one
another by oblique communicating branches.
They have an ulnar and radial network of veins on
either side. A communicating branch frequently
connects the dorsal venous network with the
cephalic vein about the middle of the forearm. The
volar digital veins on each finger are connected to

Fig. 7.28: Angiogram showing superficial palmar arch

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Atlas on X-ray and Angiographic Anatomy

Fig. 7.29: Angiogram showing deep palmar arch

the dorsal digital veins by oblique intercapitular


veins. These volar digital veins drain into a venous
plexus which is situated across the front of the
wrist. The dorsal digital veins from the adjacent
sides of the fingers unite to form three dorsal
metacarpal veins. They have an ulnar and radial
network of veins on either side. The radial part of
the venous network is continued into the forearm
as the cephalic vein. The ulnar part of the network
is continued into forearm as the basilic vein.
The cephalic vein continues from the radial
part of the dorsal venous network. It runs along
the radial border of the forearm. The cephalic vein
then ascends in front of the elbow in the groove
between the brachioradialis and the biceps
brachii muscles. In the upper third of the arm it
passes between the pectoralis major muscle and
deltoid muscle. It pierces the coracoclavicular
fascia and joins the axillary vein just below the
clavicle.

The basilic vein is formed from the ulnar part


of the dorsal venous network. It travels along the
ulnar side of the forearm and in the arm it lies
along the medial border of the biceps brachii
muscle. It perforates the deep fascia in the middle
of the arm and continues on the medial side of
the brachial artery to the lower border of the teres
major muscle, it then courses in the axilla as the
axillary vein.
The median antibrachial vein drains the
venous plexus on the volar surface of the hand. It
travels on the ulnar side of the front of the forearm
and joins with the basilic vein.
Deep Veins
The deep veins of the hand are the common
volar digital veins, volar metacarpal veins, dorsal
metacarpal veins. They unite in the hand to join
the radial veins and the superficial veins at the
dorsum of the wrist (Flow chart 7.14).

Angiograms

93

Flow chart 7.11: Axillary artery

Flow chart 7.12: Brachial artery

The venae comitantes of the radial and ulnar


are the deep veins of the forearm, they unite in
front of the elbow to form the brachial veins.
The brachial veins are placed one on either
side of the brachial artery, receiving tributaries
corresponding with the branches given off from that
vessel; near the lower margin of the subscapularis
muscle, they join the axillary vein. The deep veins
have numerous anastomoses, not only with each
other, but also with the superficial veins.
The axillary vein it begins at the lower border
of the teres major muscle, as the continuation of

the basilic vein and ends at the outer border of


the first rib as the subclavian vein. At the lower
border of the subscapularis muscle it receives the
brachial veins. The cephalic vein joins the axillary
vein close to its termination.
The subclavian vein is the continuation of
the axillary vein, extends from the outer border
of the first rib to the sternal end of the clavicle,
where it unites with the internal jugular to form
the innominate vein. It usually has a pair of
valves, which are situated around 2.5 cm from its
termination.

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Flow chart 7.13: Radial artery and ulnar artery

Flow chart 7.14: Upper limb venous system

Angiograms

95

LOWER LIMB ANGIOGRAPHY


ARTERIES
The abdominal aorta divides into a pair of
common iliac arteries at the level of the last
lumbar vertebra. The common iliac arteries then
divide into internal iliac and external iliac arteries
(Fig. 7.30). The external iliac artery descends along
the medial border of psoas major muscle and at
the midinguinal point enters the thigh region. The
midinguinal point is a point midway between the
anterior superior iliac spine and the symphysis
pubis (Flow chart 7.15).
The common femoral artery is the direct
continuation of the external iliac artery in the

thigh. The common femoral artery lies medial


to the common femoral vein in femoral canal
and in upper thigh region gives off the deep
profunda femoris artery which is the major artery
of the thigh. The other small branches of common
femoral artery are the superficial circumflex iliac
artery, superficial epigastric artery, superficial
external pudendal artery (Flow chart 7.16) and
the deep external pudendal artery (Fig. 7.31).
The profunda femoris artery gives off the
medial circumflex femoral artery, lateral femoral
circumflex femoral artery and four small
perforating branches to muscles. The medial

Fig. 7.30: Angiography of lower limb (abdominal aorta at its bifurcation)

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Flow chart 7.15: Lower limb arterial system

circumflex artery gives off the ascending and


descending branches and a horizontal branch.
The lateral circumflex femoral artery gives off
the ascending and descending branches and a
transverse branch (Fig. 7.32).
The superficial femoral artery is a direct continuation of the common femoral artery in the mid
and lower thigh region and accompanies the
superficial femoral vein. The superficial femoral
artery descends on the medial side of thigh and
enters the adductor canal (Fig. 7.33).
The popliteal artery is the continuation
of superficial femoral artery after exiting the
adductor hiatus in popliteal fossa. It gives off
the muscular branches two sural branches and
five genicular branches. The genicular branches
are superior and inferior lateral branches,
superior and inferior medial branches and single

Flow chart 7.16: Superficial femoral artery and profunda femoris artery

Angiograms

Fig. 7.31: Angiography of lower limb (external iliac and common iliac artery)

Flow chart 7.17: Popliteal artery

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middle branch. These genicular branches form


anastomoses around the knee joint (Flow chart
7.17). The popliteal artery divides into a smaller
branchthe anterior tibial artery and the larger
branch is the posterior tibial artery (Fig. 7.34).
The anterior tibial artery is a branch of
popliteal artery. In the leg the anterior tibial artery
enters the extensor compartment near the upper
border of interosseous membrane and courses
downwards towards the ankle. At the ankle, the
anterior tibial artery continues as the dorsalis
pedis artery of the foot (Figs 7.34 to 7.37).
The posterior tibial artery is considered as a
direct continuation of the popliteal artery and
it enters the posterior compartment of leg and
courses downwards. Behind the medial malleolus
the posterior tibial artery divides into medial and
lateral plantar arteries.
The dorsalis pedis artery runs forwards to the
base of first intermetatarsal space and passes

down into the sole, where it joins the lateral


plantar artery to complete the plantar arch. The
first dorsal metatarsal artery is a branch of the
dorsalis pedis artery before it enters the sole.
VENOUS ANATOMY
The veins are classified into three systemsThe
deep veins, superficial veins and perforator veins.
The superficial veins are the great saphenous vein,
short saphenous vein.The deep veins are femoral
vein, popliteal vein, anterior tibial vein, posterior
tibial veins and peroneal vein. The perforator
veins are the veins connecting the superficial
veins with deep veins and contain valves in their
walls to prevent backflow of blood and assist in
maintaining the superficial-to-deep direction of
the blood flow.
The great saphenous vein is a large superficial
vein of the lower extremity. It originates from
the dorsal venous arch of the foot. It courses

Fig. 7.32: Angiography of lower limb (external iliac and common iliac artery)

Angiograms

99

Fig. 7.33: Angiography of lower limb (superficial femoral artery)

upwards anterior to the medial malleolus and


continues on the medial side of leg. At the knee,
the great saphenous vein lies over the posterior
border of medial epicondyle of femur. The great
saphenous vein travels medially in lower thigh
and then courses anteriorly in upper thigh to
pierce the fascia lata; this opening is called the
saphenous opening. The great saphenous vein
joins the femoral vein, this junction is called
the saphenofemoral junction. The tributaries
of the great saphenous vein are many, at the
ankle it receives the medial marginal vein, it also
communicates with the small saphenous vein,
the femoral vein, anterior and posterior tibial

veins. In the upper thigh the great saphenous vein


receives the tributaries from superficial epigastric,
superficial iliac circumflex and superficial
external pudendal vein (Flow chart 7.18).
The small saphenous vein is a superficial vein
in posterior leg. It originates from the lateral end
of dorsal venous arch. It courses posterior to the
lateral malleolus and continues upwards on the
lateral aspect of leg. It passes between the heads
of gastrocnemius muscle and drains into the
popliteal vein at the knee.
The superficial femoral vein is a part of the deep
venous system of lower extremity. As the popliteal
vein exits the adductor canal and enters the thigh

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Fig. 7.34: Angiography of lower limb (popliteal artery)

Fig. 7.35: Angiography of lower limb (popliteal artery at bifurcation)

Angiograms

Fig. 7.36: Angiography of lower limb (tibial and peroneal arteries)

Fig. 7.37: Angiography of lower limb (capillary phase in leg)

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Flow chart 7.18: Lower limb venous system

region it becomes the superficial femoral vein.


The superficial femoral vein receives profunda
femoris vein in upper thigh region and becomes
the common femoral vein. At the saphenofemoral
junction, the common femoral vein receives the
great saphenous vein.
The popliteal vein lies alongside the popliteal
artery in popliteal fossa. It originates by the
unification of the anterior and posterior tibial
veins in popliteal fossa. Its tributaries in the
popliteal fossa are the peroneal vein and short
saphenous vein. The popliteal vein enters into the
adductor canal and enters into the thigh as the
superficial femoral vein.
The anterior tibial vein drains the anterior
compartment of leg and dorsum of foot. The

anterior tibial vein courses upwards alongside the


anterior tibial artery and pierces the interosseous
membrane to enter the popliteal fossa and unites
with the posterior tibial veins to form the popliteal
vein.
The posterior tibial vein drains the posterior
compartment of leg and plantar surface of foot.
It courses upwards to enter the popliteal fossa
and unites with the anterior tibial veins to form
the popliteal vein. The posterior tibial veins are
accompanied by the posterior tibial arteries along
its course in leg.
The peroneal veins, also known as venae
comitantes, are the accompanying veins of the
peroneal artery of leg. The peroneal veins course
upwards and join the popliteal vein.

8
C H A PT E R

Radiological
Procedures
BARIUM SWALLOW

The esophagus is a hollow muscular tube; it is 25 cm


in length. The esophagus begins at the lower border
of cricoid cartilage at the level of C6 vertebra. For
descriptive purposes the esophagus has a cervical
segment, thoracic segment and intrabdominal
segment. The cervical segment of esophagus is
in the midline posterior to the trachea, it courses
to the left as it enters the thoracic cavity. The
thoracic segment of esophagus courses to midline
between the 5th to 7th thoracic vertebral level,
further down in the thoracic cavity the esophagus
lies to the left of midline. The esophageal opening
in the left hemidiaphragm is at the level of 10th
thoracic vertebra. The intraabdominal segment
of esophagus is short in length, around 1-2
cm and enters the stomach. In passive state
the esophagus is collapsed, it distends when a
bolus of food or water passes through its lumen.
During barium swallow exa
minations observe
the peristaltic waves on fluoroscopy propagating
the barium bolus into the stomach below. At the
distal end of esophagus is the lower esophageal
sphincter, it helps to maintain the tone of the
esophagus preventing gastric reflux and at the
same time provides support to the esophagus
by acting as a support sling to the diaphragm. If
there is failure of the lower esophageal sphincter
to relax the esophagus dilates and food contents

may be visible on X-ray films as air-fluid levels.


One must keep in mind the normal anatomical
narrowing of the esophagus at the following sites:
(i) The cricopharyngeal sphincter in cervical
segment, at origin of esophagus, around 15 cm
from incisor teeth (ii) At the level of aortic arch,
around 22 cm from incisor teeth (iii) The left
bronchus crosses in front of esophagus, around 27
cm from incisor teeth (iv) the esophageal opening
in diaphragm, around 38 cm from the incisor teeth.
It is a upper gastrointestinal (GI) radiological
study using high density barium contrast media
(250%). Two to three table spoon scoops are
given orally and the upper GI is visualized
on fluoroscopy. A control film is necessary if
perforation is suspected; water-soluble contrast
such as gastrograffin is given orally instead of
barium. In routine studies, no special patient
preparation is required, after the patient swallows
the barium contrast in erect position and spot
films are taken under fluoroscopic guidance.
The column of barium contrast is followed
on fluoroscopy as the barium passes in the
oropharynx into the esophagus and finally into
the stomach. Normally the spot films of upper
cervical region with esophagus is covered in
posteroanterior (PA), lateral and right anteroroblique (RAO) views. The spot films of lower

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esophagus with gastroesophageal junction are


covered in posteroanterior (PA), lateral and
right antero-oblique (RAO) views. Special views

in Trendelendburg position may be needed to


demonstrate hiatus hernia. No special aftercare is
required for this procedure (Figs 8.1 to 8.3).

Fig. 8.1: Barium swallow study (upper gastrointestinal tractlateral view)

A
Fig. 8.2A

Radiological Procedures

B
Fig. 8.4B
Figs 8.2A and B: Barium swallow study (upper gastrointestinal tract posteroanterior view)

Fig. 8.3: Barium swallow study (upper gastrointestinal tractright antero-oblique view)

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BARIUM MEAL FOLLOW-THROUGH (BMFT)


The stomach is a muscular structure that distends
when filled with barium contrast on barium
meal follow-through study. At its proximal end
is the gastroesophageal junction, to the left of
midline. The main parts of stomach are the
cardia, fundus, body and pyloric portion (Fig.
8.4). The cardia refers to the portion of stomach at
the gastroesophageal junction, it is located to the
left of midline, at 10 thoracic vertebral level, it is
around 40 cm from the incisor teeth. The fundus
is the portion of stomach which lies above the
level of cardia and usually filled with air, as seen
on plain X-ray abdomen. The body of stomach
has two curvaturesThe greater curvature and
the lesser curvature. There is a small notch in the

lower part of lesser curvature; this notch is called


incisura angularis. The pylorus of stomach is the
portion which lies beyond the incisura angularis,
it has two subportionsThe proximal portion is
called the pyloric antrum and the distal portion
is called the pyloric canal. The pyloric canal
lies anterior to the head and neck of pancreas.
The gastroduodenal junction lies to the right of
midline at L1 vertebral level, the pyloric sphincter
is a thickened section of the pyloric canal at the
gastroduodenal junction (Fig. 8.5).
The duodenum is a loop of bowel that connects
the stomach to the jejunum. The duodenum
begins at L1 vertebral level to the right of midline
at the gastroduodenal junction. The curved loop

Fig. 8.4: BMFT study erect posteroanterior (PA) view of stomach with duodenal cap

Radiological Procedures

Fig. 8.5: BMFT study erect right antero-oblique (RAO) view of stomach with duodenal cap

Fig. 8.6: BMFT study erect left antero-oblique (LAO) view of stomach with duodenum

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of duodenum (Fig. 8.6) is for descriptive purposes


has four parts1st, 2nd, 3rd and 4th parts. The 1st
part of duodenum has a short horizontal course,
the duodenal cap is located in this portion. The 2nd
part of duodenum is a vertical portion that runs
downwards to the right of midline. The 2nd part
of duodenum has an opening in its posteromedial
wall approximately 10 cm from pylorus, called the
ampulla of Vater. The ampulla of Vater receives
the common bile duct and the main pancreatic
duct. The 3rd part of duodenum is horizontal in
its course, it lies anterior to the right psoas muscle
and crosses the midline to lie anterior to the left
psoas muscle. The jejunal loops of bowel lies
anterior to the 3rd part of duodenum. The 4th
part of duodenum is the short ascending loop
of duodenum which lies to the left of aorta and
anterior to the left psoas muscle. The duodenum

joins with the jejunal loops at the duodenojejunal


flexure, this flexure is fixed to the left psoas fascia
by fibrous tissue.
The small bowel is approximately 4 to 6 meters
in length. The jejunum is the proximal 2/5th
of small bowel, has thicker walls and its lumen
is wider as compared to the ileum. On barium
studies the jejunum has a feathery appearance
due to its mucosal pattern. The ileal loops form the
remaining 3/5th of small bowel; have a featureless
pattern on barium studies. The lumen of ileal
loops progressively becomes narrower distally as
they approach the cecum, at the ileocecal junction
(Figs 8.7 to 8.10).
Barium meal follow-through is a radiographic
contrast study of the gastrointestinal tract from the
stomach to the terminal ileum. It gives valuable
information of stomach, jejunum and ileum to

Fig. 8.7: BMFT studySupine posteroanterior (PA) view of stomach with ileal loops

Radiological Procedures

Fig. 8.8: BMFT studySupine posteroanterior (PA) view of ileal loops with cecum

Fig. 8.9: BMFT studySupine right antero-oblique (RAO) view of terminal ileum with ascending colon

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Fig. 8.10: BMFT studySupine right antero-oblique (RAO) view of ileocecal junction

assist in detecting various pathologies. Plain


radiograph of the abdomen is normally taken
as control film before starting the barium study.
Single contrast method is commonly used, 300 ml
of high density barium 100 percent is given orally
and the barium column is followed on fluoroscopy
and spot films taken. Less commonly used
barium techniques involve using effervescent
agents with barium to demonstrate mucosal
pattern. In cases of suspected perforation barium
is contraindicated, water-soluble, nonionic
contrast like gastrograffin is used. BMFT study is
contraindicated in cases of complete obstruction
of small bowel. Patient is kept nil orally 6-8 hours
before start of study. Metoclopramide 20 mg
can be given orally 20 minutes before the BMFT
study to slightly increase bowel peristalsis. During
the BMFT study, compression pad techniques

may be used to displace overlying bowel loops


to visualize the ileocecal junction and terminal
ileum. In double contrast barium meal study, the
barium is followed by asking the patient to ingest
a sachet of powder, like ENO antacid. The patient
is asked to roll and this allows the gas produced
to distend the mucosal folds of stomach and
mucosal patterns can be studied on fluoroscopy.
After the procedure the patient should be told that
bowel motion may appear white in color for a few
days and advised to have a good intake of water to
avoid barium impaction. Some complications of
BMFT study includes-aspiration of barium during
the procedure, barium can worsen appendicitis,
barium can couvert a partial bowel obstruction
into a total obstruction due to barium impaction,
leakage from unsuspected perforation may lead
to barium peritonitis.

Radiological Procedures

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Barium enema
The anal canal is around 4 cm in length; it is the
terminal end of gastrointestinal tract. At its distal
end is the anal opening in the perineum. The
proximal end of anal canal is the anorectal junction,
here the puborectalis muscle fibers on either side
of the perineum act as a sling around this junction
and provide support. The tone of the anal canal is
maintained by the internal and external sphincters.
The rectum is around 10 to 12 cm in length
(Fig. 8.11). It begins at the level of the 3rd sacral
vertebra; the proximal end of rectum is continuous
with the sigmoid colon above, while the distal end
of rectum terminates at the anorectal junction
below. The presacral space lies behind the rectum.
In males the rectovesical space is anterior to
rectum, while in females the rectouterine pouch
is anterior to the rectum (Fig. 8.12).

The sigmoid colon is around 40-45 cm in


length. It is a part of the large bowel located from
the level of the pelvic brim proximally to the
rectosigmoid junction at the level of S3 vertebra.
The sigmoid colon has its own mesentery, called
as the sigmoid mesocolon. Due to this sigmoid
mesocolon the sigmoid colon is more mobile and
can rotate around its mesenteric axis and can lead
to volvulus and strangulation.
The descending colon is located on the left
side of abdomen. It is about 30-35 cm in length
and extends from the splenic flexure (level of
10th rib on left side) proximally to the pelvic brim
distally. The transverse colon is around 40-45
cm in length. It extends from the hepatic flexure
to the splenic flexure crossing the midline. The
splenic flexure is normally at a bit higher level

Fig. 8.11: Barium enema studyLeft lateral view (rectum and sigmoid colon)

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than the hepatic flexure. The ascending colon


extends upwards from the ileocecal junction to
the hepatic flexure. It is around 15 cm in length
and lies on the right side of abdomen and lies
over the lumbar fascia and iliac fascia. Haustra
are hallmarks of large bowel and are due to the
taenia coli longitudinal muscles. The cecum is
a blind pouch situated between the ileocecal
junction and the ascending colon in the right
lower abdomen, overlying the iliopsoas fascia.
The cecum has its own mesentery, thus giving
the cecum some mobility. In some cases, there
may be two folds of peritoneum on either sides
of posterior cecal wall forming the retrocecal
recess. The appendix may be occasionally
located in this retrocecal recess. The ileocecal
junction is located on the medial side of cecum,
it has valves that prevent reflux of large bowel
contents into the ileum. The appendix is a blind
ended structure which opens usually on the
posteromedial side of cecum. During barium

meal follow-through examinations, the lumen


of appendix might be seen as a small structure
adjoining the cecum. The appendix is around
7 to 8 cm in length, it has a short mesentery
called the mesoappendix. The appendicular
artery travels in the mesoappendix, in cases of
appendicitis the appendicular artery is ligated in
the mesoappendix (Fig. 8.12).
It is a radiological procedure carried out with
the use of barium as contrast to visualize the
lower gastrointestinal tract for any pathology.
Some indi
cations are change in bowel habit,
obstruction, melena, anemia, mass, lower
gastrointestinal pain. Patient preparation includes
low residue diet three days prior to the procedure,
intake of plenty of fluids, laxative taken the night
before the procedure. In the single contrast
method, the barium is infused through a rubber
catheter place in rectum. Intermittent screening
is done under fluoroscopy and spot films taken.
Barium is infused until the top of barium column

Fig. 8.12: Barium enema studySupine view (ascending, transverse, descending colon)

Radiological Procedures
reaches the hepatic flexure. Barium is inert
substance and reactions to it hardly ever occur,
but certain conditions are contraindicated for
barium enema. Barium enema is contraindicated
in toxic megacolon, pseudomembranous colitis,
postrectal biopsy, bowel perforation. Nonionic
contrast media is used in cases of perforation.

113

After the barium enema procedure is completed,


advice the patient that the stools would be white
for a few days, to take plenty of fluids orally and
laxatives may be prescribed. Venous extravasation
of barium is a rare but known complication of
barium enema study, it may result in barium
pulmonary embolism.

INTRAVENOUS UROGRAM
It is a radiological procedure to investigate the
kidneys, ureter and bladder by injecting a nonionic
water-soluble contrast media intravenously.
Patient preparation includes nil per orally for at
least 8 hours but patient should not be dehydrated,
oral laxatives are usually prescribed to take the
night before the procedure. Serum creatinine and
blood urea nitrogen tests are done to evaluate if
contrast can be safely administered. Patient may
have allergic reaction to the contrast media and
all emergency drugs and equipment should be
ready before contrast is injected. In infants and
children the radiation dose should be minimized.
Pregnancy is a contraindication for this procedure.
Plain X-ray KUB control film AP taken in
supine position (Fig. 8.13), check for good bowel
preparation, outline of both renal kidneys, psoas
muscle outlines, bony pelvis, also look for any
abnormal calcific densities for example in the
renal areas and bladder. It is important to ask the
patient to void before taking the plain X-ray KUB
film and make sure the plain KUB film covers the
diaphragms above to the pubis below. Normally,
a portion of each upper renal pole usually extends
above the 12th rib, with the right kidney normally
slightly lower than the left due to the position of the
liver. Each kidney normally measures around 12
cm 6 cm 3 cm, kidneys lies in the retroperitoneal
region, the hilum of each kidney lies over the psoas
muscle, the outer convexity of each kidney lies on
the aponeurosis of transversus abdominis muscle.
The vertical axis of the kidney lies parallel the upper
one-third of the psoas muscle, due to this slight

rotation the width of each kidney appears slightly


reduced on supine AP X-ray films.
Compression band around the lower abdomen
is applied so that the ureters are compressed
against the sacral ala, this helps to concentrate
the contrast media in the kidneys and upper
ureter. Compression band is avoided in children,
abdominal trauma, large abdominal mass and
postoperative cases. A test dose of intravenous
contrast around 2-3 ml is given and look for any
reaction like nausea, dizziness, breathlessness,
contrast extravasation from displaced cannula.
If the patient is comfortable then proceed to give
the rest of dose carefully.
IVU films in supine position (AP) is taken at
5 minutes, to demonstrate the nephropyelogram
phase (Fig. 8.14). Subsequent films are taken
at 15 minutes, 30 minutes (Figs 8.15 and 8.16).
At the release of compression band, the bolus
of contrast media in urine enters the ureters
to be visualized throughout their length. Also
segmental nonvisualization of the ureter due to
peristalsis can be overcome with compression
release, and the entire ureter, is filled with contrast
laden urine from the ureteropelvic junction to the
ureterovesical junction. Full bladder film is then
taken followed by postvoid supine film (Fig. 8.17).
During the course of this procedure note
whether-both kidneys concentrate and excrete
the contrast, pelvicalyceal systems are not
dilated, the course and caliber of the ureters,
any intravesical mass or filling defects (Fig. 8.18).
The appearance of the renal pelvicalyceal system

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Fig. 8.13: X-ray KUB region (Plain film)

Fig. 8.14: IVU film at 5 minutes (nephropyelogram)

Radiological Procedures

Fig. 8.15: IVU film at 15 minutes (right lower ureter visualized)

Fig. 8.16: IVU film at 30 minutes (left midureter visualized)

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Fig. 8.17: IVU film at 40 minutes (left lower ureter visualized)

Fig. 8.18: IVU film at 50 minutes (full bladder)

Radiological Procedures
should be examined closely because intravenous
urography is the most accurate imaging modality
for visualizing the urothelium-lined surfaces and
evaluating potential abnormalities. The ureter
usually begins as a smooth extension from the
renal pelvis adjacent to the lateral margin of the
psoas muscle. At about the L3 level, the ureter
passes to anterior to the psoas muscle, crossing it
from lateral to medial side. The proximal ureteric

117

course is retroperitoneal passes along the outer


half of the transverse processes of the upper
lumbar vertebra (L1 to L3). The midureteric
portion of ureter crosses anterior to the iliac
vessels at a higher position on the right than on
the left and courses downwards. Once within the
anatomic pelvis, the distal ureter lies parallel to
the inner margin of the iliac bone until it enters
the bladder at the ureterovesical junction.

MICTURATING CYSTOURETHROGRAM
The bladder is a hollow muscular organ in the
pelvic cavity. It has a rounded appearance with
smooth margins when distended with contrast.
The ureters insert into the bladder base on the
posterior surface. The area between the opening
of the two ureters on either side and the internal
urethral opening inferiorly at bladder neck is
called the trigone of bladder. The bladder neck is
surrounded by smooth muscle fibers, also called
as the internal urethral sphincter. The urethra
begins inferiorly at the bladder neck and courses
downwards to open into the external urethral
meatus. In males the urethra is around 18 cm
in length, and for descriptive purposes divided
into anterior urethra and posterior urethra. The
posterior urethra has two segments the more
proximal segment is called the prostatic segment,
while the distal segment which lies close to the
perineal membrane is called the membranous
segment. The prostatic segment (3-4 cm in
length), it runs through the prostate downwards,
the proximal part of prostatic urethra is also
known as preprostatic part and it is surrounded
by smooth muscles of the bladder neck. This
smooth muscle encasing the preprostatic part
contracts during ejaculation to prevent seminal
reflux into the urinary bladder. The membranous
urethra is the segment of posterior urethra is
around 1.5 cm in length and it traverses the
perineal membrane. The membranous urethra

is the narrowest part of the male urethra; it is


prone to strictures and obstruction. External
urethral sphincter (sphincter urethrae) consist of
smooth muscle fibers that extend from the lower
part of prostatic urethra to the region just above
the perineal membrane. The anterior urethra is
about 15 cm in length and has two segments. After
exiting from the perineal membrane the anterior
urethra has a smooth dilated proximal segment,
this segment is called the bulbar segment. The
anterior urethra curves forwards and runs inside
the penis, this distal segment of anterior urethra
is called the penile segment. At the external
meatus the urethra is narrower as compared to
the rest of penile urethra. In females the urethra is
shorter around 4-5 cm in length, so urinary tract
infections are much more common in females.
Micturating cystourethrogram is a radiological
procedure to demonstrate the radiological
anatomy of the urinary bladder and urethra
during the micturation process (Figs 8.19 to
8.22). Some indications for this procedure
include vesicoureteric reflux, to look for any
abnormalities of the bladder, stricture or fistulas
of urethra, posterior urethral valves. Relative
contraindication includes acute urinary tract
infection. To begin with, the patients urinary
bladder is first catheterized by a plain rubber
catheter and nonionic water-soluble contrast
media (around 250300 ml) is instilled into

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Fig. 8.19: Micturating cystourethrogramAnteroposterior view (standing) with urinary catheter in the bladder

Fig. 8.20: Micturating cystourethrogramLeft oblique view (standing)

Radiological Procedures

119

Fig. 8.21: Micturating cystourethrogramRight oblique view 30o (standing)

Fig. 8.22: Micturating cystourethrogramRight oblique view 45o (standing)

the bladder. On fluoroscopy, the bladder with


contrast is identified, its smooth outer margins
should be distinct: Spot anteroposterior view is
taken. Next, the rubber catheter is removed from

bladder and the patient is asked to micturate


here; the anatomy of the urethra is observed
on fluoroscopy. Adults usually find it easier to
micturate in standing or squatting position,

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while children are comfortable to micturate in


supine position. Spot films in right anterooblique
and left anterooblique are taken to demonstrate
the urethra in males. In females anteroposterior
view is usually sufficient to demonstrate the
urethra. If the contrast is observed in the ureters

then full length abdominal film is required to


visualize the kidneys to demonstrate the reflux.
Some complications of this procedure include
temporary dysuria, transient hematuria, bladder
perforation, acute urinary tract infection, adverse
reaction to contrast.

RETROGRADE URETHROGRAM
The anterior urethra is 15 cm in length, it has
two segments, the proximal segment is called
the bulbar segment; the distal segment is called
the penile segment. Fossa navicularis is a small
dilated part of penile urethra near the external
urethral meatus. When passing the cannula
into the external urethral meatus the tip of the
cannula should be directed downwards towards
the floor of fossa navicularis, otherwise injury to

the urethra can occur resulting in a false passage


likely through the large roof of fossa navicularis.
Retrograde urethrogram (RGU) is a
radiological procedure to evaluate the anterior
urethra in males by injecting a bolus of watersoluble contrast through a cannula into the
external urethral meatus (Fig. 8.23). Some
indications for this procedure include stricture,
urethral tear, congenital abnormalities, fistulae.

Fig. 8.23: Retrograde urethrogram right antero-oblique view

Radiological Procedures
The patient does not need any special prior
preparation before procedure, but the patient
should empty his bladder before the procedure
is started. The urethra is opacified and any
narrowing or obstruction to the flow of contrast
is identified. The patient is asked to lie down
supine on the X-ray table (Bucky table) and
30o left anterior oblique view is taken when
the contrast is injected. The position of the
patient in supine position is important, the hip

121

is abducted and the knee is flexed, the pelvis is


slightly tilted to the same side so that the anterior
urethra does not overlap with the femur. Spillage
of contrast into the urinary bladder is noted.
Contraindications for this procedure are acute
urinary tract infection and recent cystoscopy.
Ideally the retrograde urethrogram should be
followed by micturating urethrogram to evaluate
the posterior urethra. No special aftercare is
needed after the procedure.

Radiological anatomy of female


Reproductive organs
The female internal genitalia consist of the
uterus, fallopian tubes and ovaries. The uterus
is a muscular pear-shaped structure, nongravid
uterus measures around 80 mm 50 mm 30 mm
approximately. The uterus comprises of a fundus,
body and cervix. The fundal portion of uterus lies
above the opening of the fallopian tube on either
side. The body of uterus lies below the opening
of the fallopian tubes. The upper end of body of
uterus has a narrow angle, it is called the cornual
end where the fallopian tube opens into the
uterine cavity. The body of uterus gradually tapers
downwards to form the cervix (Figs 8.24 and 8.25).
The cervix has two parts; the upper part which
lies above the vagina is called the supravaginal
portion. The lower part of cervix which protrudes
into the vagina is called the vaginal portion of
cervix and has an anterior lip and posterior lip
visible using a Sims speculum. The upper end
of cervical canal is called the internal os; the
lower end of cervical canal is called the external
os. Normally the external os lies at the level of
ischial spines. There are two fallopian tubes, each
uterine tube is approximately around 10 cm in
length. The fallopian tube for descriptive purpose
is subdivided into the intramural part, isthmus,
ampulla and infundibulum. The intramural
portion of fallopian tube is the most medial

portion which lies in the muscular part of uterus.


The isthmus portion lies adjacent to the uterus,
it is the most narrow portion of fallopian tube.
The ampulla is the lateral portion of the fallopian
tube, it is more wider as compared to the isthmus.
The infundibular portion of fallopian tube is the
lateral end of fallopian tube, it has finger-like
projections called fimbriae and connect it to the
ovary. The ovary is ovoid structure one on either
side in the parametrium, measuring around 30
mm 20 mm 10 mm. The ovary size is smaller in
premenarchal and postmenopausal age groups.
The upper pole of each ovary is tilted towards the
infundibular portion of each fallopian tube. The
location of ovary changes during pregnancy and
usually never returns to its original position. The
vagina is a hollow muscular structure, at its upper
end the cervix projects into it, creating anterior,
posterior and two lateral vaginal fornices (Figs
8.26 and 8.27). The lower end of vagina opens into
the external genital opening surrounded by labia.
HYSTEROSALPHINGOGRAM
It is a radiological procedure where nonionic
contrast is injected into the uterus. Spillage from
the fallopian tubes into the peritoneal cavity is
observed on fluoroscopy and spot films are taken

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Fig. 8.24: Hysterosalpingogram

A
Fig. 8.25A

Radiological Procedures

B
Fig. 8.25B
Figs 8.25A and B: Hysterosalpingogram (uterus with both fallopian tubes)

Fig. 8.26: Hysterosalpingogram (fallopian tubes with spillage into peritoneal cavity)

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Fig. 8.27: Hysterosalpingogram (fallopian tubes with spillage into peritoneal cavity)

(Fig. 8.27) or preferably cine recording is done.


Common indications for this procedure are
infertility, recurrent miscarriages and previous
ectopic pregnancy. Pregnancy is an absolute
contraindication. Usually the procedure is done
around the 8th to 10th day of the menstrual cycle,
as the patient is unlikely to be pregnant during
this period, also the cervix would be firm enough
to hold the cannula. Normally, the procedure is
explained to the patient to make her comfortable
and cooperative, and consent form is signed by
the patient prior to the procedure. Atropine 1 mg
is injected intramuscularly prior to the procedure
to counter any vagal response when inserting
the cannula into the cervix. The patient is placed
supine and the external genitalia and the external
cervical os is cleaned with povidone-iodine
soaked swab. Any bleeding from the external
cervical os is noted at this point of time, if this
is present then the procedure is postponed. If
there is no bleeding observed from the cervix,

Sims speculum is inserted to get a clear view


of external cervix os, the anterior lip of cervix is
grasped by vulsellum forceps carefully and the
cannula (Leech-Wilkinson cannula) is inserted
carefully into the cervix until it is firmly in the
cervical canal (Fig. 8.24). Non-ionic contrast is
injected around 3ml to visualize the uterine cavity
and then followed by the rest of contrast (up to 20
ml). Spot films of the uterus and fallopian tubes
with spillage into peritoneal cavity are taken (Figs
8.25A and B). Patient might experience some
discomfort when the spillage occurs into the
peritoneal cavity. After the spot films are exposed
and viewed to assess for diagnostic quality (Figs
8.26 and 8.27) and then the cannula is carefully
withdrawn from the cervix. Oral analgesics and
antibiotics may be prescribed to the patient
after the procedure. Hysterosalphingogram is a
safe and effective procedure to demonstrate any
block in the fallopian tubes and can demonstrate
abnormal anatomy of uterine cavity.

Radiological Procedures

125

DACROCYSTOGRAM
The lacrimal apparatus consists of the lacrimal
gland, lacrimal canaliculi, lacrimal sac and the
nasolacrimal duct. The lacrimal gland lies in the
lacrimal fossa, located on the lateral part of the
roof of the orbit. The lacrimal gland secretes clear
fluid known as tears which helps to lubricate and
protect the cornea and the sclera of the eye. At the
medial end of each eyelid on its inner surface is
a small punctum which opens directly into the
lacrimal canaliculus. The lacrimal canaliculus is
a small tubular canal that leads into the lacrimal
sac. Excess tears produced by the lacrimal gland
are conveyed into the lacrimal sac through the
lacrimal canaliculus. The lacrimal sac is a small
structure located in the lacrimal groove (Figs
8.28 and 8.29). The lacrimal groove is lies at the

junction of lacrimal bone with the maxillary bone.


When the eyelids are wide open the lacrimal
punctum and canaliculi are closed, so the tears
cannot drain into them, but when the eyes are
closed the orbicularis oculi muscle allows the
muscle fibers and ligaments around the lacrimal
punctum to relax thus allowing the excess tears
to drain into the lacrimal sac. The lacrimal sac
opens inferiorly into the nasolacrimal duct. The
nasolacrimal duct is about 20 to 22 mm in length
and it runs downwards and laterally to open into
the ipsilateral inferior meatus in the nasal cavity.
At the opening of the nasolacrimal duct into the
inferior meatus, the mucous membrane of nasal
cavity is thrown into folds to act as a valve to
prevent air entering into the nasolacrimal duct.

Fig. 8.28: DacrocystogramAP view

126

Atlas on X-ray and Angiographic Anatomy

Fig. 8.29: DacrocystogramRight oblique view

Dacrocystogram is a radiological procedure


to evaluate the lacrimal sac and nasolacrimal
duct with water-soluble contrast media. Patient
is placed in supine position and the lacrimal
sac is gently massaged to release any collection
within it. Next, the lower eyelid is everted to
locate on the medial aspect a tiny punctum. This
tiny punctum opens into the lower canaliculus,
which leads into the lacrimal sac. A lacrimal

punctum dilator is used to carefully dilate the


punctum. A syringe with water-soluble contrast
is placed into the lacrimal punctum and contrast
is injected. The lacrimal canaliculi, sac and the
nasolacrimal duct are opacified and observed
on fluoroscopy, spot X-rays are taken in AP and
oblique positions. Any obstruction to the flow of
contrast or abnormally dilated portions is noted
during this procedure.

9
C H A PT E R

Ossification Centers

Ossification is the first area of a bone which


starts to ossify, the point where ossification
commences is termed as ossification center.
There are two types of ossification centers a)
The primary ossification center is the first area
of a bone to start ossifying. It appears during
prenatal development in the central part of each
developing bone. In long bones the primary
centers occur in the shaft and in other it occurs
usually in the body of the bone. Usually bones

have one primary center as in all long bones.


Few bones like hip and vertebrae have multiple
primary centers, b) The secondary ossification
center is the area of ossification that appears after
the primary ossification center, most secondary
ossification center appear during the postnatal
and adolescent years. Most bones have more than
one secondary ossification center. In long bones,
the secondary centers appear in the epiphysis
(Figs 9.1 to 9.6 and Tables 9.1 to 9.6).

Fig. 9.1: Shoulder joint

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Atlas on X-ray and Angiographic Anatomy

Fig. 9.2: Elbow joint

Fig. 9.3: Wrist and hand

Ossification Centers

Fig. 9.4: Hip joint

Fig. 9.5: Knee joint

129

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Atlas on X-ray and Angiographic Anatomy

Fig. 9.6: Foot


Table 9.1: Shoulder joint

Bones
Body of scapula
Body of clavicle (two centers)
Shaft of humerus
Epiphysis
Head of humerus
Greater tuberosity
Lesser tuberosity
Acromion process
Middle of coracoid process
Root of coracoid process
Inferior angle of scapula
Medial border of scapula
Medial end of clavicle

Ossification
8th week of fetal life
5th and 6th week of fetal life
8th week of fetal life
Appearance
1 year
3 years
5 years
1518 years
1 year
17th years
1420 years
1420 years
1820 years

Bones
Radial shaft
Ulnar shaft
Epiphysis
Lateral epicondyle
Medial epicondyle
Capitellum
Head of radius
Trochlea
Olecranon process

Ossification
8th week of fetal life
8th week of fetal life
Appearance
1012 years
0508 years
0103 years
0506 years
11th year
1013 years

Fusion

25th year
15th year
25th year
2225 years
2225 years
25th year

Table 9.2: Elbow joint

Fusion
1718 years
1718 years
1718 years
1619 years
18th year
1620 years

Ossification Centers

131

Table 9.3: Wrist and hand

Bones

Ossification

Capitate

4 months

Hamate

4 months

Triquetral

3 years

Lunate

45 years

Trapezium

6 years

Trapezoid

6 years

Scaphoid

6 years

Pisiform

11 years

Metacarpals

10th week of fetal life

Proximal phalanges

11th week of fetal life

Middle phalanges

12th week of fetal life

Distal phalanges

9th week of fetal life

Middle phalanx of 5th digit

14th week of fetal life

Epiphysis

Appearance

Fusion

Lower end of radius

12 years

20th year

Lower end of ulna

58 years

20th year

Metacarpal heads

2.5 years

20th year

Base of proximal phalanges

2.5 years

20th year

Base of middle phalanges

3 years

1820 years

Base of distal phalanges

3 years

1820 years

Base of 1st metacarpal

2.5 years

20th year

Table 9.4: Hip joint

Bones

Ossification

Proximal femoral shaft

7th week of fetal life

Epiphysis

Appearance

Fusion

Femoral head

1 year

1820 years

Greater trochanter

35 years

1820 years

Lesser trochanter

814 years

1820 years

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Atlas on X-ray and Angiographic Anatomy


Table 9.5 Knee joint

Bones

Ossification

Tibial shaft

7th week of fetal life

Fibular shaft

8th week of fetal life

Patella

5 years

Epiphysis

Appearance

Fusion

Proximal tibia

At birth

20th year

Tibial tubercle

510 years

20th year

Proximal fibular

4th year

25th year

Distal femur

At birth

20th year

Table 9.6: Foot

Bones

Ossification

Calcaneus

6th month of fetal life

Talus

6th month of fetal life

Navicular

34 years

Cuboid

At birth

Lateral cuneiform

1 year

Middle cuneiform

3 years

Medial cuneiform

3 years

Metatarsal shafts

8th9th week of fetal life

Phalangeal shafts

10th week of fetal life

Epiphysis

Appearance

Fusion

Metatarsals

3 years

1720 years

Proximal phalangeal base

3 years

1720 years

Middle phalangeal base

3 years

1720 years

Distal phalangeal base

5 years

1720 years

Posterior calcaneal

5 years

At puberty

10
C H A PT E R

Production of X-rays

X-rays are invisible, highly penetrating, electro


magnetic radiations having wavelength of 0.11 and speed is same as that of light (3108 m/
sec). They are considered as a form of modified
electrons.
X-ray tube is a diode consisting of tungsten
filament cathode and a rotating anode target of
tungsten held in an evacuated glass. Tungsten
anode is inclined at an angle so that it works on
line-focus principle.
X-rays are produced when the electron
beam strikes the anode made of tungsten or
molybdenum. Tungsten (atomic number 74)
is used as target material for X-ray production.
Molybdenum (atomic number 42) is used as the
target in mammography.
Cathode is connected to the negative terminal
and consists of small coil of wire made of tungsten
(filament). Cathode generates the electrons from
the electric circuit and focuses them into welldefined beam aimed at anode. Anode is relatively
large piece of metal that connects to positive end
of electric circuit. It converts electronic energy
into X-rays and rapidly dissipates heat produced
during this process. Anode is made up of tungsten
because it has high melting point, low rate of
evaporation and maintains strength at high
temperature (Fig. 10.1).
The electrons are produced by cathode filament
by electric current, emitting photoelectrons. The
electrons coming from the filament cathode are

then accelerated towards the target anode by a


large electrical potential applied between the
filament and target. When the beam of electrons
hits the target anode there is rapid deceleration
of electrons leading to emission of X-rays and
heat. About one percent of the energy generated
is emitted as X-rays. The rest of the energy is
released as heat.
The assembly of cathode and anode is
enclosed by the envelope which is made of
glass. It provides support and electric insulation,
keeps cathode and anode in air-tight enclosure
and maintains vacuum in tube. Housing is the
outermost covering that encloses and supports
the envelope. It is filled with oil that provides
electric insulation, allows heat dissipation and
cooling.
Modern X-ray tubes are based on hot cathode
tube principle invented by Coolidge in 1913
which enables excellent control of kVp (kilovolt
peak) and mAs (milliampere second). kVp is
responsible for penetration of X-ray beam, low
kVp gives high contrast. mAs is responsible for
the film blackening. The radiation intensity on the
cathode side of the X-ray tube is higher than on
the anode side and this principle is called as the
anode Heel effect. The heat generated in the tube is
dissipated in three ways: conduction, convection
and radiation. Diagnostic X-ray machine uses
voltage upto 150 kVp whereas machines used for
radiotherapy use high voltage > 200 KVP.

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Atlas on X-ray and Angiographic Anatomy

Fig. 10.1: Line diagram shows production of X-rays

Two different interactions give rise to X-rays.


An interaction with electron shell produce
characteristic X-rays photons, while interaction with
atomic nucleus produces Bremsstrahlung X-ray
photons. In diagnostic radiology about 85 percent
of X-rays arise from Bremsstrahlung radiation and
15 percent from characteristic radiation.
X-ray filter made of aluminum absorbs low
energy radiation and decreases unnecessary
patient exposure and thus improves film contrast.

Grid is made of parallel lead lines with intervening


radiolucent material. It absorbs scattered
radiation. Cones and collimators restrict field size
and decrease scatter.
Distance from X-ray tube (focus) to the X-ray
film is called focus film distance (FFD). It is 100
cm for usual radiographs of extremities, abdomen
and skull. However, for standing radiograph
of chest, it is 180 cm (6 ft) so as to reduce the
magnification.

11
C H A PT E R

Digital Subtraction
Angiography

Digital subtraction angiography (DSA) is a type


of fluoroscopy technique used in interventional
radiology to clearly visualize blood vessels in a
bony or dense soft tissue environment. Images are
produced using contrast medium by subtracting a
precontrast image or the mask from later images,
hence the term digital subtraction angiography.
Digital subtraction angiography (DSA) is
primarily used to image blood vessels. It is
useful in the diagnosis and treatment of: Arterial
and venous occlusions, carotid artery stenosis,
pulmonary embolisms, acute limb ischemia,
and arterial stenosis, which is particularly
useful for potential renal donors in detecting
renal artery stenosis, cerebral aneurysms and
arteriovenous malformations. In addition to
above applications others include carotid and
peripheral arteriography, thoracic and abdominal
aortography, pulmonary arteriography, and
ventriculography. Future applications may
include intracerebral and coronary arteriography.
DSA provide low-risk out
patient screening
arteriography.
In DSA, a computer is used to subtract an
initial image without contrast medium taken
directly from the image intensifier from the
angiographic images with contrast medium in
the blood vessels. The intravenous administration
of contrast material permits safe outpatient
screening for arterial disease. The bone, softtissue and gas are removed leaving only the

contrast-medium- filled blood vessels in the


final subtracted arterial images. DSA requires
cooperative patient who can keep still and hold
breath, because any type of movement can cause
image degradation. Abdominal examinations are
performed after an intravenous injection of 20
mg hyoscine butyl bromide to prevent peristalsis
in the gastrointestinal tract and thoracic
examinations can be done with ECG-triggered
gating to prevent cardiac pulsations.
Advantages of DSA are both volume and
iodine concentration of the nonionic contrast
medium used for each run, because of the high
contrast resolution of the imaging system in
DSA, reduction in the length of the procedure,
reduction in the size of the catheters used from
6-8 Fr down to 3-5 Fr, reduction in the number of
radiographic film used, reduction in the radiation
dose to the patient and angiographic staff.
Disadvantage of DSA is the fact that the
images it produces are inferior in the quality of
their spatial resolution to those produced by
conventional film angiography. The magnitude of
this difference in image quality has been reduced
with technical improvements in DSA systems.
In intravenous DSA, the high contrast
resolution of the imaging system allows nonionic
contrast medium to be injected intravenously
in order to produce arterial images in patients
with no femoral pulse, large volume of contrast
medium is injected rapidly by a pump injector

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Atlas on X-ray and Angiographic Anatomy

through a catheter positioned in the SVC or right


atrium. The contrast medium is diluted as it
passes through the lungs and into the left side of
the heart and systemic circulation, but the images
are of good quality.
Complication of intravenous DSA are
hemorrhage from puncture site, vascular
thrombosis, peripheral embolization, aneurysm,
local sepsis, injury to local structures, guidewire
fracture, and vasovagal reaction, and vascular
disorders.
For peripheral angiography carbon dioxide
digital subtraction angiography can be used as
an alternative or adjunct to iodinated contrast in

vascular imaging and interventional procedures.


Its unique qualities make it useful in diagnostic
as well as therapeutic procedures in arteries
and veins. Because of its endogenous gaseous
attributes, it is nonallergic, does not affect the
kidneys, and can be used in unlimited quantities.
Compared with iodinated contrast, the low
viscosity of CO2 permits greater sensitivity for
arterial hemorrhage and arteriovenous fistulas
as well as it is more facile using microcatheters.
Certain simple principles must be used with CO2
as a contrast agent. When used appropriately, CO2
is safe and can be useful when iodinated contrast
is either not sufficient or is contraindicated.

12
C H A PT E R

Computed and Digital


Radiography

Computed Radiography
Computed radiography (CR) uses similar
equipment as conventional radiography except
that in place of a film to create the image, an
imaging plate (IP) made of photostimulable
phosphor is used. The imaging plate housed in a
special cassette is placed under the body part or
object to be examined and the X-ray exposure is
made. Thereafter, instead of taking an exposed film
into a darkroom for developing in chemical tanks
or an automatic film processor, the imaging plate is
run through a special laser scanner, or CR reader,
that reads and digitizes the image. The digital
image can then be viewed and enhanced using
software that has functions very similar to other
con
ventional digital image-processing software,
such as contrast, brightness, filtration and zoom.
The CR imaging plate (IP) contains photo
stimulable storage phosphors, which store the
radiation level received at each point in local
electron energies. When the plate is put through
the scanner, the scanning laser beam causes the
electrons to relax to lower energy levels, emitting
light that is detected by a photomultiplier
tube (Fig. 12.1), which is then converted to an
electronic signal. The electronic signal is then
converted to discrete (digital) values and placed
into the image processor pixel map. The signals
generated by the photodetector as the plate is
being scanned are amplified and digitized by an

analog-to-digital converter (ADC). The spatial


resolution of computed radiography is influenced
by factors such as the phosphor plate thickness,
the readout time and the diameter of the laser
beam, which is typically about 100 m.
Imaging plates can theoretically be reused
thousands of times if they are handled carefully.
An image can be erased by simply exposing the
plate to a room-level fluorescent light. Most laser
scanners automatically erase the image plate
after laser scanning is complete. The imaging
plate can then be reused. Reusable phosphor
plates are environmentally safe. A fundamental
limitation of CR is the time required to read
the latent image. Since, the decay time of the
phosphor luminescence is ~0.7 s, typically the
readout of a 3,0003,000 pixel image can takeover
half a minute to complete. An improvement can
be obtained by line scanning, where a full line of
pixels is stimulated and read out simultaneously
instead of single pixels. This line-scanning
approach requires a linear array of laser light
sources, e.g. laser diodes, as well as a linear array
of photodetectors as wide as the imaging plate,
and gives rise to readout times of less than 10
seconds.
Advantages Over Conventional Radiography
No silver-based film or chemicals are required
to process film.

138

Atlas on X-ray and Angiographic Anatomy


Digital Radiography

Fig. 12.1: Schematic mechanism of CR system: Imaging


plate-coated with photostimulable phosphor (PSP) exposed
to X-rays and contains image data. In CR reader, imaging
plate is read using red laser beam, which is swept across the
plate by a rotating polygonal mirror. The light emitted by
imaging plate is converted into electrical signal and used to
form image

Reduced film storage costs because images


can be stored digitally.
Computed radiography often requires fewer
retakes due to under or over exposure which
results in lower overall radiation dose to the
patient.
Image acquisition is much faster image previews
can be available in less than 15 seconds.
By adjusting image brightness and/or contrast,
a wide range of thicknesses may be examined
in one exposure, unlike conventional film
based radio
graphy, which may require a
different exposure or multiple film speeds in
one exposure to cover wide thickness range in
a component.
Images can be enhanced digitally to aid in
interpretation.
Images can be stored on disk or transmitted
for off-site review.
Ever growing technology makes the CR more
affordable than ever today. With chemicals,
dark-room storage and staff to organize them,
you could own a CR for the same monthly
cost while being environmentally conscious,
depending upon the size of the radiographic
operation.

Digital radiography (DR) is a form of X-ray


imaging, where digital X-ray sensors are used
instead of tra
ditional photographic film (Fig.
12.2). Advantages include time efficiency through
bypassing chemical processing and the ability to
digitally transfer and enhance images. Also less
radiation can be used to produce an image of
similar contrast to conventional radiography.
Digital radiography is essentially filmless X-ray
image capture. In place of X-ray film, a digital
image capture device is used to record the X-ray
image and make it available as a digital file that can
be presented for interpretation. The advantages of
DR over film include immediate image preview
and availability, a wider dynamic range which
makes it more forgiving for over and under
exposure as well as the ability to apply special
image processing techniques that enhance overall
display of the image. DR has the potential to reduce
costs associated with processing, managing and
storing films. The digital image capture devices
include flat panel detectors (FPDs).
FPDs are classified in two main categories:
1. Indirect FPDs: Amorphous silicon (a-Si) is the
most frequent used FPD in the medical imaging
industry today. Combining a-Si detectors with a
scintillator in the detectors outer layer, which is
made from Cesium Iodide (CsI) or Gadolinium
Oxysulfide (Gd2O2S), converts X-ray to light.
Because the X-ray energy is converted to light,
the a-Si detector is considered an indirect
image capture technology. The light is then
channeled through the a-Si photodiode layer
where it is converted to a digital output signal.
The digital signal is then read out by Thin Film
Transistors (TFTs) or by fiber coupled Charged
Couple Devices (CCDs). The image data file is
sent to a computer for display.
2. Direct FPDs: Amorphous Selenium Flat
Panel Detectors (a-Se) are known as direct
detectors because X-ray photons are converted
directly to charge. The outer layer of the flat

Computed and Digital Radiography

139

Fig. 12.2: Schematic diagram showing types of DR flat panel detectors (FPD): (i) Direct conversion flat panel detectors: X-rays are
converted to electronic signal by amorphous selenium photoconductor; (ii) Indirect conversion flat panel detector: X-rays are
converted to visible light by scintillator, which is further converted to electronic signal by silicon photodiode. Electronic signal is
converted to digital image by TFT arrays

panel in this design is typically a high voltage


bias electrode. The bias electrode accelerates
the captured energy from an X-ray exposure
through the amorphous selenium layer. X-ray
photons flowing through the selenium layer
create electron hole pairs. These electron
holes transit through the selenium based on
the potential of the bias voltage charge. As the
electron holes are replaced with electrons, the
resultant charge pattern in the selenium layer
is read out by a TFT array. The image data file
is sent to a computer for display.
Computed radiography (CR) and DR use a
medium to capture X-ray energy and produce a
digital image. Both also present an image within

seconds of exposure. CR involves the use of a


cassette that houses the imaging plate, similar
to traditional film-screen systems to record the
image whereas DR captures the image directly
onto a flat panel detector without the use of a
cassette. Image processing or enhancement can
be applied on both DR and CR images due to the
digital format. DR may offer improved workflow
for routine procedures due to the elimination of
cassette manipulation and processing, as well as
a greater capacity to limit radiation exposure. CR
continues to offer flexible position of the image
receptor for procedures such as those done for
portable film, trauma, surgical cases and crosstable lateral projections.

13
C H A PT E R

Picture Archiving and


Communication System

Picture archiving and communication system


(PACS), is based on universal DICOM (Digital
imag
ing and communications in medicine)
format. DICOM solutions are capable of
storing and retrieving multi
modality images
in a proficient and secure manner in assisting
and improving hospital workflow and patient
diagnosis (Flow chart 13.1).
The aim of PACS is to replace conventional
radiographs and reports with a completely
electronic network. These digital images can be
viewed on monitors in the radiology department,
emergency rooms, inpatient and outpatient
departments, thus saving time, improving
efficiency of hospital and avoid incurring the
cost of hard copy images in a busy hospital. The
three basic means of rendering plain radiographs
images to digital are computed radiography (CR)
using photostimulable phosphor plate technology;
direct digital radiography (DDR) and digitizing
conventional analog films. Non image data,
such as scanned documents like PDF (portable
document format) is also incorporated in DICOM
format. Dictation of reports can be integrated into
the system. The recording is automatically sent to a
transcript writers workstation for typing, and can
also be made available for access by physicians,
avoiding typing delays for urgent results.
Radiology has led the way in developing PACS
to its present high standards. Picture archiving
and communication system (PACS) consists of

four major components: The hospital information


system (HIS) with imaging modalities such as
radiography, computed radiography, endoscopy,
mammography, ultrasound, CT, PET-CT and
MRI, a secured network for the transmission of
patient information, workstations for interpreting
and reviewing images and archives for the storage
and retrieval of images and reports. Backup
copies of patient images are made provisioned
in case the image is lost from the PACS. There are
several methods for backup storage of images,
but they typically involve automatically sending
copies of the images to a separate computer for
storage, preferably off-site.
In PACS, no patient is irradiated simply
because a previous radiograph or CT scan
has been lost; the image once acquired onto
the PACS is always available when needed.
Simultaneous multilocation viewing of the same
image is possible on any workstation connected
to the PACS. Numerous post-processing soft
copy manipulations are possible on the viewing
monitor. Film packets are no longer an issue as
PACS provides a filmless solution for all images.
The PACS can be integrated into the local area
network and images from remote villages can be
sent to the tertiary hospital for reporting.
Picture archiving and communication system
(PACS) is an expensive investment initially but
the costs can be recovered over 5 years period. It
requires a dedicated maintenance. It is important

Picture Archiving and Communication System

141

Flow chart 13.1: Picture archiving and communication system (PACS)

to train the doctors, technicians, nurses and other


staff to use PACS effectively. Once PACS is fully
operational no films are issued to patients.
Picture archiving and communication
system (PACS) breaks the physical and time
barriers associated with traditional film-based
image retrieval, distribution and display.
PACS can be linked to the internet, leading to

teleradiology, the advantages of which are that


images can be reviewed from home when on
call, can provide linkage between two or more
hospitals, outsourcing of imaging examinations
in understaffed hospitals. The PACS is offered
by all the major medical imaging equipment
manufacturers, medical IT companies and many
independent software companies.

14
C H A PT E R

Computed Tomography
Contrast Media

IODINATED INTRAVASCULAR AGENTS


Intravascular radiological contrast media are
iodine containing chemicals which add to the
details in any given CT scan study and thereby
aid in the diagnosis. Contrast overall enhances
the body tissues. It helps to show the lesion which
could not be appreciated on plain scan or shows
the lesion better than what was seen in the plain
scan. Contrast was first introduced by Moses
Swick. Iodine (atomic weight 127) is an ideal
choice element for X-ray absorption because the
korn (K) shell binding energy of iodine (33.7) is
nearest to the mean energy used in diagnostic
radiography and thus maximum photoelectric
interactions can be obtained which are a must
for best image quality. These compounds after
intravascular injection are rapidly distributed
by capillary per
meability into extravascularextracellular space and almost 90 percent is
excreted via glomerular filtration by kidneys
within 12 hours.
Following iodinated contrast media are available:
1. Ionic monomers, e.g. Diatrizoate, Iothalamate,
Metrizoate.
2. Nonionic monomers, e.g. Iohexol, Iopamidol,
Iomeron.
3. Ionic dimer, e.g. Ioxaglate.
4. Nonionic dimer, e.g. Iodixanol, Iotrolan.

The amount of contrast required is usually 1-2


ml/kg body weight. Normal osmolality of human
serum is 290 mOsm/kg. Ionic contrast media
have much higher osmolality than normal human
serum and are known as high osmolar contrast
media (HOCM), while nonionic contrast media
have lower osmolality than HOCM and are known
as low osmolar contrast media (LOCM).
Side effects or adverse reactions to contrast
media are divided as:
1. Idiosyncratic anaphylactoid reactions.
2. Nonidiosyncratic reactions like nephrotoxicity
and cardiotoxicity.
Adverse reactions are more with HOCM than
LOCM, hence LOCM are preferred. Delayed
adverse reactions although very rare are, however,
more common with LOCM and include iodide
mumps, systemic lupus erythematosus (SLE) and
Stevens-Johnson syndrome. Principles of treat
ment of adverse reaction involves mainly five
basic steps: ABCDE
A: Maintain proper airway
B: Breathing support for adequate breathing
C: Maintain adequate circulation. Obtain an IV
access
D: Use of appropriate drugs like antihistaminics
for urticaria, atropine for vasovagal
hypotension and bradycardia, beta agonists
for bronchospasm, hydrocortisone, etc.

Computed Tomography Contrast Media

143
143

E: Always have emergency back-up ready


including ICU care.
Following intravascular iodinated agent
arterial opacification takes place at approximately
20 seconds with venous peak at approximately 70
seconds. The level then declines and the contrast
is finally excreted by the kidneys. These different
phases of enhancement are used to image various
organs depending on the indication. Spiral CT,
being faster is able to acquire images during each
phase, thus provide much more information.

of barium (37) is near to the mean energy used


in diagnostic radiography and thus maximum
photoelectric interactions can be obtained which
are a must for best image quality. Moreover,
barium sulfate is nonabsorbable, nontoxic and
can be prepared into a stable suspension. For CT
scan of abdomen, 1000-1500 ml of 1-5 percent w/
vol barium sulfate suspension can be used. Severe
adverse reactions are rare. Rarely mediastinal
leakage can lead to fibrosing mediastinitis while
peritoneal leakage can cause adhesive peritonitis.

ORAL CONTRAST

Iodinated Agents

The bowel is usually opacified in CT examinations


of the abdomen and pelvis as the attenuation
value of the bowel is similar to the surrounding
structures and as a result pathological lesions can
be obscured. Materials used are barium or iodine
based preparations, which are given to the patient
to drink preceding the examination to opacify the
gastrointestinal tract.

Iodine containing oral contrast agents like gastro


graffin and trazograf are given for evaluating
gastrointestinal tract on CT scan.

Barium Sulfate
Barium sulfate preparations are used for
evaluating gastrointestinal tract. Barium (atomic
weight 137) is an ideal choice element for X-ray
absorption because the K shell binding energy

AIR
Air is used as a negative per rectal contrast
medium in large bowel during CT abdomen and
during CT colonography.
CARBON DIOXIDE
Rarely,
carbon
dioxide
is
used
for
infradiaphragmatic CT angiography in patients
who are sensitive to iodinated contrast.

Index
Page numbers followed by f refer to figure and t refer to table

A
Abdominal
angiography 81
aorta 81, 95f
branches 82
radiograph 34
Acromion process 130
Advantages over conventional
radiography 137
Amorphous selenium flat panel
detectors 138
Analog-to-digital converter 137
Anatomical segmental division of
lungs 28
Angiogram of
abdominal aorta 82f
celiac arterial trunk 83f
posterior cerebral circulation
arterial phase 74f, 75f
capillary phase 75f, 76f
venous phase 77f
renal arteries in
pyeloureterogram phase 87f
right anterior cerebral
circulation
arterial phase 70f, 71f
capillary phase 71f, 72f
venous phase 72f, 73f
right renal artery
early arterial phase 85f
late arterial phase 86f
nephrogram phase 86f
superior mesenteric artery 84f
Angiography of lower limb 95f,
97f-101f
Angle of Louis 79
Ankle joint 60
Anterior
cerebral artery 69
communicating artery 69
interosseous artery 90f
spinal arteries 73

Arch of aorta 80f


Artery of
foregut 83
midgut 85
Ascending thoracic aorta curves 80f
Atlantoaxial junction 20f
Axillary artery 89f, 93f

B
Barium
enema 111
study 111f
sulfate 143
swallow 103
study 104f, 105f
Base of
distal phalanges 131
middle phalanges 131
proximal phalanges 131
Basilar artery 73
Body of
clavicle 130
scapula 130
Brachial artery 89f, 93f
Branches of
aortic arch 67
external carotid artery 67
Bucky table 121

Cervical spine 13
Cervicothoracic junction 18f
Circle of Willis 68
Clivus canal angle 27
Coccyx 16
Computed radiography
137, 139, 140
contrast media 142
Coupled charged couple devices 138
Craniovertebral angle 27

D
Dacrocystogram 125, 125f, 126f
Deep
cerebral veins 74
palmar arch 92f
vein 92
Digital
radiography 138
subtraction angiography 135
veins 91
Direct digital radiography 140
Distal
femur 132
phalanges 131
Dorsolumbar spine 14
Dural sinuses 76, 79

Calcaneus 132
Capitellum 130
Carbon dioxide 143
Cavernous portion of internal
carotid artery 67
Celiac
arterial trunk 83
trunk 81
Cephalic veins 91
Cerebral
circulation 67, 68
cortical veins 74

Elbow joint 41, 128f, 130t


Epiphysis 132
External iliac and common iliac
artery 97f, 98f
Extracranial carotid arteries 67

F
Fallopian tubes 123, 123f, 124
Femoral head 131
Fibular shaft 132
Forearm 44

146

Atlas on X-ray and Angiographic Anatomy

G
Greater
trochanter 131
tuberosity 130

H
Head of
humerus 130
radius 130
Hilgenreiners line 49
Hip joint 49, 129f, 131t
Hysterosalpingogram 121,
122f-124f

I
Inferior
angle of scapula 130
mesenteric artery 84
Internal carotid artery 67-69

J
Jugular bulb 78

K
Knee joint 55, 129f, 132

L
Lateral
cuneiform 132
decubitus 34
epicondyle 130
Leech-Wilkinson cannula 124
Lesser
trochanter 131
tuberosity 130
Locating lesions of lungs 31
Location of arches of foot 64f
Low osmolar contrast media 142
Lower
end of
radius 131
ulna 131
limb 49

angiography 95
arterial system 96
venous system 102
Lumbosacral spine 14, 24f
X-ray 25f, 26f
Lung fissures 31

M
Medial
border of scapula 130
cuneiform 132
end of clavicle 130
epicondyle 130
Metacarpal
heads 131
veins 91
Metatarsal shafts 132
Micturating cystourethrogram
117, 118f, 119f
Middle
cerebral artery 69
cuneiform 132
of coracoid process 130
phalangeal base 132
phalanges 131
Multiplanar
reconstructed CT scan image of
elbow joint 42f
forearm 44f
hand and wrist joint 46f
shoulder joint 37f
upper arm 40f
reconstructed images of
abdomen 35f
joint 61f
foot with ankle 63f
knee joint 56f
lower leg with ankle 59f
thorax 29f

N
Nasal
cavity 9
septum 9

Normal
intracranial
arterial system 67
venous system 74
venous anatomy of brain 78

O
Olecranon process 130
Orbit 10
Ossification centers 127

P
Paranasal sinuses 6f, 10
Patella 132
Pelvic phleboliths 34
Perkins line 49
Petrous portion of internal carotid
artery 67
Phalangeal shafts 132
Pituitary fossa 5f
Popliteal artery 97, 100, 100f
Posterior
cerebral arteries 69, 73
communicating arteries 67, 69
fossa veins 74, 78
inferior cerebellar artery 69
Production of X-rays 133
Profunda femoris artery 96
Proximal
femoral shaft 131
phalanges 131
tibia 132

R
Radial arteries 90f, 94
Radiological
anatomy of female reproductive
organs 121
importance of
craniovertebral junction 27
vertebral column in spinal
injuries 24
Renal artery 88
angiogram 87

Index
Retrograde urethrogram 120
Root of coracoid process 130

S
Sacrum and coccyx X-ray 27f
Shaft of humerus 130
Shoulder joint 37, 127f, 130t
Sims speculum 124
Spinal
canal 21
cord 21
Subclavian artery 89f
Superficial
femoral artery 96, 99f
palmar arch 91f
veins 91
Superior
internal carotid artery 69
mesenteric
arteriogram 85
artery 83
Systemic lupus
erythematosus 142

T
Teres minor 37
Thoracic aorta 79, 80f

Tibial
shaft 132
tubercle 132
Trochlea 130
Turkish saddle 9

U
Ulnar
artery 90f, 94
shaft 130
Upper
arm 38
gastrointestinal tract 104f, 105f
limb 37
angiography 88
venous system 94

V
Vein of
Galen 74
Trolard and Labbe 74
Venous system 91
Vertebral arteries 69
Vertebrobasilar circulation 69

W
Wrist joint and hand 44

147

X
X-ray 28
abdomen 36f
ankle
and foot 63f
joint 62f
cervical spine 15f-20f
open mouth 20
right posterior oblique for
intervertebral foramina
19f
cervicothoracic junction 18f
chest 29f-32f
dorsolumbar spine 22f, 23f
elbow joint 42f, 43f
foot 64f, 65f
forearm 45f
hand and wrist joint 47f
hip joint with pelvis 52f
knee joint 57f
skyline 58f
KUB region 114f
leg 60f, 61f
pelvis with both hip joints 51f
right hip joint 51f, 52f
shoulder joint 38f, 39f
skull 3f, 4f, 5, 5f, 6, 6f-8f, 11f, 12f
thigh 54f, 55f
upper arm 40f, 41f