Positron emission tomography (PET) is a nuclear medicine imaging technique which produces a three-dimensional image or picture

of functional processes in the body. The system detects pairs of gamma rays emitted indirectly by a positron-emitting radionuclide
(tracer), which is introduced into the body on a biologically active molecule. Images of tracer concentration in 3-dimensional or 4-
dimensional space (the 4th dimension being time) within the body are then reconstructed by computer analysis. In modern scanners,
this reconstruction is often accomplished with the aid of a CT X-ray scan performed on the patient during the same session, in the
same machine.

If the biologically active molecule chosen for PET is FDG, an analogue of glucose, the concentrations of tracer imaged then give
tissue metabolic activity, in terms of regional glucose uptake. Although use of this tracer results in the most common type of PET
scan, other tracer molecules are used in PET to image the tissue concentration of many other types of molecules of interest.

Operation

To conduct the scan, a short-lived radioactive tracer isotope is injected into the living subject (usually into blood circulation). The
tracer is chemically incorporated into a biologically active molecule. There is a waiting period while the active molecule becomes
concentrated in tissues of interest; then the subject is placed in the imaging scanner. The molecule most commonly used for this
purpose is fluorodeoxyglucose (FDG), a sugar, for which the waiting period is typically an hour. During the scan a record of tissue
concentration is made as the tracer decays.

As the radioisotope undergoes positron emission decay (also known as positive beta decay), it emits a positron, an antiparticle of the
electron with opposite charge. The emitted positron travels in tissue for a short distance (typically less than 1 mm, but dependent on
the isotope[9]), during which time it loses kinetic energy, until it decelerates to a point where it can interact with an electron. [10] The
encounter annihilates both electron and positron, producing a pair of annihilation (gamma) photons moving in approximately opposite
directions. These are detected when they reach a scintillator in the scanning device, creating a burst of light which is detected by
photomultiplier tubes or silicon avalanche photodiodes (Si APD). The technique depends on simultaneous or coincident detection of
the pair of photons moving in approximately opposite direction (it would be exactly opposite in their center of mass frame, but the
scanner has no way to know this, and so has a built-in slight direction-error tolerance). Photons that do not arrive in temporal "pairs"
(i.e. within a timing-window of a few nanoseconds) are ignored.

[edit] Localization of the positron annihilation event

The most significant fraction of electron-positron decays result in two 511 keV gamma photons being emitted at almost 180 degrees to
each other; hence it is possible to localize their source along a straight line of coincidence (also called formally the line of response or
LOR). In practice the LOR has a finite width as the emitted photons are not exactly 180 degrees apart. If the resolving time of the
detectors is less than 500 picoseconds rather than about 10 nanoseconds, it is possible to localize the event to a segment of a chord,
whose length is determined by the detector timing resolution. As the timing resolution improves, the signal-to-noise ratio (SNR) of the
image will improve, requiring fewer events to achieve the same image quality. This technology is not yet common, but it is available
on some new systems

Magnetic resonance imaging (MRI), nuclear magnetic resonance imaging (NMRI), or magnetic resonance tomography (MRT)
is a medical imaging technique used in radiology to visualize detailed internal structures. The good contrast it provides between the
different soft tissues of the body make it especially useful in brain, muscles, heart, and cancer compared with other medical imaging
techniques such as computed tomography (CT) or X-rays.

Unlike CT scans or traditional X-rays MRI uses no ionizing radiation. Instead it uses a powerful magnetic field to align the
magnetization of some atoms in the body, then uses radio frequency fields to systematically alter the alignment of this magnetization.
This causes the nuclei to produce a rotating magnetic field detectable by the scanner—and this information is recorded to construct an
image of the scanned area of the body.[1]:36

Magnetic resonance imaging is a relatively new technology. The first MR image was published in 1973 [2][3] and the first cross-
sectional image of a living mouse was published in January 1974.[4] The first studies performed on humans were published in 1977.[5][6]
By comparison, the first human X-ray image was taken in 1895

The body is largely composed of water molecules. Each water molecule has two hydrogen nuclei or protons. When a person goes
inside the powerful magnetic field of the scanner, the magnetic moments of some of these protons changes, and aligns with the
direction of the field.
In an MRI machine a radio frequency transmitter is briefly turned on, producing an electromagnetic field. The photons of this field
have just the right energy, known as the resonance frequency, to flip the spin of the aligned protons in the body. As the intensity and
duration of application of the field increase, more aligned spins are affected. After the field is turned off, the protons decay to the
original spin-down state and the difference in energy between the two states is released as a photon. It is these photons that produce
the electromagnetic signal that the scanner detects. The frequency the protons resonate at depends on the strength of the magnetic
field. As a result of conservation of energy, this also dictates the frequency of the released photons. The photons released when the
field is removed have an energy — and therefore a frequency — due to the amount of energy the protons absorbed while the field was
active.

It is this relationship between field-strength and frequency that allows the use of nuclear magnetic resonance for imaging. Additional
magnetic fields are applied during the scan to make the magnetic field strength depend on the position within the patient, in turn
making the frequency of the released photons dependent on position in a predictable manner. Position information can then be
recovered from the resulting signal by the use of a Fourier transform. These fields are created by passing electric currents through
specially-wound solenoids, known as gradient coils. Since these coils are within the bore of the scanner, there are large forces between
them and the main field coils, producing most of the noise that is heard during operation. Without efforts to dampen this noise, it can
approach 130 decibels (dB) with strong fields [7] (see also the subsection on acoustic noise).

An image can be constructed because the protons in different tissues return to their equilibrium state at different rates, which is a
difference that can be detected. Five different tissue variables — spin density, T1 and T2 relaxation times and flow and spectral shifts
can be used to construct images.[8] By changing the parameters on the scanner, this effect is used to create contrast between different
types of body tissue or between other properties, as in fMRI and diffusion MRI.

Contrast agents may be injected intravenously to enhance the appearance of blood vessels, tumors or inflammation. Contrast agents
may also be directly injected into a joint in the case of arthrograms, MRI images of joints. Unlike CT, MRI uses no ionizing radiation
and is generally a very safe procedure. Nonetheless the strong magnetic fields and radio pulses can affect metal implants, including
cochlear implants and cardiac pacemakers. In the case of cochlear implants, the US FDA has approved some implants for MRI
compatibility. In the case of cardiac pacemakers, the results can sometimes be lethal,[9] so patients with such implants are generally not
eligible for MRI.

MRI is used to image every part of the body, and is particularly useful for tissues with many hydrogen nuclei and little density
contrast, such as the brain, muscle, connective tissue and most tumors.

Computed tomography (CT) is a medical imaging method employing tomography created by computer processing.[1] Digital
geometry processing is used to generate a three-dimensional image of the inside of an object from a large series of two-dimensional
X-ray images taken around a single axis of rotation.[2]

CT produces a volume of data which can be manipulated, through a process known as "windowing", in order to demonstrate various
bodily structures based on their ability to block the X-ray beam. Although historically the images generated were in the axial or
transverse plane, orthogonal to the long axis of the body, modern scanners allow this volume of data to be reformatted in various
planes or even as volumetric (3D) representations of structures. Although most common in medicine, CT is also used in other fields,
such as nondestructive materials testing. Another example is archaeological uses such as imaging the contents of sarcophagi or the
DigiMorph project at the University of Texas at Austin which uses a CT scanner to study biological and paleontological specimens.

Head

CT scanning of the head is typically used to detect infarction, tumours, calcifications, haemorrhage and bone trauma.
Of the above, hypodense (dark) structures indicate infarction or tumours, hyperdense (bright) structures indicate calcifications and
haemorrhage and bone trauma can be seen as disjunction in bone windows.

Lumbar puncture
A patient undergoes a lumbar puncture at the hands of a neurologist. The reddish-brown swirls on the patient's back are tincture of
iodine (an antiseptic).

In medicine, a lumbar puncture (colloquially known as a spinal tap) is a diagnostic and at times therapeutic procedure that is
performed in order to collect a sample of cerebrospinal fluid (CSF) for biochemical, microbiological, and cytological analysis, or very
rarely as a treatment ("therapeutic lumbar puncture") to relieve increased intracranial pressure.
Indications

The most common purpose for a lumbar puncture is to collect cerebrospinal fluid in a case of suspected meningitis, since there is no
other reliable tool with which meningitis, a life-threatening but highly treatable condition, can be excluded. Young infants commonly
require lumbar puncture as a part of the routine workup for fever without a source, as they have a much higher risk of meningitis than
older persons and do not reliably show signs of meningeal irritation (meningismus). In any age group, subarachnoid hemorrhage,
hydrocephalus, benign intracranial hypertension and many other diagnoses may be supported or excluded with this test.

Lumbar punctures may also be done to inject medications into the cerebrospinal fluid ("intrathecally"), particularly for spinal
anesthesia or chemotherapy. It may also be used to detect the presence of malignant cells in the CSF, as in carcinomatous meningitis
or medulloblastoma.

Procedure
Spinal needles used in lumbar puncture.

In performing a lumbar puncture, first the patient is usually placed in a left (or right) lateral position with his/her neck bent in full
flexion and knees bent in full flexion up to his/her chest, approximating a fetal position as much as possible. It is also possible to have
the patient sit on a stool and bend his/her head and shoulders forward. The area around the lower back is prepared using aseptic
technique. Once the appropriate location is palpated, local anaesthetic is infiltrated under the skin and then injected along the intended
path of the spinal needle. A spinal needle is inserted between the lumbar vertebrae L3/L4 or L4/L5 and pushed in until there is a
"give" that indicates the needle is past the dura mater. The needle is again pushed until there is a second 'give' that indicates the needle
is now past the arachnoid mater, and in the subarachnoid space. The stylet from the spinal needle is then withdrawn and drops of
cerebrospinal fluid are collected. The opening pressure of the cerebrospinal fluid may be taken during this collection by using a simple
column manometer. The procedure is ended by withdrawing the needle while placing pressure on the puncture site. In the past, the
patient would often be asked to lie on his/her back for at least six hours and be monitored for signs of neurological problems, though
there is no scientific evidence that this provides any benefit. The technique described is almost identical to that used in spinal
anesthesia, except that spinal anesthesia is more often done with the patient in a sitting position.

The upright seated position is advantageous in that there is less distortion of spinal anatomy which allows for easier withdrawal of
fluid. It is preferred by some practitioners when a lumbar puncture is performed on an obese patient where having them lie on their
side would cause a scoliosis and unreliable anatomical landmarks. On the other hand, opening pressures are notoriously unreliable
when measured on a seated patient and therefore the left or right lateral (lying down) position is preferred if an opening pressure needs
to be measured.

Patient anxiety during the procedure can lead to increased CSF pressure, especially if the person holds their breath, tenses their
muscles or flexes their knees too tightly against their chest. Diagnostic analysis of changes in fluid pressure during lumbar puncture
procedures requires attention both to the patient's condition during the procedure and to their medical history.[citation needed]

Reinsertion of the stylet may decrease the rate of post lumbar puncture headaches.