CXR:

1) Devices / Lines2) Vasculature

a. Heart size, contour, valves, calcifications (valvular or arterial)b. Look behind heart for retrocardiac opacity / hiatal herniac. Aortic knob, calcifications, tortuosity, width of mediastinumd. Pulmonary artery trunk mogul and rt/lt main pulmonary arteriese. Left Pulmonary atrium mogulf. Pulmonary Vasculature – edema, pruned

3) Mediastinuma. Hilar, subcarinal and paratracheal mass/lymphadenopathyb. Trachea midline, superior mediastinum widenedc. pneumomediastinum

4) Airwaya. Tracheal stenosisb. Branching pattern of trachea, endoluminal masses / cutoff

5) Pleural Spacea. Pneumothoraxb. Plural massc. Plural fat / thickeningd. Plaques / calcifications

6) Lungsa. Consolidationsb. Nodules (side to side comparison)c. Effusionsd. Air bronchograms e. Bronchiectasis, peribronchial cuffing or thickeningf. Retrocardiac area

7) Ribs, clavicles, shoulders, spine, 8) Abdomen (free air, gastric air bubble, bowel gas pattern, calcifications)

KUB:

1) Gas Patterna. Normalb. SBO Low grade v. Ileus (small bowel or colonic)c. SBO High grade (gasless or large distention)d. Free Air

2) Solid Organsa. Identify Liver edge, spleen, kidneys, psoas, bladder

3) Bones4) Appliances / Surgical Changes5) Periphery of Film

a. Properitoneal fat stripesb. Herniac. Free Air

Abdomen CT:

1) Scout Image review2) Contrast bolus phase, limitations, artifacts3) Heart base

a. sizeb. anemia on non-contrast

4) Lung basesa. nodulesb. airspace disease

5) Solid organs: Liver, Gallbladder, Spleen, Kidneys, Adrenals, Pancreasa. fatty liver, liver masses, includes liver windowb. adrenal nodules

6) Mesentary7) Esophagus, stomach, duodenum, small bowel,

a. special focus on terminal ileumb. appendix

8) Cecum, colon, rectum9) Coronal for 5-810) Vessels

a. include sagital11) Bones

a. include sagital12) Body superficial soft tissue and muscles

Hounsfield Units:0-10 = water10-30 = mixed30-40 = blood un-clotted40-60 = blood clotted (sentinel clot)80-130 = blood and contrast (active extravasation)

Enhancement is a >15 HU change

Right hepatic vein divides the right lobe into anterior and posterior segments.Middle hepatic vein divides the liver into right and left lobes (or right and left hemiliver). This plane runs from the inferior vena cava to the gallbladder fossa.Left hepatic vein divides the left lobe into a medial and lateral part.

Portal vein divides the liver into upper and lower segments.The left and right portal veins branch superiorly and inferiorly to project into the center of each segment.

The Couinaud classification of liver anatomy divides the liver into eight functionally indepedent segments. Each segment has its own vascular inflow, outflow and biliary drainage.In the centre of each segment there is a branch of the portal vein, hepatic artery and bile duct.In the periphery of each segment there is vascular outflow through the hepatic veins.

Chest CT:

1) Scout Image review2) Contrast bolus phase, limitations, artifacts3) Lines and tube positioning4) Thyroid5) Cardiovascular

a. Artery: Aorta, bracheocephalics, subclavian, carotids, vertebrals, coronaries, abdominalb. Vein: IVC, SVC, bracheocepalics, internal jugularsc. Heart: LV, RV, LA, RA, Pulmonary artery trunk diameter, calcifications, aortic and mitral

valvesd. Epicardiume. Pulmonary Artery (max. diameter <30mm) – filling defectsf. Anemia (blood attenuates less than interventricular septum attenuates in noncontrast –

Hbg < 10) 6) Lymph nodes; axillary (<1.5cm) , paratracheal, hilar (<1cm), subcarinal, AP window, esophageal7) Trachea/bronchi, debris?8) Lung: airspace disease, nodules9) Soft Tissues

a. Breast Masses, fibroglandular tissueb. Muscles and Symmetry

10) Bonesa. Ribs, vertebral bodies, transverse process, clavicle, scapulab. MPR for vertebral bodies

11) Esophagus12) Upper Abdomen

Supraclavicular nodes 1. Low cervical, supraclavicular and sternal notch nodesFrom the lower margin of the cricoid to the clavicles and the upper border of the manubrium.The midline of the trachea serves as border between 1R and 1L.

Superior Mediastinal Nodes 2-42R. Upper Paratracheal2R nodes extend to the left lateral border of the trachea. From upper border of manubrium to the intersection of caudal margin of innominate (left brachiocephalic) vein with the trachea.2L. Upper ParatrachealFrom the upper border of manubrium to the superior border of aortic arch.2L nodes are located to the left of the left lateral border of the trachea. 3A. Pre-vascularThese nodes are not adjacent to the trachea like the nodes in station 2, but they are anterior to the vessels. 3P. Pre-vertebralNodes not adjacent to the trachea like the nodes in station 2, but behind the esophagus, which is prevertebral. 4R. Lower Paratracheal From the intersection of the caudal margin of innominate (left brachiocephalic) vein with the trachea to the lower border of the azygos vein.4R nodes extend from the right to the left lateral border of the trachea. 4L. Lower Paratracheal From the upper margin of the aortic arch to the upper rim of the left main pulmonary artery.

Aortic Nodes 5-65. SubaorticThese nodes are located in the AP window lateral to the ligamentum arteriosum. These nodes are not located between the aorta and the pulmonary trunk but lateral to these vessels.6. Para-aorticThese are ascending aorta or phrenic nodes lying anterior and lateral to the ascending aorta and the aortic arch.

Inferior Mediastinal Nodes 7-97. Subcarinal8. ParaesophagealNodes below carina.9. Pulmonary LigamentNodes lying within the pulmonary ligaments.

Hilar, Lobar and (sub)segmental Nodes 10-14These are all N1-nodes.10. Hilar nodesThese include nodes adjacent to the main stem bronchus and hilar vessels. On the right they extend from the lower rim of the azygos vein to the interlobar region. On the left from the upper rim of the pulmonary artery to the interlobar region.

MSK:

Fracture Description (General)1) Location

a. Either in prox, mid, distal thirds or specific anatomic location.2) Type

a. Incompletei. Bowing

ii. Torus (buckled cortex)iii. Greenstick

b. Completei. Simple

ii. Comminuted3) Direction

a. Transverse, oblique, spiral, longitudinal, segmental4) Alignment

a. Angulation i. “apex medial/lateral angulation”

b. Displacementi. Distal fragment relative to proximal fragment

Ankle (ap, lateral, mortise)

Shoulder (ap, axillary, scapular y)

Knee (ap, lateral, oblique)

Elbow1) anterior / posterior fat pad sign2) humeral capiteller line

Foot (ap, oblique, lateral )? lining up of 2nd metacarpal and cuneiforms

Pelvis1) Iliopubic line (anterior column)2) Ilioischial line (posterior column)3) Sacral Arcuate lines4) SI joints5) Pubic symphysis6) Anterior acetabular rim7) Posterior acetabular rim

IVP (worthless study that misses 1/3 of renal masses – still performed at the VA), replaced by CT IVP at most institutions at this point.

1) Preliminary scout radiograph to detect calcifications2) Three tomograms following ~100ml (children 1cc/lb) of IV contrast. The most posterior cut

(eg 9 of 9, 10, 11) should have L2 pedicles in focus.3) Nephrogram should appear symmetric4) Edge around kidney should be complete5) Axis of kidney (long axis of kidney should parrellel the psoas)6) Collecting system axis (should be relatively in line with the longitudinal renal axis o/w a mass

is posible7) All the calces should display contrast simultaneously. An amputed infundibulum may be TCC

or TB8) 5 min radiograph. Check for sharp fornix, pappillary necrosis (ball on tee, lobster claw,

medullary spounge, calyx tic <over the fornix tip as opposed to over the mid papilla as in necrosis)

9) 12 minute bilateral obliques. May also get prone or upright views at this time to see whole ureter

10) Collimated bladder pre and post void

Neuro

Spine MRI:

Protocol: General Note: T1 sequences are angled with the disc so you get entire disc en face. T2 are in a fixed axial or semi-axial plane to allow determination of pars defectDisc disease without hx of operation: Sag T1, T2; Axial T1, T2Disc disease with hx of operation: Sag T1, T2, postcontrast fat sat T1; Axial T1, T2, postcontrast fat sat T1. Post contrast sequences are required to differentiate scar from disc material. Disc does not enhance before 10 minutes or only rim enhances from rim granulation tissue. Scars enhance diffusely and immediately.Cervical Spine: Sag T1, T2; Axial gradient. If there is hx surgery, get T2 axial for hardware (less artifact). Scar is less of a concern in c-spine so contrast is not needed.Trauma: Sag Stir, gradient echo, T1, T2; Axial T1 and T2Metastasis / Infection: Sag Stir, T1, T2, postcontrast fat sat T1; Axial T1, T2, postcontrast fat sat

T1

1) Sagitals T1: Cord Disk signal/height Disk contour Vertebral bodies/marrow signal Spinous processes Nerve roots Neural foramina Central canal Ligaments (ALL/PLL, interspinous, supraspinous Epidural Space In C-spine C1-C2 interval, atlanto-occipital junctions, clivus In lumbar look for conus termination. Muscles

2) Sagital T2: Cord Ligaments (all, pll <attached firmly only at vertebral corners, interspinous, ligamentum

flavum). Annular tear check & disc hydration In c-spine check basilar void and chiari, brain stem and sphenoid sinus.

3) Sagital STIR: Marrow signal (should be isointense to muscle). Ligaments for high signal

4) Sagital Gradient: Epidural hematoma (usually bright on T1 as linear structures)

5) Axial T1/ T2: Nerve roots (clumping) Cord Disk contour Vertebral bodies Neural foramina Central canal Lateral recesses Ligaments (ligamentum flavum)

Epidural space Facets Paraspinal muscles Aorta Retroperitoneum or prevertebral soft tissues / organs Roots for clumping Axial and Sagital T1 post-contrast Soft tissue, cord, roots or for scar enhancment.

6) (See separate document for nomenclature).

Head MRI

1) Axial T2a. Muscles of mastication

i. Tongue, Masseter, Medial & Lateral pterygoids, Temporalis, longus colib. Parotidsc. Orbits

i. Optic Nerve, Extraocular muscles, Intraconal and extraconal post septal fat, Opthalmic vein, Lense, Vitreous

d. Nasopharynx & Paranasal sinusesi. Nasal Cavity

ii. Fossa of Rosenmueller, Torus tuberious, eustachion ostiumiii. Paranasal sinuses and mastoid air cellsiv. Middle ear - blackv. Inner ear - white

e. Blood Vessel voidsi. 2 Verts to basilar

ii. Carotid (cervical, petrous, lacerum, cavernous, supraclinoid)iii. MCA, ACA, ACOM, PCOM

f. Brain stemg. Basal Gangliah. Thalamii. Corpus Callosumj. Cerebral hemispheresk. Sulcil. Sylvian Fissurem. Ventricles

i. Lateral, Foramen of monroe, Aqueduct of Sylvius (check of flow void artifact), Fourth ventricle, Foramen of Luschka and Magendie.

n. Supraseller cistern and associated structures.o. IAC’s

2) FLAIRa. Bright things

3) Sagital T1a. Tongueb. Calvariumc. Skull base, clivusd. Atlanto-occipital jointe. Vertebraef. Spinal cordg. Cerebellar tonsil positionh. Cerebellar vermisi. Medulla, Pons, Midbrain, Tectum, Pineal gland, Mamillary bodies, Tuber cinereum,

Pituitary stalk, Optic chiasmj. Corpus Callosumk. Sagital Sinus flow, Straight sinusl. Tentorium

4) Gradienta. Blood products

5) T1 Axial

a. Review osseous structures6) Diffusion

a. Diffusion restriction7) Post Contrast T1

a. Meninges, ventricles, cisterns, nasal cavity, facial nerve, choroid, orbits, infundibulum, pineal

Head CT:

1) Scout

2) Brain Windowa. 2 Vertebral to basilar, carotid arteryb. Brain stemc. Cerebellumd. Basal gangliae. Thalamif. Corpus Callosumg. Cerebral hemispheresh. Sulcii. Sylvian Fissurej. Lateral and 3rd ventriclesk. Pituitary stalk / optic chiasm l. Suprasellar cisternm. Quadrageminal plate cisternn. Interpeduncular cisterno. 4th ventricle and foramen of Luschka and Magendiep. Pineal gland regionq. Pituitary regionr. Sagital and transverse sinuss. *density of vessels – basilar, bilateral MCA

3) Soft Tissue Windowa. Peripheral soft tissuesb. Muscles of masticationc. Pharynx, d. Retromaxillary fat, parapharyngeal fate. Orbits

4) Bone Windowa. Sinusesb. Mastoidsc. Skull base and foraminad. Sutures

Cervical Spine CT:

1) Sagittal Reconsa. Skull baseb. Atlantooccipital jointc. Predental spaced. Clivus dens relationshipe. Alignment (ant/post spinal, spinolaminar, posterior spinous)f. Facetsg. Spinous processesh. Prevertebral soft tissue width

2) Axial Soft Tissuea. Lung window

i. Large airways, Lung apicesb. Soft tissue

i. Peripheral soft tissuesii. Aerodigestive Tract

1. Orophayrnx2. Epiglottis, vellecula3. Aryepiglottic folds, piriform sinus4. Vocal cords5. Esophagus

iii. Thyroidiv. Lymph nodesv. Submandibular and Parotid glands.

vi. Vessels1. bl Carotids, bl Vertebrals, bl int Jugular

3) Axial Bonea. Vertebral body, posterior elementsb. Spinal canal & Neural foramenc. Hyoidd. Thyroid cartilage

Neck Soft Tissue:

1) Spinal Canal2) Brain algorithm3) Orbits4) Nasopharynx5) Soft palate/uvula (Tensor Veli Palatini CN X, Levator Veli Palatini CN III)6) Tongue (Genioglossus, geniohyoid, mylohyoid, hyoglossus, digastric, fat filled sublingual

space with hypoglossal neurovascular bundle)7) Strap muscles (omohyoid, sternothyroid, thyrohyoid)8) Muscles of mastication9) Parotids (Stensons duct posterior to facial vein, facial muscle is anterior)10) Parapharyngeal fat11) Retromaxillary fat12) Submandibular glands13) Pharynx14) Epiglottis / Vellecula / Piriform Sinus / Aryepiglottic folds / Pre-epiglottic fat15) False Cord, ventricle, true cords16) Subglottic larynx and trachea17) Hyoid18) Arytenoid cartilage19) Thyroid cartilage20) Cricoid cartilage21) Thyroid gland22) Esophagus23) Nodes: right, left, mediastinal, supraclavicular (anywhere you can see clavicles is

supraclavicular level), posterior triangle24) Vessels / carotid sheath25) Posterior neck tissues26) Lungs27) Bones28) Sinuses29) Sagittal bones

Level 1: SubmentalLevel 2: Internal jugular from skull base to carotid bifurcation. (or hyoid bone)Level 3: Internal jugular below carotid bifurcation to omohyoid. (or hyoid bone to cricoid cartilage)Level 4: Internal jugular below omohyoid. (from cricoid to supraclavicular region)Level 5: Posterior triangle.Level 6: Adjacent to thyroid. (This level can spread all the way to mediastinum, the 2,3,4 stations are like train station and must spread to each one before hitting mediastinum.)Level 7: Tracheal esophageal groove and superior mediastinum. (Tracheoesophageal groove is where recurrent laryngeal nerve lies)

Level I : below myohyoid to hyoid bone anteriorly, Level Ia : submental, Level Ib : submandibularLevel II : jugulodigastric (base of skull to hyoid)Level III : deep cervical (hyoid to cricoid) Level IV : Virchow (cricoid to clavicle) Level Va : accessory spinal (posterior triangle) : superior halfLevel Vb : accessory spinal (posterior triangle) : inferior half Level VI : prelaryngeal / pretracheal / Delphian nodeLevel VII : superior mediastinal (between CCAs, below top of manubrium)

Brain Ultrasound:

1) How to Aquire images: Use ?5/8Mhz curved small transducer. Light points to patient right on transverse and forward on sagitals. Capture serial cronoal images anterior to posterior. Aquire sagitals starting on right then to left.

2) Ventriclesa) Chroid plexus usually in body, trigone, extending into 3rd ventricle. Should not be in frontal or occipital

hornsb) Echogenicity. Blood > choroid plexus > periventricular blush.c) Differential for echogenic signal is blood, acute stroke or periventricular leukomalacia, periventricular

blushd) 3rd ventricle typically not visible unless enlarged.

3) Periventricular paranchyma for PVL (cystic lesions chronically or echogenic acutely).4) Gyration – premature brain has less gyri.5) Calcifications – look periventricularly – indicitive of TORCH infection6) Caudate Nucleus – on sagitals a hypoechoic band adjacent to lateral ventricles.7) Corpus callosum8) Caudo-thalamic groove for hemorrhage.9) Vein of gallen (posterior to 3rd ventricle)

L-spine:Lateral

1) Number of rib bearing vertebrae2) Alignment3) Spinous processes4) Facets5) Body shape6) Disc height

AP1) Transverse processes2) Alignment3) Pedicles (widened in dural ectasia and spinal tumors, gone in mets or surgery)4) Urolithiasis

C-Spine:Views: Open-mouth odontoid, AP, Lateral,

Obliques (when patient looks to the right, you see the left neural foramen)

1) Look for C-collar2) Count vertebral bodies visible on lateral view3) Anterior vertebral line4) Posterior vertebral line5) Spinolamenar line6) Posterior spinous line7) Uncal-vertebral joints should shingle8) Predental space < 3mm adults, < 5mm children9) Examine skull / mandible / occiput for fractures 10) Space between atlanto-axial space (base, dens and lateral mass of c1 & c2 should line up) C1-

C2 distance should be < 3mm in adults 11) Scottie dog, check neural foramen 12) Posterior soft tissues: Hyoid & stylohyoid ligament, epiglotis and areyepiglotic folds,

vallecula, larynx, subglottic trachea 13) Prevertebral soft tissue C4-C5 can be width of vertebral body, above this, <=7mm or 1/3

vertebral body width okay) 14) Lung apices

Sinus Plain Films:Sinus Development: Birth: rudimentary ethmoid and maxillary

3-5 yrs: Development of sphenoid and then frontal with enlargement of ethoids and maxillary

Visualization of the Paranasal Sinuses*Maxillary 2 - 3 moEthmoidal 3 - 6 moSphenoidal 1 - 2 yFrontal 8 -10 y

All Views: Evaluate thin cortical rim of sinuses and adjacent density (mucosal thickening) and look for straight lines (air fluid levels).

AP: evaluate ethmoids, frontalLateral: evaluate sphenoid, frontal, ethmoids)Waters: looking up to move petrous temporal (mastoid) out of way of

maxillary sinus

Cardiac

MRI1) Left Ventricle chamber size2) Left Ventricle wall thickness3) Left Ventricle contractility4) Right Ventricle chamber size5) Right Ventricle wall thickness6) Right Ventricle contractility7) Right Atrial size8) Left Atrial size9) Interatrial septum10) Interventricular septum11) Aortic valve12) Pulmonic valve13) Tricuspid valve14) Mitral valve15) (velocity encoded sequences)

Breast Calcifications:1) Density

a. Highb. Low

2) Calcificationa. Round or linearb. Course or finec. Mono or pleomorphic

3) Distributiona. Uni or bilateralb. Focal or multifocalc. Diffuse or segmental.