Anatomy for Diagnostic Imaging, 3e
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Anatomy for Diagnostic Imaging, 3e

385 Lei 336 Lei(TVA inclus)
Livrare gratis la comenzi peste 500 RON. Pentru celelalte comenzi livrarea este 20 RON.

Cod produs/ISBN: 9780702029714

Disponibilitate: La comanda in aproximativ 4 saptamani

Editura: Elsevier

Limba: Engleza

Nr. pagini: 337

Coperta: Paperback

Dimensiuni: 22.23 x 1.91 x 27.94 cm

An aparitie: 24 Sept. 2010

 

Description:

 

This book covers the normal anatomy of the human body as seen in the entire gamut of medical imaging. It does so by an initial traditional anatomical description of each organ or system followed by the radiological anatomy of that part of the body using all the relevant imaging modalities. The third edition addresses the anatomy of new imaging techniques including three-dimensional CT, cardiac CT, and CT and MR angiography as well as the anatomy of therapeutic interventional radiological techniques guided by fluoroscopy, ultrasound, CT and MR. The text has been completely revised and over 140 new images, including some in colour, have been added. A series of 'imaging pearls' have been included with most sections to emphasise clinically and radiologically important points. The book is primarily aimed at those training in radiology and preparing for the FRCR examinations, but will be of use to all radiologists and radiographers both in training and in practice, and to medical students, physicians and surgeons and all who use imaging as a vital part of patient care. The third edition brings the basics of radiological anatomy to a new generation of radiologists in an ever-changing world of imaging.

This book covers the normal anatomy of the human body as seen in the entire gamut of medical imaging. It does so by an initial traditional anatomical description of each organ or system followed by the radiological anatomy of that part of the body using all the relevant imaging modalities. The third edition addresses the anatomy of new imaging techniques including three-dimensional CT, cardiac CT, and CT and MR angiography as well as the anatomy of therapeutic interventional radiological techniques guided by fluoroscopy, ultrasound, CT and MR. The text has been completely revised and over 140 new images, including some in colour, have been added. A series of 'imaging pearls' have been included with most sections to emphasise clinically and radiologically important points. The book is primarily aimed at those training in radiology, but will be of use to all radiologists and radiographers both in training and in practice, and to medical students, physicians and surgeons and all who use imaging as a vital part of patient care. The third edition brings the basics of radiological anatomy to a new generation of radiologists in an ever-changing world of imaging.

Anatomy of new radiological techniques and anatomy relevant to new staging or treatment regimens is emphasised.

'Imaging Pearls' that emphasise clinically and radiologically important points have been added throughout.

The text has been revised to reflect advances in imaging since previous edition.

Over 100 additional images have been added.

 

 

Table of contents:

 

1 Head and neck

The skull and facial bones

The skull vault (Figs 1.1–1.4)

Figure 1.1 • (A) Lateral view of skull. (B) Frontal view of skull.

Figure 1.2 • Three-dimensional (3D) CT skull of a 2-month-old infant to show sutures, (A) lateral and (B) anterior. 1Coronal suture2Zygomaticofrontal suture3Pterion4Sphenotemporal (sphenosquamosal) suture5Temporoparietal (squamosal) suture6Asterion7Lambdoid suture8Wormian bones9Lambda10Sagittal suture11Anterior fontanelle12Metopic suture13Nasofrontal suture14Zygomaticofrontal suture

The skull base (Figs 1.5, 1.6)

Individual bones of the skull base

Figure 1.3 • Lateral skull radiograph. Bony landmarks1Bregma2Coronal suture3Lambda4Lambdoid suture5Vertex6Inner skull table7Outer skull table8Internal occipital protuberance9External occipital protuberance10External auditory meatus11Styloid process12Clivus13Dorsum sellae14Posterior clinoid process15Anterior clinoid process16Pituitary fossa (sella turcica)17Tuberculum sellae18Planum sphenoidale19Greater wings of sphenoid20Undulating floor of anterior cranial fossa (roof of orbit)21Anterior limit of foramen magnum22Posterior limit of foramen magnum23Posterior wall of maxillary sinus24Floor of orbit25Hard palate26Neck of mandible27Temporomandibular joint28Condylar (mandibular) canalVascular markings29Middle meningeal vessels: anterior branches30Middle meningeal vessels: posterior branches31Transverse sinus32Diploic vein33Diploic venous confluence: parietal starSinuses/air cells34Frontal sinus35Sphenoid sinus36Posterior ethmoidal cells37Maxillary sinus38Mastoid air cellsSoft tissues39Soft palate40Base of tongue

Bony landmarks

Vascular markings

Sinuses/air cells

Soft tissues

Figure 1.4 • OF20 skull radiograph. 1Sagittal suture2Frontal sinus3Planum sphenoidale4Crista galli5Perpendicular plate of ethmoid6Floor of pituitary fossa7Nasal septum8Ethmoid air cells9Superior orbital fissure10Lesser wing of sphenoid11Innominate line12Zygomatic process of frontal bone13Zygomaticofrontal suture14Frontal process of zygomatic bone15Foramen rotundum16Petrous ridge17Maxillary sinus18Inferior nasal turbinate19Mastoid process20Occipital bone21Dens of atlas

Figure 1.5 • (A) Skull base: internal aspect. (B) 3D CT of skull base, internal aspect. 1Crista galli2Anterior clinoid process3Optic canal4Posterior clinoid process5Cribriform plate6Posterior ethmoidal foramen7Foramen ovale8Foramen spinosum9Foramen lacerum10Jugular foramen11Foramen magnum

Figure 1.6 • (A) SMV view of skull; (B) Skull base. 3D CT of skull base, inferior view.(A) Bony landmarks1Odontoid process of C22Anterior arch of C13Posterior limit of foramen magnum4Transverse process of C15Foramen transversarium of C16Condylar process of mandible7Coronoid process of mandible8Zygomatic arch9Posterior wall of maxillary sinus10Lateral boundary of orbit11Lesser wing of sphenoid: anterior limit of middle cranial fossa12Nasal septum13Posterior limit of hard palate14ClivusForamina and canals15Foramen ovale16Foramen spinosum17Carotid canal18Bony part of eustachian tube(Note: Foramen rotundum or jugular foramen cannot be seen on SMV.)Air space and sinuses19Air in nasopharynx20Sphenoid sinus21Ethmoid air cells22Mastoid air cells23Pneumatization in petrous bone24Maxillary sinus(B) 1Greater palatine foramen2Pterygoid plate3Foramen ovale4Foramen spinosum5External acoustic foramen6Jugular fossa7Foramen lacerum8Groove for pharyngotympanic tube9Styloid process10Stylomastoid foramen11Foramen magnum

Bony landmarks

Foramina and canals

Air space and sinuses

Figure 1.7 • Pituitary fossa: lateral view.

Cranial fossae (Fig. 1.5)

Foramina of the skull base (Figs 1.5, 1.6; Table 1.1)

Radiology pearl

Table 1.1 Foramina of the skull base

Radiological features of the skull base and vault

Plain films

Radiology pearl

Radiology pearl

Cross-sectional imaging

The neonatal and growing skull

Radiology pearl

Calcification on the skull radiograph in the normal person (see also Chapter 2)

The facial bones (Figs 1.1, 1.8)

The zygoma

The nasal bones

Radiology pearl

The bony orbit (Fig. 1.10)

Radiology pearl

Figure 1.8 • OM skull radiograph. 1Frontal sinus2Ethmoid sinus3Nasal septum4Inferior orbital rim5Infraorbital foramen6Lamina papyracea (medial wall of orbit)7Medial wall of maxillary sinus8Maxillary sinus9Innominate line10Anterior nasal spine11Zygomatic process of frontal bone12Zygomaticofrontal suture13Zygomatic arch14Coronoid process of mandible15Body of mandible16Odontoid process of C217Transverse process and foramen transversarium of C1

Figure 1.9 • Lateral radiograph of nasal bones. 1Frontonasal synchondrosis2Nasal spine of frontal bone3Groove for anterior ethmoidal nerve

Radiology of the bony orbit

Plain films

Computed tomography

The nasal cavity and paranasal sinuses (Figs 1.8, 1.11)

The nasal cavity

Blood supply of the nasal cavity

Figure 1.10 • (A) Bony orbit.(B) 3D CT of orbit AP. 1Supraorbital notch2Nasal septum3Infraorbital foramen4Superior orbital fissure5Zygomaticofrontal suture6Greater wing of sphenoid7Nasolacrimal canal8Lateral aspect of inferior orbital fissure9Orbital process of maxillary bone

Radiology pearl

The paranasal sinuses

The frontal sinuses

Figure 1.11 • Coronal CT scan of the sinuses: (A) coronal view at level of ostiomeatal complex and (B) posterior at level of sphenoethmoidal recess. 1Nasal septum2Maxillary sinus3Middle nasal turbinate4Inferior nasal turbinate5Superior meatus6Middle meatus7Inferior meatus8Ethmoid infundibulum9Uncinate process10Maxillary ostium11Maxillary infundibulum12Infraorbital nerve13Alveolar process of maxilla14Ethmoid sinus15Sphenoid sinus16Sphenoethmoidal recess17Superior turbinate18Greater palatine canal

The ethmoid sinuses

The sphenoid sinuses

The maxillary sinuses

Radiology of the nasal cavity and paranasal sinuses

Plain films (Fig. 1.8)

Computed tomography and MRI

Radiology pearl

The mandible and teeth

The mandible (Figs 1.12, 1.13, 1.18)

Figure 1.12 • Mandible: inner aspect.

Figure 1.13 • 3D CT of mandible. 1Oblique line2Mental foramen3Mental protuberance4Mental tubercle5Body of mandible6Coronoid process7Mandibular notch8Condylar process9Neck10Ramus11Angle12Mandibular foramen13Mylohyoid line

Figure 1.14 • Temporomandibular joint.

The temporomandibular joint (Figs 1.14–1.16)

Figure 1.15 • Radiographs of temporomandibular joints, (A) closed mouth and (B) open mouth views. 1Articular tubercle2Temporomandibular fossa3Head4External auditory meatus5Neck

The teeth – nomenclature and anatomy (Figs 1.17–1.19)

Figure 1.16 • MRI of the TMJ; (A) closed mouth view; (B) open mouth view. 1Head of mandible2Articular tubercle3Temporal lobe4External auditory meatus5Lateral pterygoid muscle6Fibrocartilaginous disc

Radiology of the mandible and teeth (Figs 1.15–1.19)

Plain films

Cross-sectional imaging (Figs 1.13, 1.16)

Dental pantomography

Figure 1.17 • (A) The structure of teeth, adult.(B) Radiograph of the teeth, adult. 1Bone2Lamina dura3Periodontal membrane4Root canal5Pulp cavity6Dentine7Enamel

Arthrography

The oral cavity and salivary glands

The oral cavity (Figs 1.20, 1.21)

Figure 1.18 • Dental pantomogram. The third molars have been extracted. 1Condylar process of mandible2Temporomandibular fossa3Hard palate4Maxillary sinus5Medial wall of maxillary sinus6Floor of maxillary sinus7Condylar canal8Ramus of mandible9Angle of mandible10Body of mandible11Mandibular notch12Upper left incisor13Hyoid bone (projected laterally)14Ear lobe

Figure 1.19 • Radiograph of the teeth of 9-year-old child. 1Resorbing roots of a deciduous tooth2Unerupted teeth

Radiology of the oral cavity (Fig. 1.21)

Figure 1.20 • Floor of mouth: coronal section.

Figure 1.21 • MRI of mouth. (A) Coronal section; (B) Sagittal section.(A) 1Hard palate2Intrinsic muscles of tongue3Lingual septum4Mandible5Genioglossus muscle6Platysma muscle7Submandibular gland8Geniohyoid muscles9Mylohyoid muscle(B) 1Hard palate2Soft palate3Intrinsic muscles of tongue4Lingual septum5Genioglossus muscle6Mylohyoid muscle7Hyoid bone8Mandible

Figure 1.22 • Parotid gland: (A) lateral view; (B) transverse section.

The salivary glands

The parotid gland (Figs 1.22–1.24)

Figure 1.23 • Axial MRI parotid. 1Medial pterygoid muscle2Mandible3Masseter muscle4Internal carotid artery5Internal jugular vein6Parotid gland7External carotid artery and posterior facial vein8Mastoid process9Sternocleidomastoid muscle

Figure 1.24 • Sialography: (A) AP view of parotid gland; (B) lateral view of parotid gland; (C) lateral view of submandibular gland. Note how the duct and its branches are moulded around the ramus of the mandible.(A) 1Cannula in parotid duct2Parotid duct (Stensen's)3Normal branching ductules4Condylar process of mandible5Angle of mandible6Body of mandible(B) 1Cannula in parotid orifice2Parotid duct3Secondary ductules4Contrast on surface of tongue5Condylar process of mandible6Angle of mandible(C) 1Cannula in orifice of submandibular duct2Submandibular duct3Secondary ductules4Contrast on superior surface of tongue5Condylar process of mandible6Coronoid process of mandible7Mandibular notch

The submandibular gland (Figs 1.24C, 1.25)

The sublingual gland (Fig. 1.20)

Radiology of the salivary glands

Sialography (Fig. 1.24)

CT and MRI (Figs 1.23, 1.35)

Figure 1.25 • Ultrasound of submandibular gland. 1Submandibular gland – superficial part2Submandibular gland – deep part3Mylohyoid muscle4Submandibular duct5Facial vein6Digastric muscle

Ultrasound (Fig. 1.25)

Radiology pearl

Nuclear imaging

The orbital contents (Fig. 1.26)

Figure 1.26 • (A) Orbit: sagittal section. (B) Eye: internal anatomy; sagittal section.

Radiology pearl

Figure 1.27 • Ultrasound of eye.(A) Transverse image showing anterior structures. 1Anterior chamber2Iris3Anterior aspect of lens4Posterior aspect of lens5Vitreous body(B) Longitudinal image showing posterior structures. 1Vitreous body2Retinal surface3Optic nerve4Retrobulbar fat5Lateral rectus muscle6Lateral wall of bony orbit

Internal anatomy and coverings of the eye (Fig. 1.26)

Radiology of the orbit and eye (Figs 1.27–1.29)

Plain films

Radiology pearl

Ultrasound

Figure 1.28 • CT scan of orbit: axial section through optic nerve. 1Nasal septum2Nasal bone3Ethmoid air cells4Globe of left eye5Sclera6Optic nerve7Medial rectus muscle8Lateral rectus muscle9Superior ophthalmic vein10Optic canal11Anterior clinoid process (pneumatized)12Superior orbital fissure13Middle cranial fossa14Greater wing of sphenoid15Frontal process of zygomatic bone16Temporal fossa/temporalis muscle

Computed tomography (Fig. 1.28)

Figure 1.29 • MR of orbit: axial image at level of nasolacrimal gland. 1Globe of right eye2Sclera3Optic nerve4Larimal gland5Medial rectus muscle6Lateral rectus muscle7Optic canal8Temporal lobe of brain9Greater wing of sphenoid10Frontal process of zygomatic bone11Temporalis muscle12Ethmoid air cells

Magnetic resonance imaging (Fig. 1.29)

Figure 1.30 • (A) Lacrimal apparatus: coronal section.(B) Nasolacrimal duct. Coronal CT through anterior nose. 1Lacrimal gland2Ethmoid infundibulum draining to middle meatus3Upper end of right nasolacrimal duct4Inferior turbinate5Crista galli6Middle turbinate7Inferior part of left nasolacrimal duct8Opening of nasolacrimal duct

The lacrimal apparatus (Fig. 1.30)

Radiology of the lacrimal gland

Dacryocystography

CT (Fig. 1.30B) and MRI

The ear (Figs 1.31–1.33)

The external ear

The middle ear

Figure 1.31 • Ear: coronal section showing outer, middle and inner ear.

Radiology pearl

The inner ear

Figure 1.32 • (A) Axial T2 MRI to show the internal auditory meatus and its contained nerves; (B) Diagram of membranous labyrinth; (C) Membranous labyrinth as seen on 3D MRI.(A) 1Cochlea2Vestibulocochlear nerve3Facial nerve4Basilar artery with flow artefact5Cerebellopontine angle cistern(C) 1Cochlear duct2Superior semicircular canal3Posterior semicircular canal4Lateral semicircular canal5Utricle6Endolymphatic duct7Utriculosaccular duct8Saccule9Internal auditory meatus

The internal auditory meatus (Fig. 1.33)

Figure 1.33 • CT scan of inner ear: (A) axial section at mid-cochlear level; (B) coronal section in vestibular plane; (C) axial CT to show the cochlear duct; (D) axial CT to show the vestibular duct. 1Cochlear turns2Internal auditory meatus3Vestibule4Posterior semicircular canal5Facial nerve in its bony canal6Malleus7Incus8Epitympanic recess9Mastoid air cells10Middle cranial fossa11Posterior cranial fossa12Lambdoid suture13Superior semicircular canal14Lateral semicircular canal15Oval window16Crista falciformis17Scutum18External auditory meatus19Mastoid antrum20Aditus ad antrum

Development of the ear

Radiology of the middle and inner ear

Plain films

Computed tomography (Fig. 1.33)

Magnetic resonance imaging (Fig. 1.32)

Radiology pearl

The pharynx and related spaces (Fig. 1.34)

Radiology pearl

The nasopharynx and related spaces (Fig. 1.35)

The nasopharynx

Figure 1.34 • Pharynx: sagittal section: (A) diagram; (B) sagittal T1 MRI. 1Soft palate2Adenoids3Middle turbinate4Inferior turbinate5Hard palate6Intrinsic muscle of tongue7Genioglossus8Mandible9Mylohyoid muscle10Hyoid bone11Epiglottis12Vocal cord13Thyroid cartilage14Nasopharynx15Oropharynx16Corniculate cartilage17Arytenoid cartilage18Cricoid cartilage

Figure 1.35 • Nasopharynx: axial section.(A)Diagram.(B)Axial CT.1Nasopharyngeal space2Prevertebral muscle3Lateral pharyngeal recess, fossa of Rosenmueller4Cartilaginous end of eustachian tube5Opening of eustachian tube6Torus tubarius7Pterygoid bone8Medial pterygoid plate9Medial pterygoid muscle10Lateral pterygoid plate11Lateral pterygoid muscle12Parapharyngeal space13Styloid process14Internal carotid artery15Internal jugular vein16Parotid gland17Ramus of mandible18Infratemporal space19Coronoid process of mandible and masseter muscle20Zygoma21Maxillary sinus22Polyp in left maxillary sinus23Nasal bone24Nasal septum

Figure 1.36 • Infratemporal fossa: axial section.

Spaces related to the nasopharynx

Figure 1.37 • CT of pterygopalatine fossa. * = pterygopalatine fossa.(A) 1Inferior orbital fissure2Foramen rotundum3Pterygomaxillary fissure4Cut ends of zygomatic arch5Maxilla6Lateral pterygoid plate7Greater palatine foramen(B) 1Maxillary sinus2Sphenopalatine foramen3Pterygomaxillary fissure4Zygomatic arch5Vidian canal6Foramen ovale7Foramen spinosum8Mandibular head9Carotid foramen10Jugular foramen(C) 1Sphenoid sinus2Inferior orbital fissure3Sphenopalatine foramen4Pterygomaxillary fissure5Maxillary sinus6Greater palatine canal7Greater palatine foramen8Nares9Unerupted teeth10Zygomatic arch11Mandible

The oropharynx and laryngopharynx

Cross-sectional anatomy of the nasopharynx (Figs 1.34–1.36)

Radiology of the pharynx (Figs 1.34–1.38)

Plain films (Fig. 1.38)

Figure 1.38 • Lateral radiograph of the neck: soft-tissue view showing pharynx and larynx. 1Nasopharynx2Soft palate3Oropharynx4Laryngopharynx5Hyoid bone6Epiglottis7Aryepiglottic fold8Laryngeal ventricle9Prevertebral space10Trachea

Palatal studies and videofluoroscopic feeding studies

Radiology pearl

Cross-sectional imaging

Radiology pearl

The larynx (Figs 1.38–1.42)

Figure 1.39 • 3D CT larynx. 1Nares2Nasopharynx3Tongue4Oropharynx5Epiglottis6Vallecula7Piriform sinus8False cocal cord9Laryngeal ventricle10True vocal cord11Trachea

Figure 1.40 • Larynx: (A) sagittal section showing cartilages; (B) coronal section.

Cross-sectional anatomy of the larynx (Figs 1.41, 1.42)

Supraglottic level (Figs 1.41A, 1.42A)

Glottic level (Figs 1.41B, 1.42B)

Figure 1.41 • Larynx: (A) axial section, supraglottic level; (B) axial section, glottic level; (C) axial section, infraglottic level.

Infraglottic level (Figs 1.41C, 1.42C)

Radiology of the larynx (Figs 1.38, 1.39, 1.42)

Plain radiography

CT and MRI

The thyroid and parathyroid glands

The thyroid gland (Figs 1.42–1.44)

Figure 1.42 • CT scan of the larynx/neck: (A) supraglottic level; (B) glottic level; (C) infraglottic level.(A) 1Base of tongue2Median glossoepiglottic fold3Lateral glossoepiglottic fold4Vallecula5Epiglottis6Laryngopharynx7Pharyngeal constrictor muscle8Greater cornu of hyoid bone9Tip of piriform sinus (the sinus is separated from the laryngopharynx on lower cuts by the aryepiglottic fold)10Internal carotid artery11Internal jugular vein12Sternomastoid muscle13External jugular vein14Submandibular gland15Platysma muscle16Subcutaneous fat17Prevertebral muscle18Foramen transversarium(B) (There is a pathological abscess in the left sternomastoid muscle.) 1Thyroid cartilage2Cricoid cartilage3Vocal process of arytenoid cartilage4Vocal cord5Anterior commissure6Laryngopharynx7Upper pole of thyroid gland8Anterior jugular vein9Strap muscles10Sternomastoid muscle11Internal jugular vein12Common carotid artery13External jugular vein14Prevertebral muscle15Abscess in sternomastoid muscle(C) 1Cricoid cartilage2Cricothyroid membrane3Right lobe of thyroid gland4Left lobe of thyroid gland5Oesophagus (collapsed)6Prevertebral muscles7Common carotid artery8Internal jugular vein9Sternomastoid muscle10External jugular vein11Anterior jugular veins

Figure 1.43 • Thyroid gland: (A) gross anatomy; (B) axial section.

Cross-sectional anatomy (Fig. 1.43B)

Figure 1.44 • Ultrasound of the thyroid gland showing left lobe. 1Strap muscle2Sternomastoid muscle3Isthmus4Trachea5Left common carotid artery6Left lobe of gland7Left internal jugular vein

Blood supply and lymph drainage

Ectopic thyroid tissue

Radiology pearl

Radiology of the thyroid gland

Ultrasound (Fig. 1.44)

Nuclear medicine studies

CT (Fig. 1.42C)

Magnetic resonance imaging

The parathyroid glands

Radiology of the parathyroid glands

Cross-sectional imaging

Nuclear medicine studies

The neck vessels

The carotid arteries in the neck (Figs 1.45–1.52)

Figure 1.45 • Ultrasound of the carotid artery: longitudinal section. CCCommon carotid arteryICInternal carotid arteryECExternal carotid artery

Figure 1.46 • Carotid artery in the neck.

Anatomical relations of the common carotid artery within the carotid sheath

Figure 1.47 • Arch aortogram: subtraction film. The catheter is in the aortic arch. All branches of the external carotid are shown except the occipital artery. The facial artery is not filling on the right. 1Arch of aorta2Brachiocephalic trunk3Right common carotid artery (superimposed upon the subclavian artery)4Right subclavian artery5Right vertebral artery6Left common carotid artery7Left subclavian artery8Left vertebral artery9Right external carotid artery10Sinus of right internal carotid artery11Left internal carotid artery12Left external carotid artery13Right superior thyroid artery (arising from the external carotid artery)14Left superior thyroid artery (arising from common carotid artery)15Right lingual artery16Left lingual artery17Left facial artery18Left ascending pharyngeal artery19Left posterior auricular artery20Right posterior auricular artery21Right maxillary artery22Middle meningeal artery (branch of right maxillary artery)23Right superficial temporal artery

Anatomical relations of the internal carotid artery within the carotid sheath

Anatomical relations of the external carotid artery

Figure 1.48 • Carotid arteries in neck. (A) MR angiogram; (B) CT angiogram.(A) 1Superficial temporal artery2Maxillary artery3Lingual artery4External carotid artery5Origin of superior thyroid artery6Common carotid artery7Posterior auricular artery8Occipital artery9Ascending pharyngeal artery10Internal carotid artery11Vertebral artery(B) 1Occipital artery2Internal carotid artery3Facial artery4Lingual artery5External carotid artery6Superior thyroid artery7Common carotid artery

Branches of the external carotid artery (Figs 1.46–1.48)

Superior thyroid artery

Ascending pharyngeal artery

Lingual artery

Facial artery

Figure 1.49 • Veins of the face and neck.

Figure 1.50 • Subclavian angiogram. 1Left common carotid artery2Left subclavian artery3Vertebral artery4Thyrocervical trunk5Transverse cervical artery6Internal thoracic artery7Thoracoacromial artery8Acromial artery9Lateral thoracic artery10Subscapular artery

Figure 1.51 • Arteries in the root of the neck.

Figure 1.52 • Veins in the root of the neck.

Occipital artery

Posterior auricular artery

Superficial temporal artery

Maxillary artery

Radiology of the carotid vessels (Figs 1.45, 1.47, 1.48)

Ultrasound (Fig. 1.45)

Angiography

CT and MRI

Venous drainage of the head and neck (Figs 1.49, 1.52)

Radiology of the veins of the head and neck

The subclavian arteries in the neck (Figs 1.50, 1.51)

Branches of the subclavian artery in the neck

Figure 1.53 • Brachial plexus.

The subclavian veins in the neck (Fig. 1.52)

Radiology of the subclavian vessels

Ultrasound

Figure 1.54 • Coronal MRI brachial plexus. 1Sternomastoid muscle2Roots of brachial plexus3Scalenus anterior muscle

Angiography, CT angiography and MR angiography

The brachial plexus (Figs 1.53, 1.54)

Radiology of the brachial plexus

CT and MRI (Fig. 1.54)

2 The central nervous system

Cerebral hemispheres

Cerebral cortex (Figs 2.1, 2.2)

Frontal lobe

Motor cortex

Premotor cortex

Figure 2.1 • (A) Superolateral surface of the cerebral hemisphere. (B) Sagittal MRI of brain lateral to midline.(B) 1Central sulcus2Parieto-occipital sulcus3Insula4Temporal horn of lateral ventricle and hippocampus

Figure 2.2 • (A) Medial surface of the cerebral hemisphere. (B) Midline sagittal MRI of the brain.(B) 1Cingulate gyrus2Central sulcus3Parieto-occipital sulcus4Corpus callosum5Fornix

Prefrontal area

Parietal lobe

Sensory cortex

Parietal association cortex

Temporal lobe

Auditory cortex

Temporal association cortex

Occipital lobe

Visual cortex

Occipital association cortex

Insula (of Reil)

Radiological features of the cerebral cortex

CT and MRI

Ultrasound examination of the neonatal brain

White matter of the hemispheres

Commissural fibres

The corpus callosum (Figs 2.4, 2.5)

Figure 2.3 • MRI of brain: (A) level of the pons; (B) level of midbrain; (C) level of the lateral ventricles; (D) above lateral ventricles.(A) 1Ethmoid sinus2Globe3Left temporal lobe4Pons5Fourth ventricle6Right cerebellar hemisphere7Petrous part of temporal bone8Basilar artery9Cerebellar peduncle10Transverse sinus11Pinna of ear12Greater wing of sphenoid bone(B) 1Interhemispheric fissure2Left frontal lobe3Sylvian fissure (containing branches of the middle cerebral artery)4Cerebral peduncle of midbrain5Aqueduct of Sylvius6Great cerebral vein in quadrigeminal cistern7Cerebellar vermis8Optic tract9Left ambient cistern10Superior colliculus and quadrigeminal plate (tectum) of midbrain11Left occipital lobe12Superior sagittal sinus13Anterior cerebral arteries(C) 1Interhemispheric fissure2Tapetum3Corpus callosum4Head of caudate nucleus5Anterior horn of right lateral ventricle6Interventricular foramen7Sylvian fissure8External capsule9Anterior limb of internal capsule10Putamen of lentiform nucleus11Globus pallidus of lentiform nucleus12Posterior limb of internal capsule13Thalamus14Atrium and choroid plexus of lateral ventricle15Calcarine sulcus16Superior sagittal sinus17Septum pellucidum(D) 1Centrum semiovale2Central sulcus – note characteristic inverted omega shape

Anterior commissure (Figs 2.4, 2.6)

Figure 2.4 • Corpus callosum and other commissures.

Habenular commissure

Posterior commissure

Figure 2.5 • MRI scan of brain: midline sagittal image. 1Frontal lobe2Parietal lobe3Occipital lobe4Rostrum of corpus callosum5Genu of corpus callosum6Body of corpus callosum7Splenium of corpus callosum8Septum pellucidum9Foramen of Monro10Fornix11Massa intermedia of thalami12Third ventricle13Supraoptic recess of third ventricle14Suprapineal recess of third ventricle15Pineal gland16Optic chiasm17Midbrain18Interpeduncular cistern19Aqueduct of Sylvius20Quadrigeminal plate (superior and inferior colliculi)21Quadrigeminal plate cistern22Fourth ventricle23Vermis of cerebellum24Pons25Tonsil of cerebellum26Prepontine cistern27Medulla oblongata28Odontoid process29Cisterna magna30Clivus31Pituitary32Tentorium cerebelli33Spinal cord

Hippocampal commissure

Projection fibres

Internal capsule (see Fig. 2.3C)

Radiological features of the commissural and projection fibres

Plain films of the skull

CT and MRI

Figure 2.6 • Anterior commissure. (A) Axial T2 MRI. (B) Midline sagittal MRI. (C) Cor MRI.(B) 1Corpus callosum2Head of caudate nucleus3Internal capsule4External capsule5Anterior commissure(C) 1Corpus callosum2Fornix3Anterior commissure4Mamillary body

Figure 2.7 • Coronal MRI of brain. (A) Image through the third ventricle. (B) Subthalamic nuclei.(A) 1Superior sagittal sinus2Interhemispheric fissure3Tapetum4Body of corpus callosum5Septum pellucidum6Fornix7Third ventricle8Sphenoid sinus9Sylvian fissure10Insula11External capsule12Lentiform nucleus13Head of caudate nucleus14Internal capsule(B) 1Head of caudate nucleus2Thalamus3Putamen4Globus pallidus5Subthalamic nucleus

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Figure 2.8 • Myelination of infant brain as seen on T1 and T2 MR images at level of the internal capsule. (A) T1 newborn – only the white matter in the posterior limb of internal capsule is bright, indicating that only these fibres are myelinated. (B) T1 at 1 year old; almost all white matter is bright now. Only the most superficial subcortical fibres have not achieved adult appearance so that grey–white differentiation remains a little blurred. (C) T1 at 2 years old. All white matter is bright and myelinated now including the subcortical white matter into the depth of each gyrus. The grey–white differentiation is sharp now. (D) T2 newborn – only the white matter in the posterior limb of internal capsule is dark indicating myelination. (E) T2 at 1 year old. All of the internal capsule, the corpus callosum and the deep white matter (especially posteriorly) are dark. The superficial subcortical fibres have not achieved adult appearance and grey–white differentiation remains blurred. (F) T2 at 2 years old. All white matter is dark and myelinated now including the subcortical white matter into the depth of each gyrus.

Ultrasound examination of the neonatal brain (Fig. 2.10)

Basal ganglia (Figs 2.11, 2.12)

Figure 2.9 • MR tractography 3D image depicting fibres passing from brain stem to cerebral cortex. Reference axial slice shows fibres as they pass through the posterior limb of the internal capsule on both sides.

Figure 2.10 • Ultrasound of infant brain. (A) Coronal image through the frontal horns of the lateral ventricles; (B) coronal image through body of the lateral ventricle. (C) Midline sagittal image; (D) parasagittal image through lateral ventricle. 1Interhemispheric fissure2Sulci3Frontal horn of lateral ventricle4Corpus callosum5Caudate above, lentiform nucleus below, separated by internal capsule (these three are not distinguished separately)6Sylvian fissure7Brainstem8Parahippocampal gyrus of temporal lobe9Choroid plexus in atrium of lateral ventricle10Calcarine sulcus11Genu of corpus callosum12Cavum septum pellucidum13Cingulate gyrus14Midbrain15Pons16Medulla17Fourth ventricle18Vermis of cerebellum19Third ventricle20Body of lateral ventricle21Hippocampus22Fornix

Caudate nucleus

Lentiform nucleus

Figure 2.11 • Basal ganglia.

Claustrum (Fig. 2.12)

Radiological features of the basal ganglia

CT and MRI

Figure 2.12 • MRI of Claustrum + striatal fibres. (A) Cor; (B) axial. 1Claustrum2Head of caudate nucleus3Striatal fibres across the internal capsule4Lentiform nucleus5Putamen6Globus pallidus

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Ultrasound examination of the neonatal brain (Fig. 2.10)

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Thalamus, hypothalamus and pineal gland

Thalamus

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Figure 2.13 • Anterior surface of brainstem.

Hypothalamus (Figs 2.13, 2.21)

Pineal gland (see Figs 2.4, 2.5)

Radiological features of the thalamus, hypothalamus and pineal gland

Skull radiographs

CT and MRI

Ultrasound examination of the neonatal brain (Fig. 2.10)

Pituitary gland (Fig. 2.14)

Blood supply

Radiological features of the pituitary gland

Skull radiographs

MRI (Fig. 2.14)

Figure 2.14 • Pituitary gland and cavernous sinus: coronal section. (A) Diagram. (B) Coronal T1 MRI after IV contrast. (C) More posterior T2 view to show Meckel's cave.(B) 1Suprasellar cistern2Anterior cerebral artery3Optic chiasm4Pituitary stalk5Pituitary gland6Internal carotid artery in cavernous sinus(C) 1Optic chiasm2Carotid artery3Trigeminal ganglion in Meckel's cave

CT

Limbic lobe (Fig. 2.15)

Figure 2.15 • Components of the limbic lobe.

Hippocampus (Fig. 2.16)

Fornix (Fig. 2.15)

Radiological features of the limbic lobe

MRI

Ultrasound examination of the neonatal brain (see Fig. 2.10)

The brainstem (Fig. 2.13)

Figure 2.16 • Hippocampus: (A) coronal T1 MRI; (B) diagram of coronal section right hippocampus; (C) parasagittal MRI showing hippocampus; (D) parasagittal MRI showing indusium griseum.(A) 1Fimbria2Alveus3Cornu ammonis4Dentate gyrus5Temporal horn of lateral ventricle6Tail of caudate7Alveus8Cornu ammonis9Subiculum10Collateral sulcus(C) 1Amygdala2Temporal horn of lateral ventricle3Hippocampal tail4Hippocampal body5Fimbria of hippocampus6Hippocampal head7Parahippocampal gyrus(D) 1Indusium griseum2Corpus callosum

Midbrain

External features

Internal features (Fig. 2.17)

Cranial nerves

Blood supply

Radiological features of the midbrain

CT and MRI

Figure 2.17 • Midbrain, axial section: (A) T2 MRI; (B) diagram.

Pons

External features

Cranial nerves

Blood supply

Radiological features of the pons

CT and MRI (Fig. 2.3A)

Medulla oblongata

External features

Cranial nerves

Blood supply

Radiological features of the medulla oblongata

CT and MRI

Cerebellum (Figs 2.18, 2.19)

Figure 2.18 • Cerebellum: (A) anterior view; (B) posterior view; (C) midline sagittal section of vermis.

Figure 2.19 • Midline sagittal T2 MRI to show vermis of cerebellum. 1Lingula on superior medullary velum2Primary fissure3Horizontal fissure4Prepyramidal fissure5Foramen of Magendie

Hemispheres

Vermis

Subdivisions of the cerebellum

The function of the cerebellum

Arterial supply

Venous drainage

Radiological features of the cerebellum

CT and MRI

Ventricles, cisterns, CSF production and flow ventricles (Figs 2.20–2.22)

Figure 2.20 • The ventricular system.

The lateral ventricles (Fig. 2.20)

Frontal (anterior) horn

Body

Temporal (inferior) horn

Figure 2.21 • Third and fourth ventricles and related midline sagittal structures.

Figure 2.22 • The subarachnoid cisterns. 1Suprasellar cistern2Pontine cistern3Cavum velum interpositum4Quadrigeminal plate cistern5Interpeduncular cistern6Cisterna magna

Occipital horn

The choroid plexus of the lateral ventricle

Figure 2.23 • Axial CT to show cavum velum interpositum.

The third ventricle (Figs 2.20–2.22)

The cerebral aqueduct (Figs 2.20, 2.21)

The fourth ventricle (Figs 2.20–2.22)

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Radiological features of the ventricular system

Skull radiographs

CT and MRI (Figs 2.3, 2.7, 2.22)

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Ultrasound examination of the neonatal brain (see Fig. 2.10 and 2.24)

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Figure 2.24 • Coronal ultrasound through interventricular foramina. 1Interhemispheric fissure2Corpus callosum3Anterior horn of left lateral ventricle4Cavum septum pellucidum5Choroid plexus marking position of interventricular foramen6Third ventricle

Pneumoencephalography and air or contrast ventriculography

The subarachnoid cisterns (Fig. 2.22)

Cisterna magna (cerebellomedullary cistern)

Pontine cistern

Interpeduncular cistern

Quadrigeminal cistern

Cistern of the velum interpositum (Figs 2.21–2.23)

Ambient cisterns

Suprasellar cisterns

Pericallosal cistern

Radiological features of the subarachnoid cisterns

CT and MRI

Cervical myelography

Cranial ultrasound

Pneumoencephalography

Figure 2.25 • Ultrasound through the foramen magnum. 1Inferior margin of occipital bone = posterior border of foramen magnum2Cisterna magna3Cervical cord4Medulla oblongata5Dura6Cervical vertebral bodies7Pons

Cerebrospinal fluid production and flow

Radiological features of CSF production and flow

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Skull radiographs

Radionuclide cisternography

Magnetic resonance CSF flow study

Meninges

Dura mater

Arachnoid mater

Pia mater

Arterial supply of the meninges

The nerve supply of the meninges

Radiological features of the meninges

Extradural haematoma

Subdural haematoma

Subarachnoid haemorrhage

Skull radiographs

CT and MRI

Arterial supply of the CNS (Figs 2.26–2.30)

Internal carotid artery (Figs 2.26, 2.27; see also the section on the carotid arteries in neck in Chapter 1)

Figure 2.26 • Distribution of the cerebral arteries: (A) superolateral surface of the cerebral hemisphere; (B) medial surface of the cerebral hemisphere.

Branches of the internal carotid artery

Figure 2.27 • The arterial circle of Willis and arteries of the brainstem.

Ophthalmic artery (Fig. 2.28)

Posterior communicating artery

Anterior choroidal artery

Figure 2.28 • Internal carotid angiogram: (A) AP view; (B) lateral view. The posterior communicating artery does not fill in this case.(A) 1Internal carotid artery in the neck2Petrous part of the internal carotid artery (carotid canal)3Cavernous part of the internal carotid artery4Carotid siphon5Intracranial part of the internal carotid artery6Ophthalmic artery7A1 segment of the anterior cerebral artery8Pericallosal artery9Callosomarginal artery10Middle cerebral artery11Anterior choroidal artery12Lenticulostriate arteries: medial and lateral13Sylvian point14Posterior parietal artery15Angular artery16Posterior temporal artery(B) 1Internal carotid artery in the neck2Internal carotid artery in the petrous bone3Internal carotid artery in the cavernous sinus4Carotid siphon5Intracranial part of the internal carotid artery6Ophthalmic artery7Anterior cerebral artery8Middle cerebral artery9Anterior choroidal branches10Callosomarginal artery11Pericallosal artery

Striate arteries

Figure 2.29 • Vertebral angiogram: (A) AP view; (B) lateral view.(A) 1Left vertebral artery2Right vertebral artery (reflux of contrast)3Posterior inferior cerebellar artery4Anterior inferior cerebellar artery5Basilar artery6Superior cerebellar artery7Posterior cerebral artery8Thalamoperforate branches9Internal occipital artery10Posterior temporal artery11Calcarine branch of the internal occipital artery12Parieto-occipital branch of the internal occipital artery(B) 1Vertebral artery2Posterior inferior cerebellar artery (PICA) – anterior medullary segment3Lateral medullary segment of PICA4Posterior medullary segment of PICA5Inferior tonsillar loop of PICA6Supratonsillar loop of PICA7Retrotonsillar segment of PICA8Vermis branch of PICA9Tonsillohemispheric branch of PICA10Hemispheric branch11Superior cerebellar artery12Posterior cerebral artery13Posterior communicating artery14Thalamoperforate branches of posterior cerebral artery15Medial posterior choroidal branches16Lateral posterior choroidal branches (arise distal to 15)17Superior vermian branches of 1118Internal occipital branch of 1219Parieto-occipital artery20Calcarine artery

Anterior cerebral artery

Figure 2.30 • MR angiogram of the cerebral circulation. (A) MR angiogram as viewed from above. (B) A variant on circle of Willis on MRA. Note absence of the first segment of left anterior cerebral artery. The remainder of this artery is filled through the anterior communicating artery from the right side. (C) MRA of right internal carotid and MCA and ACA. (D) MRA of posterior circulation, lateral view. (ACA = anterior cerebral artery, ACoA = anterior communicating artery; ICA = internal carotid artery; MCA = middle cerebral artery; PCoA = posterior communicating artery; PCA = posterior cerebral artery; BA = basilar artery; VA = vertebral artery.)(A) 1Ophthalmic artery2Anterior temporal artery3Opercular branches of MCA4Superior cerebellar artery5Anterior inferior cerebellar artery (AICA)6Posterior inferior cerebellar artery (PICA)7Left ACA8ACoA9Left ICA10Left MCA11Left PCoA (small)12Left PCA13BA14VA(B) 1Right ACA2Left ACA3ACoA4Absent horizontal segment of left ACA5Left PCoA6Right PCoA(C) 1Ophthalmic artery2Lenticulostriate artery3Anterior temporal artery4Opercular branches of MCA5MCA6Vertical segment of ACA7Horizontal segment of ACA8ACoA9Right ICA(D) 1Parieto-occipital artery2Posterior cerebral artery3Calcarine artery4Superior cerebellar artery5Basilar artery6Anterior inferior cerebellar artery – AICA confluence of vertebral arteries7Posterior inferior cerebellar artery – PICA

Middle cerebral artery

Vertebrobasilar system (Figs 2.27, 2.29)

Vertebral artery

Basilar artery

Posterior cerebral arteries

The arterial circle of Willis (Figs 2.27, 2.30)

Commonest variants of the circle of Willis

Radiological features of the arterial supply of the CNS

Plain radiographs

Angiography of the carotid and vertebral system (Figs 2.28, 2.29)

CT and MRI

Ultrasound examination of the neonatal brain (Fig. 2.10)

Radionuclide cerebral angiography

Venous drainage of the brain

Venous sinuses (Fig. 2.31)

Figure 2.31 • Superficial cerebral veins and venous sinuses.

Superficial cerebral veins (Fig. 2.31)

Deep cerebral veins (Fig. 2.32)

Veins of the posterior fossa (Fig. 2.32)

Figure 2.32 • Deep cerebral veins: (A) diagram; (B) deep veins on MR venogram.(B) 1Thalamostriate vein2Choroidal vein3Septal vein4Inferior sagittal sinus5Internal cerebral veins6Great cerebral vein7Basal veins

Radiological features of the cerebral veins and venous sinuses

Skull radiographs

MR venography (Fig. 2.33)

Angiography during the venous phase (Fig. 2.34)

Figure 2.33 • MR venogram. 1Internal cerebral vein2Great cerebral vein3Basal vein4Superior petrosal sinus5Inferior anastomotic vein6Superior sagittal sinus7Superior anastomotic vein8Inferior sagittal sinus9Straight sinus10Transverse sinus11Sigmoid sinus12Internal jugular vein

Figure 2.34 • Venous phase of internal carotid angiogram. 1Internal cerebral vein2Great cerebral vein3Thalamostriate vein4Venous angle5Superficial middle cerebral vein6Cavernous sinus7Superior sagittal sinus8Superficial cortical veins9Inferior sagittal sinus10Straight sinus transverse sinus11Sigmoid sinus

CT and MRI (see Fig. 2.3)

3 The spinal column and its contents

The vertebral column

A typical vertebra (Figs 3.1, 3.4, 3.5)

The cervical vertebrae

Typical cervical vertebra (Fig. 3.1)

The atlas – C1 (Fig. 3.2)

Figure 3.1 • Cervical vertebra. (A) 3D CT cervical vertebra viewed from above. (B) 3D CT cervical vertebra anterolateral view.(A) 1Body2Foramen transversarium3Transverse process with anterior and posterior tubercles4Superior articular facet5Lamina6Bifid spinous process(B) 1Body2Anterior tubercle3Transverse process4Posterior tubercle5Lamina6Spinous process

The axis – C2 (Fig. 3.3)

Vertebra prominens – C7

The thoracic vertebrae (Fig. 3.4)

The lumbar vertebrae (Fig. 3.5)

The sacrum (Fig. 3.6)

Figure 3.2 • The atlas. (A) diagram of superior view. (B) 3D CT of atlas viewed from above. (C) T2 MRI through lateral masses of atlas showing the course of the upper part of the vertebral arteries.(B) 1Anterior tubercle2Transverse process3Foramen transversarium4Superior articular facet5Groove for vertical artery6Posterior arch7Posterior tubercle(C) 1Dens2Lateral mass of atlas3Vertebral artery4Spinal cord

The coccyx

Radiological features of the vertebrae

Radiographs of the vertebral column (Figs 3.7–3.9)

Figure 3.3 • The axis. (A) Lateral view. (B) Anterior view. (C) Anterior view of 3D CT of upper cervical vertebrae.(C) 1Occipital condyle2Atlas3Anterior arch of atlas4Dens5Atlantoaxial joint6Body of axis

Figure 3.4 • Typical thoracic vertebra. (A) Lateral view. (B) Superior view. (C) 3D CT of thoracic vertebrae and ribs, lateral view.(C) 1Vertebral body2Intervertebral disc3Pedicle4Facet joint5Rib

Figure 3.5 • Typical lumbar vertebra. (A) Lateral view. (B) Superior view. (C) 3D CT of lumbosacral spine.(C) 1Vertebral body2Intervertebral disc3Transverse process4Facet joint5Pars interarticularis6Spinous process

Figure 3.6 • The sacrum, 3D CT. (A) Pelvic surface. (B) Dorsal surface. (C) Lateral view of the sacrum showing the sacroiliac joint surface.(A) 1Sacral promontory2Ala3Pelvic sacral foramina(B) 1Superior articular process2Upper end of sacral canal3Depressions for sacroiliac ligament4Spinous tubercle5Dorsal sacral foramen6Lower end of sacral canal(C) 1Spinous tubercle2Superior articular facet3Sacral promontory4Depressions for sacroiliac ligament5Auricular surface

Figure 3.7 • Lateral radiograph of the cervical spine. 1Anterior arch of atlas2Dens3Body of axis4Posterior arch of atlas5Pedicle6Lamina7Spinous process8Articular facets

Figure 3.8 • AP radiograph of thoracic spine. 1Trachea2Spinous process of C73Left transverse process of C74Tubercle of first rib, articulating with transverse process of T15Medial end of clavicle.6Superior margin of manubrium sterni7Lateral margin of manubrium sterni8Left pedicle of T59T5/T6 intervertebral disc space10Tubercle of seventh rib, articulating with transverse process of T711Head of eighth rib12Neck of eighth rib13Shaft of eighth rib14Left paraspinal line15Left transverse process of L116Dome of left hemidiaphragm

Figure 3.9 • Oblique radiograph of lumbar spine. 1Vertebral body of L22Superior articular process of L33Pedicle of L34Pars interarticularis5Transverse process of L36Transverse process of L37Inferior articular process of L38Spinous process of L2

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Radiographs of the cervical spine

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Radiographs of the thoracic spine (Fig. 3.8)

Radiographs of the lumbar spine

Computed tomography (Figs 3.1–3.6 and 3.10)

Figure 3.10 • CT scan (A) through L4 vertebral body, (B) through L4/L5 intervertebral disc space.(A) 1Body of L42Right lamina of L43Spinous process of L44Thecal sac containing cauda equina5Epidural veins6Dorsal root ganglia of L4 nerve7Intervertebral foramen of L4/L58Psoas muscles9Erector spinae muscles(B) 1Disc of L4/L52Inferior articular process of L43Superior articular process of L54Right lamina of L55Spinous process of L56Ligamentum flavum

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Magnetic resonance imaging (Fig. 3.11)

Figure 3.11 • MRI of the cervical spine. (A) Midline sagittal T1-weighted and (B) fat-suppressed inversion recovery images. 1Obliquus capitis superior2Rectus capitis posterior minor3Semispinalis capitis muscle4Ligamentum nuchae5Interspinous ligament6Spinous process of C77Spinal cord8C4 vertebral body9Posterior longitudinal ligament10Odontoid peg11Anterior arch of C112Medulla oblongata13Vertebral body haemangioma14Ligamentum flavum15Basivertebral vein16Anterior longitudinal ligament(C) Axial T2-weighted image in the midcervical spine at the level of the true vocal cords or fourth cervical vertebral body. 1Thyroid cartilage and vocal cords2Vertebral body and longus colli muscles3Ventral nerve root4Sternocleidomastoid muscle5Scalenus medius6Vertebral artery in the foramen transversarium7Levator scapulae8Semispinalis cervicis9Semispinalis capitis10Trapezius11Splenius capitis12Splenius capitis13Facet joint14Carotid sheath15Posterior nerve root

Ossification of the vertebrae (Fig. 3.12)

Figure 3.12 • Ossification of the cervical spine, CT of 2-year-old boy: (A) axial image through C1 and C2; (B) midline sagittal CT reconstruction of cervical spine.(A) 1Ossification centre for anterior arch of atlas2Dens3Ossification for left lateral mass(B) 1Ossification centre for odontoid2Ossification centre for body of axis

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Joints of the vertebral column

Radiological features of the joints of the vertebral column

Plain radiographs (Figs 3.7–3.9)

Facet (apophyseal joint) arthrography

Computed tomography

Magnetic resonance imaging

The C1/C2 articulation

Lumbar facet joints

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Ligaments of the vertebral column (Figs 3.13, 3.14)

Radiological features of the ligaments of the vertebral column

Lumbar puncture for myelography

Myelogram

CT and MRI (Figs 3.10, 3.11)

The intervertebral discs

Figure 3.13 • MRI of the lumbar spine: (A) T1-weighted midline sagittal and (B) T2-weighted midline sagittal images. 1Posterior epidural space2Interspinous ligament3Subcutaneous fat4Latissimus dorsi muscle attachments5Spinous process of L46Anterior epidural fat pad7Presacral fat space8Intervertebral disc (central nucleus pulposus)9Basivertebral vein10L2 vertebral body11Conus at L112Cauda equina nerve roots13Posterior longitudinal ligament Sequential axial images through L5 to S1: (C) at the level of the inferior endplate of L5; (D) at the level of the L5/S1 disc; (E) at the level of the superior endplate of S1; (F) at the level of the mid-S1 vertebral body. 1L5 vertebral body2Common iliac veins3Psoas muscle4L5 nerve root (exited at foramen above the L5/S1 disc space)5S1 nerve root in the lateral recess6Thecal sac7Posterior epidural space8Erector spinae muscle9Lamina of L510Inferior articular facet of L511Superior articular facet of S112L5/S1 intervertebral disc13Spinous process of L514Exit foramen at L5/S115Central disc bulge to anterior epidural fat16Pedicle of S117L5/S1 facet joint18Transverse process of S1 (sacral ala)19S1 vertebral body20Presacral plexus21Anterior epidural space

Somatic and autonomic nerve supply to the lumbar intervertebral disc

Figure 3.14 • Ligaments of the vertebral column.

Radiological features of the intervertebral discs

Plain radiographs

Discography

Computed tomography (Fig. 3.10)

Magnetic resonance imaging

Intranuclear cleft

Blood supply of the vertebral column

Figure 3.15 • (A) Cross-section of the thoracic spinal cord. (B) Cross-section of the spinal cord showing the main descending tracts (on right) and ascending tracts (on left).

Radiological features of the blood supply of the vertebral column

Spinal angiography

The spinal cord (Fig. 3.15)

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Cross-section of the spinal cord (Fig. 3.15)

Figure 3.16 • Dermatomes of (A) legs and (B) arms.

The lateral recess

The neural foramen

Figure 3.17 • Meninges of the spinal cord.

The spinal meninges (Fig. 3.17)

Blood supply of the spinal cord (Fig. 3.18)

Venous drainage of the spinal cord

Figure 3.18 • Arterial supply of the spinal cord. (A) Axial section. (B) Coronal view.

Radiological features of the spinal cord, its meninges and blood supply

Myelographic technique

Myelographic appearance

Cervical

Thoracic

Lumbar (Fig. 3.19)

Figure 3.19 • Lumbar myelogram: left posterior oblique view to show nerve roots. Below the level of C7 each nerve root emerges below the pedicle of its corresponding vertebral body. 1Nerves of the cauda equina in the thecal sac, outlined by contrast2Body of L43Left superior articular process of L44Left pedicle of L45Left L4 root6Left L5 nerve root7L4/L5 disc space

The epidural space

Computed tomography (Fig. 3.10)

Magnetic resonance imaging (Figs 3.11, 3.13)

Figure 3.20 • Spinal ultrasound. (A) Composite sagittal view of lower cord and conus. (B) Transverse section through spinal cord.(A) 1Dura2Vertebral bodies3Central echo complex4Conus5Cauda equina(B) 1Dorsal nerve root2Denticulate ligament3Ventral nerve root4Anterior median sulcus

Spinal ultrasound (Fig. 3.20)

Spinal angiography (Fig. 3.21)

Radiology pearl

Figure 3.21 • (A) Coronal MR angiogram. The anterior spinal artery (arrowhead) is seen within the cervical region anterior to the cord. In this patient the artery arises from the right vertebral artery (arrow). No radiculomedullary feeders are visualized. From Sheehy N, Boyle G, Meaney JFM 2005 High-resolution 3D contrast-enhanced MRA of the normal anterior spinal arteries within the cervical region. Radiology 236(2):637–641, with permission of the authors. (B) Angiogram.(B) 1Arteria radicularis magna2Anterior spinal artery3Intercostal arteries4Aorta

Therapeutic interventions

4 The thorax

The thoracic cage

The ribs

The typical rib (Fig. 4.1)

Atypical ribs

First rib (Fig. 4.2)

Second rib

Tenth rib

Eleventh rib

Twelfth rib

Figure 4.1 • A typical rib.

Figure 4.2 • (A) First rib; (B) structures crossing first rib.

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Costal cartilages

The intercostal space and vessels

Intercostal arteries

Posterior

Anterior

Intercostal veins

Posterior (see Fig. 4.39)

Anterior

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Muscles of the thoracic cage (see Figs 4.45, 4.46)

Radiological features of the thoracic cage (Fig. 4.3)

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The sternum (Fig. 4.4A)

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Figure 4.3 • Ribs. (A) Subcostal groove clearly visible below the second left rib (arrowheads). Note also the scalene tubercle on the first rib (arrow).(B) Prominence on upper surface of the second rib due to the insertion of part of scalenus anterior muscle.(C) Cervical rib – a well-developed bony cervical rib on the left side (arrows).

Radiological features of the sternum

Plain films

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Ossification of the sternum

Computed tomography and MRI of the sternum (Fig. 4.4B, C)

Figure 4.4 • The sternum. (A) Coronal reformatted CT image of the sternum and (B) MRI of the sternum.

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The diaphragm (Fig. 4.5)

Openings in the diaphragm

Structures that pierce the diaphragm

Figure 4.5 • Diaphragm. (A) View from below showing origin and openings; CC, costal cartilage. (B) Crura and arcuate ligaments; LV, lumbar vertebra. (C and D) Crura of the diaphragm as seen on axial (C) and coronal (D) MRI. 1Right crus of diaphragm2Left crus of diaphragm3IVC4Aorta5Vertebral body6Spinal cord7Pedicle8Lamina9Psoas muscle

Blood supply to the diaphragm

Nerve supply to the diaphragm

Radiological features of the diaphragm (Fig. 4.5)

PA chest radiograph (Fig. 4.6)

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Lateral chest radiograph (Fig. 4.7)

Curvature of the dome

Ultrasound

Computed tomography

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Magnetic resonance imaging (see Fig. 4.5)

The pleura (Figs 4.8, 4.9)

Figure 4.6 • PA chest radiograph. 1Posterior junctional line2Anterior junctional line3Azygo-oesophageal line4Lateral wall of descending aorta5Aortic knuckle6Aortopulmonary window7Pulmonary trunk/left pulmonary artery8Left superior pulmonary vein9Left inferior pulmonary artery10Left hilar point11Right superior pulmonary vein12Interlobar artery13Right hilar point14Trachea15Right main bronchus16Left main bronchus17Azygos vein and position of azygos node18Position of left atrial appendage19Left ventricle20Right atrium21Inferior aspect of left brachiocephalic vein22Medial end of right clavicle23Right lateral aspect of manubrium sterni24Spinous process of T125Superior surface of clavicle26Companion shadow of clavicle27Medial aspect of right scapula28Coracoid process of right scapula29Dome of right hemidiaphragm30Dome of left hemidiaphragm31Stomach bubble32Gas in splenic flexure of colon

Figure 4.7 • Lateral chest radiograph. 1Anterior wall of trachea2Posterior tracheal stripe3Scapulae4Left lower-lobe bronchus5Right lower-lobe bronchus6Aorta (not well seen)7Vertebral body of T48Anterior aspect of right ventricle9Pulmonary outflow tract10Main pulmonary artery11Right pulmonary artery12Left pulmonary artery13Left atrium14Left ventricle15Inferior vena cava16Horizontal (minor) fissure17Oblique (major) fissure18Sternum19Manubriosternal joint20Left hemidiaphragm21Right hemidiaphragm22Stomach bubble23Lung projected anterior to sternum in intercostal space24Retrosternal airspace

Table 4.1 Lower limits of lung and pleura at rest

Radiological features of the pleura

Plain films

Computed tomography

Figure 4.8 • Pleura: (A) anterior view; (B) posterior view.

Figure 4.9 • (A) PA chest radiograph; (B) axial high-resolution CT scan of lungs which shows fissures as fine white lines (arrows). 1Posterior junction line (arrows)2Azygo-oesophageal line

The trachea and bronchi (Figs 4.10–4.12)

The trachea

Relations of the trachea

Cervical (see Figs 1.34, 1.35)

Figure 4.10 • Trachea and main bronchi: anterior relations.

Figure 4.11 • Diagrammatic representation of normal anatomy: situs solitus.

Thoracic (see Figs 4.7, 4.17, 4.45, 4.46)

Blood supply of the trachea

Main bronchi (Figs 4.10–4.12)

Carina

Radiology pearl

The right main bronchus (eparterial bronchus)

Relations

Figure 4.12 • Bronchial tree – main and segmental anatomy as seen on bronchography: (A) anterior view; (B) right lateral view; (C) left lateral view; (D) left oblique view.

Left main bronchus (hyparterial bronchus)

Relations

Figure 4.13 • Bronchopulmonary segments as seen on PA chest radiograph: (A) upper lobes; (B) middle lobes; (C) lower lobes.

Blood supply

Radiological features

The lungs (Fig. 4.13)

Interlobar fissures (see Fig. 4.8)

The oblique (major) fissure

The transverse (minor) fissure

Accessory fissures

The azygos fissure (Fig. 4.14)

Figure 4.14 • Azygos fissure: (A) PA chest radiograph; (B) CT thorax. 1Azygos fissure2Azygos vein3Azygos ‘lobe’

The superior accessory fissure

The inferior accessory fissure

Figure 4.15 • Pulmonary arteries.

Left transverse fissure

Bronchopulmonary segments (Figs 4.12, 4.13)

The pulmonary artery (Fig. 4.15; see also Fig. 4.47; see also section on the great vessels, p. 140)

Figure 4.16 • Pulmonary veins: digital subtraction angiography (DSA) of pulmonary veins draining into left atrium. This angiogram was achieved by passing a venous catheter from the right atrium through a ‘probe-patent’ foramen ovale into the left atrium. 1Right upper pulmonary vein2Left upper pulmonary vein3Catheter4Right inferior pulmonary vein5Left inferior pulmonary vein6Left atrium

The pulmonary veins (Fig. 4.16)

The bronchial arteries

Radiology pearl

Bronchial veins

Lymphatics (Fig. 4.17)

Lung roots (Fig. 4.18)

Figure 4.17 • Lymph nodes related to the trachea and main bronchi.

Figure 4.18 • Lung roots: (A) right lung root; (B) left lung root.

Radiological features of the lung and bronchial tree

PA chest radiograph (see Fig. 4.6)

Fissures

Radiology pearls

Trachea

Bronchi

Bronchopulmonary segments

Pulmonary vasculature

Situs inversus

Lymphatics

Lateral chest radiograph (Fig. 4.7)

Fissures

Trachea

Bronchi

Vasculature

Radiology pearl

Pulmonary angiography

Bronchial angiography

Computed tomography (see Figs 4.43 and 4.45–4.47)

Fissures

Bronchi

Vasculature

Magnetic resonance imaging

Isotope ventilation–perfusion scanning

Radiology pearl

The mediastinal divisions (Fig. 4.19)

Figure 4.19 • Mediastinal divisions.

Figure 4.20 • Heart: anterior view.

The heart

Gross anatomy and orientation (Figs 4.20–4.22; also Figs 4.6, 4.7)

Figure 4.21 • Heart and mediastinum viewed from right.

Figure 4.22 • Heart and mediastinum viewed from left.

Pericardium (Fig. 4.23)

Radiological features of the pericardium

CT and MRI (Fig. 4.23)

Cardiac chambers and valves (Figs 4.20–4.22 and Fig. 4.24)

Right atrium

Figure 4.23 • Pericardium: (A) CT scan showing pericardium; (B) CT; and (C) MRI showing pericardial recesses.(A) 1Pericardium2Right ventricle3Left ventricle4Interventricular septum5Aorta6Oesophagus(B) 1Aorta2Superior aortic recess of the transverse sinus3Superior vena cava4Right pulmonary artery5Aorta6Oblique sinus

Right ventricle

Figure 4.24 • (A) CT scan of the thorax: axial section through the heart; (B) oblique sagittal MRI through the long axis of heart. 1Right ventricle2Left ventricle3Interventricular septum4Pericardium5Atrioventricular groove6Mitral valve7Papillary muscle8Right atrium9Left atrium10Right pulmonary vein11Oesophagus12Descending aorta13Azygos vein14SVC

Left atrium

Left ventricle

Figure 4.25 • Relationship of aortic and pulmonary valves and origin of right and left pulmonary arteries. RP, right posterior; LP, left posterior; A, anterior; Post, posterior; RA, right anterior; LA, left anterior.

Figure 4.26 • Right coronary angiogram: (A) left anterior oblique projection; (B) right anterior oblique projection. The AV nodal branch is not seen.(A) 1Sinus artery2Right coronary artery3Conus branch4Right ventricular branch5Posterolateral branch6Posterior descending artery(B) 1Right coronary artery2Right ventricular branch3Conus branch4Posterolateral branch5Posterior descending artery

The coronary arteries and veins (Figs 4.25–4.28)

Right coronary artery (Figs 4.26, 4.28)

Branches

Figure 4.27 • Left coronary angiogram: (A) right anterior oblique projection; (B) left lateral projection.(A) 1Left main coronary artery2Left anterior descending artery (LAD)3Septal branch4First diagonal branch5Second diagonal branch6Continuation of LAD7Circumflex artery8First obtuse marginal branch9Second obtuse marginal branch(B) 1Left main coronary artery seen end on2Circumflex artery3Obtuse marginals4Posterolateral branch5Left anterior descending artery (LAD)6Septal branch7First diagonal branch8Second diagonal branch9Continuation of LAD

Left coronary artery (Figs 4.27, 4.28)

Branches of the anterior descending artery

Figure 4.28 • The coronary arteries.

Branches of the left circumflex artery

Figure 4.29 • The coronary veins.

The veins of the heart (Fig. 4.29)

The conducting system of the heart

Radiology of the heart

Chest radiography

Radiology pearl

Radiology pearl

Fluoroscopy

Echocardiography

Figure 4.30 • Position of cardiac valves: (A) as seen on AP chest radiograph; (B) as seen on lateral CXR; (C) AP CXR; (D) lateral CXR. P, pulmonary; A, aortic; M, mitral; T, tricuspid.

Angiocardiography

Coronary angiography

Nuclear medicine

Computed tomography (Fig. 4.31)

Figure 4 31 • (A, B) CT Coronary angiograms.(A) 1Left anterior descending coronary artery (LAD)2Diagonal coronary artery3Circumflex coronary artery4Origin of the right coronary artery(B) 1Origin of left main stem coronary artery2Origin of circumflex coronary artery3Left anterior descending coronary artery

Coronary calcium score

Relevant CT anatomy

Variations

Coronary artery dominance

Radiology pearl

Blood supply of the papillary muscles

Radiology pearl

Coronary blood flow

Radiology pearl

Magnetic resonance imaging

PET CT (Fig. 4.33)

The great vessels (see Figs 4.10, 4.20, 4.22, 4.43 and 4.45–4.47)

The aorta (see Fig. 4.10 and Figs 4.34, 4.35)

The aortic arch

Figure 4.32 • (A, B) Coronary MR angiograms.(A) 1Proximal left anterior descending coronary artery(B) 1Right coronary artery2Posterior descending coronary artery

Figure 4.33 • (A) PET scan and (B) PET CT scan acquired following injection of 18-fluorodeoxyglucose (FDG) radiotracer showing avid uptake by healthy contracting cardiac muscle. 1Left ventricle2FDG uptake by pathological paratracheal node

Figure 4.34 • Aortograms: (A) DSA; (B) MR angiogram. 1Brachiocephalic artery2Left common carotid3Left subclavian artery4Ascending aorta5Descending aorta6Angiography catheter7Anterior cusp of aortic valve8Left posterior cusp of aortic valve9Left coronary artery10Left atrium11Left pulmonary artery

Figure 4.35 • Posterior mediastinum.

Radiology pearl

The descending aorta

Subclavian artery (see Fig. 1.47)

Pulmonary arteries (Figs 4.15 and 4.20; see also section on the pulmonary artery in the lungs, p. 126)

Great veins (see Figs 4.10 and 1.44)

Tributaries of the brachiocephalic veins

Radiology of the great vessels

The oesophagus (Figs 4.35, 4.36; see also Figs 4.48–4.52)

Figure 4.36 • Barium-swallow technique showing the oesophagus: (A) upper oesophagus and oropharynx, lateral view; (B) midoesophagus, right anterior oblique view; (C) distal oesophagus; (D) distal oesophagus in another patient with prominent Schatzki ring.(A) 1Hyoid bone2Cricoid cartilage3Cricoid impression4Cricopharyngeus muscle impression5Postcricoid venous plexus6Oesophagus7Impression caused by osteophytes(B) 1Impression of aortic arch2Impression of left main bronchus(C) 1Cardiac impression (mainly left atrium)2A ring: upper limit of ampulla (vestibule)3B ring (Schatzki ring): lower limit of ampulla4Ampulla (oesophageal vestibule)5Diaphragmatic hiatus6Oesophageal mucosal folds7Oesophagogastric junction (Z-line)8Diaphragm9Air in fundus of stomach(D) 1Schatzki ring2Gastro-oesophageal junction

Blood supply

Radiology pearl

Lymph drainage

Radiology of the oesophagus (Fig. 4.36)

Plain films

Barium studies

Cross-sectional imaging

The thoracic duct and mediastinal lymphatics (Figs 4.17, 4.35)

Radiology pearl

PET/CT

The thymus (Figs 4.37, 4.38)

Radiology of the thymus (Figs 4.37, 4.38)

Chest radiograph

CT and MRI

Ultrasound

The azygos system (Figs 4.21, 4.35, 4.39, 4.40, 4.46, 4.47)

Figure 4.37 • Variable appearance of normal thymus on chest radiographs of young children: (A) sail-like; (B) like consolidation of right upper lobe; (C) like mediastinal mass; (D) like cardiomegaly.

Figure 4.38 • Coronal MRI of thymus: (A) T1-weighted; (B) T2-weighted. 1Left lobe of thymus2Right lobe of thymus3Left ventricle4Ascending aorta5Brachiocephalic vein6Right subclavian vein7Left subclavian vein

Figure 4.39 • Azygos system.

Important nerves of the mediastinum

Radiology pearl

Figure 4.40 • Axial CT thorax with contrast to show azygos and hemiazygos system of veins: (A) contrast densely opacifies the arch of the azygos vein: (B) accessory hemiazygos vein drains to azygos system (arrows) at T8 level; (C) at a slightly lower level the hemiazygos vein also drains to the azygos vein; (D) below this both the hemiazygos and azygos veins are visible. 1Arch of azygos vein2Accessory hemiazygos vein3Azygos vein4Hemiazygos vein

The mediastinum on the chest radiograph

Mediastinal contour on the frontal chest radiograph (Fig. 4.6)

Figure 4.41 • PA chest radiograph showing an ‘aortic nipple’ (arrows) caused by the left superior intercostal vein as it passes anterior to the arch of the aorta.

Radiology pearl

Mediastinal contours on the lateral chest radiograph (Fig. 4.7)

Figure 4.42 • PA chest radiograph showing the azygo-oesophageal line (arrows).

The aorta

Mediastinal lines (Figs 4.6, 4.7, 4.9, 4.42, 4.43)

Right paratracheal stripe

Posterior junction line (Fig. 4.9)

Figure 4.43 • CT scan of thorax: upper T4 level showing mediastinal lines. 1Anterior junction line2Air-filled trachea3Oesophagus4Right paratracheal stripe5Azygo-oesophageal stripe6Superior vena cava7Aortic arch8Right paraspinal line9Left paraspinal line10Azygos vein

Anterior junction line

Pleuro-oesophageal line

Azygo-oesophageal line (Fig. 4.42)

Paraspinal lines

Aortopulmonary mediastinal stripe

Posterior tracheal stripe

Cross-sectional anatomy

Level T3 (Fig. 4.44)

Level T4 (Fig. 4.48)

Figure 4.44 • Cross-sectional anatomy: level T3.

Figure 4.45 • CT scan of thorax: level T3. 1Body of T32Body of manubrium sterni3Right brachiocephalic vein4Left brachiocephalic vein5Right subclavian artery6Right common carotid artery7Left common carotid artery8Left subclavian artery9Trachea10Oesophagus11Right scapula12Spine of scapula13Erector spinae muscle14Trapezius muscle15Supraspinatus muscle16Infraspinatus muscle17Subscapularis muscle18Deltoid muscle19Fat in axilla20Pectoralis minor muscle21Pectoralis major muscle22Subcutaneous fat

Figure 4.46 • CT scan of thorax: level T4. 1Body of T42Thecal sac and spinal cord3Arch of aorta4Superior vena cava5Azygos vein6Trachea7Oesophagus8Erector spinae muscle9Trapezius muscle10Infraspinatus muscle11Subscapularis muscle12Pectoralis minor muscle13Pectoralis major muscle

Figure 4.47 • CT scan of thorax: lower T5 level. 1Body of T52Sternum3Spinous process of T54Ascending aorta5Descending aorta6Superior vena cava7Main pulmonary trunk8Right pulmonary artery9Left pulmonary artery10Carina11Left main bronchus12Oesophagus13Azygos vein14Azygo-oesophageal recess15Mediastinal fat

Level T5 (Fig. 4.49)

Level T6 (Fig. 4.50)

Figure 4.48 • Cross-sectional anatomy: level T4.

Figure 4.49 • Cross-sectional anatomy: level T5.

Figure 4.50 • Cross-sectional anatomy: level T6.

Figure 4.51 • Cross-sectional anatomy: level T8.

Figure 4.52 • Cross-sectional anatomy: level T10.

Level T8 (Fig. 4.51)

Level T10 (Fig. 4.52)

5 The abdomen

Anterior abdominal wall

Muscle layers

Umbilical ligaments (see Fig. 6.13)

Properitoneal fat

Radiological features of the anterior abdominal wall

Plain films of the abdomen (Fig. 5.1)

Radiology pearl

CT of the abdomen (Figs 5.2–5.4, 5.46, 6.13B)

Radiology pearl

Radiology pearl

The stomach (Figs 5.5–5.9)

Radiology pearl

Anterior relations of the stomach

Posterior relations of the stomach (Fig. 5.6)

Figure 5.1 • Plain film of abdomen. 1Internal oblique muscle2Fat between internal oblique muscle and transversus abdominis muscle3Transversus abdominis muscle4Properitoneal fat line (extraperitoneal fat layer)5Inferior border of right lobe of liver6Gas in hepatic flexure7Right twelfth rib8Gas in transverse colon9Inferior border of spleen10Left kidney11Left psoas muscle outline12Right psoas muscle outline13Left transverse process of L314Spinous process of L5

Figure 5.2 • CT scan: level of body of pancreas (T12). 1Left lobe of liver2Right lobe of liver3Gallbladder4Stomach5Portal vein origin6Inferior vena cava7Splenic vein8Body of pancreas9Tail of pancreas10Spleen11Right adrenal gland12Left adrenal gland13Left kidney14Aorta

Arterial supply of the stomach (Fig. 5.7; see also Figs 5.12, 5.13)

Figure 5.3 • CT scan: level of pancreatic head (L1). 1Right lobe of liver2Confluence of splenic and superior mesenteric veins to form portal vein3Splenic vein4Head of pancreas5Second part of duodenum6Loops of small bowel7Hepatic flexure8Descending colon9Spleen10Aorta11Superior mesenteric artery12Inferior vena cava13Left adrenal gland14Right kidney15Renal cortex16Renal pyramid in renal medulla17Rectus abdominis muscle18Transversus abdominis muscle19Latissimus dorsi muscle20Erector spinae muscle

The venous drainage of the stomach (Fig. 5.8)

Figure 5.4 • CT scan: level of renal hila (L2). 1Right lobe of liver2Aorta3Inferior vena cava4Right renal vein5Left renal vein6Left renal artery7Superior mesenteric artery8Third part of duodenum passing between aorta and superior mesenteric artery9Loops of small bowel10Ascending colon11Transverse colon12Descending colon13Psoas muscle14Lower end crus of right hemidiaphragm15Lower end crus of left hemidiaphragm16Right renal pelvis17Rectus abdominis muscle18Transversus abdominis muscle19Internal oblique muscle20External oblique muscle21Latissimus dorsi muscle22Erector spinae muscle23Gerota's fascia24Fascia of Zuckerkandl25Lateral conal fascia (fusion of Gerota's fascia and fascia of Zuckerkandl)

Figure 5.5 • The stomach.

Lymph drainage of the stomach

Radiological features of the stomach

Plain film of the abdomen (see Fig. 5.1)

Double-contrast barium-meal examination (Fig. 5.9)

Radiology pearls

CT and MRI of the stomach

Figure 5.6 • Posterior relations of the stomach (viewed from anterior through the stomach).

Figure 5.7 • Arterial supply of the stomach.

Figure 5.8 • Venous drainage of stomach.

Figure 5.9 • Barium-meal technique. This film demonstrates the various rugal and mucosal folds in the stomach and in the non-distended duodenum. 1Lesser curve of stomach2Greater curve of stomach3Longitudinal mucosal folds (‘magenstrasse’)4Gastric rugae5Areae gastricae6Incisura7Duodenal bulb (partially gas-distended)8Mucosal pattern of non-distended duodenum

Figure 5.10 • CT upper abdomen: level of gastro-oesophageal junction (T10). 1Left lobe of liver2Right lobe of liver3Right branch of portal vein4Fissure for ligamentum venosum5Contrast medium in stomach6Spleen7Descending aorta8Azygos vein9Hemiazygos vein10Splenic flexure11Left lung12Left diaphragm13Rectus abdominis muscle14External oblique muscle15Serratus anterior muscle16Latissimus dorsi muscle17Erector spinae muscle18Oesophagogastric junction

Radiology pearls

Ultrasound studies of the abdomen

Figure 5.11 • CT abdomen: level of body of stomach (T11). 1Left lobe of liver: lateral segment2Left lobe of liver: medial segment3Right lobe of liver4Caudate lobe of liver5Fissure for ligamentum teres6Interlobar fissure (for ligamentum venosum)7Inferior vena cava8Portal vein9Right branch of portal vein10Gallbladder11Hepatic artery12Abdominal aorta13Splenic artery14Spleen15Splenic vein16Left crus of diaphragm17Left adrenal gland18Right adrenal gland19Stomach20Splenic flexure21Linea alba (aponeurosis of rectus sheath)

Figure 5.12 • Coeliac axis angiogram. 1Catheter in aorta2Catheter tip in coeliac trunk3Splenic artery4Left gastric artery5Common hepatic artery6Hepatic artery proper7Left hepatic artery8Right hepatic artery9Right gastric artery10Cystic artery11Gastroduodenal artery12Right gastroepiploic artery13Left gastroepiploic artery14Posterior superior pancreaticoduodenal artery15Anterior superior pancreaticoduodenal artery16Dorsal pancreatic artery17Transverse pancreatic artery18Gastric branches of gastroepiploic artery19Phrenic branch of left hepatic artery20Contrast in right renal pelvis21Left ureter

Radiology pearl

Angiography of the coeliac trunk (Figs 5.12, 5.13)

Radiology pearl

The duodenum (Figs 5.14, 5.15)

Figure 5.13 • Branches of the coeliac artery.

Figure 5.14 • Duodenum: arterial supply.

Figure 5.15 • Barium follow-through study of the small bowel. Notice the feathery mucosal pattern of the jejunum compared with the more featureless ileum. The presence of generous mesenteric fat is separating the bowel loops slightly. The valvulae conniventes are thicker and more prominent in the jejunum. The highest part of the duodenum (marking the ligament of Treitz) is hidden by the stomach. Contrast has passed into the colon. Notice the high position of the splenic flexure. Notice the normal linear mucosal pattern of the collapsed colon due to its longitudinal muscle bands (taenia) and its sacculations. 1Sacculation2Collapsed transverse colon3Duodenal bulb4Stomach5Splenic flexure6Duodenojejunal junction7Jejunum8Ileum

Arterial supply (Fig. 5.14)

Venous drainage

Lymphatic drainage

Radiological features of the duodenum

Barium studies of the duodenum (Figs 5.9, 5.15)

Radiology pearls

Angiography

Ultrasound

The small intestine

Figure 5.16 • Posterior abdominal wall showing peritoneal attachment of mesentery.

Arterial supply of the small intestine (Figs 5.20, 5.21)

Venous drainage of the small intestine

Lymphatic drainage of the small intestine

Meckel's diverticulum

Table 5.1 Comparison between jejunum and ileum

Radiology pearl

Radiological features of the small intestine

Plain films of the abdomen

Barium studies of the small intestine (Fig. 5.15)

Computed tomography (Figs 5.2–5.4; Fig. 5.59)

Angiography (Fig. 5.20)

The ileocaecal valve (Fig. 5.17)

Radiological features of the ileocaecal valve

Plain films of the abdomen

Barium-enema examinations

Radiology pearl

Computed tomography

The appendix (Figs 5.17–5.19)

Figure 5.17 • Internal view of caecum showing ileocaecal valve and appendix.

Figure 5.18 • Variation in position of appendix.

Radiology pearl

Radiological features of the appendix

Plain abdominal film

Ultrasound

Radiology pearl

Barium enema (Fig. 5.19A)

CT and MRI

Appendiceal abscess

The large intestine (Fig. 5.19; see also sections on the rectum and anal canal in Chapter 6)

Radiology pearl

Figure 5.19 • (A) Barium study of the colon. (B) Reformatted CT colonogram 1Rectum2Valve of Houston (lateral mucosal fold)3Sigmoid colon4Descending colon5Splenic flexure6Transverse colon7Hepatic flexure8Ascending colon9Caecum10Caecal pole11Base of appendix12Tip of appendix

Peritoneal attachments of the colon (Fig. 5.16)

Figure 5.20 • Superior mesenteric angiogram. The inferior pancreaticoduodenal artery (not shown) also arises from the proximal superior mesenteric artery and runs superiorly. 1Catheter in aorta2Superior mesenteric artery3Jejunal branches4Ileal branches5Terminal superior mesenteric artery6Ileocolic artery7Right colic artery8Middle colic artery running superiorly9Contrast-filled bladder

Figure 5.21 • Branches of the superior mesenteric artery.

Figure 5.22 • Inferior mesenteric angiogram. 1Catheter in right common iliac artery2Catheter in aorta3Inferior mesenteric artery4Left colic artery5Sigmoid arteries6Marginal artery of Drummond7Superior rectal artery and branches8Middle rectal artery (filling by reflux: a branch of the internal iliac artery)9Gas in ascending colon10Descending colon11Sigmoid colon12Rectum

Relations of the colon

The arterial supply of the colon (Figs 5.20–5.23; see also section on the rectum in Chapter 6)

Figure 5.23 • Branches of the inferior mesenteric artery.

Table 5.2 Anatomical features of small and large intestine in intestinal obstruction

Radiology pearl

Venous drainage of the colon

Lymphatic drainage of the colon

Development of the colon

Radiological features of the colon

Plain films of the abdomen (Fig. 5.1)

Radiology pearl

Double-contrast barium-enema examination (Fig. 5.19A)

Radiology pearls

Angiography

CT of the abdomen (Figs 5.19B, 5.54–5.59)

The liver (Figs 5.24–5.26)

Figure 5.24 • Liver: (A) anterior view; (B) posterior view; (C) view through the liver.

Figure 5.25 • Segmental anatomy of liver.

Old lobar anatomy

Figure 5.26 • Schematic view of segmental anatomy of liver. This division is based on the principal divisions of the hepatic artery and portal vein. Hepatic veins run between the segments.

Table 5.3 Surgical and traditional anatomical terminology

Segmental liver anatomy (Figs 5.25, 5.26; Table 5.3)

The arterial supply of the liver

Variations in arterial supply to the liver

Portal vein (Fig. 5.27)

Figure 5.27 • Portal vein: segmental anatomy. Usual configuration (>90% cases).

Figure 5.28 • Axial CT of the upper abdomen. The caudate lobe demonstrates focal fatty infiltration resulting in its relatively low density. Note the vein draining directly into the inferior vena cava (arrow).

Venous drainage of the liver (Figs 5.28, 5.29)

Lymphatic drainage of the liver

Radiological features of the liver

Plain films of the abdomen (see Fig. 5.1)

CT and MRI (Figs 5.2–5.4, 5.10, 5.11, 5.55–5.59)

Figure 5.29 • Ultrasound of liver. (A) Transverse image showing confluence of hepatic veins. In this case, two middle hepatic veins join close to the confluence. (B) Sagittal section through the left lobe of the liver to show gastro-oesophageal junction. (C) Sagittal section of IVC in liver.(A) 1IVC2Left hepatic vein3Middle hepatic veins4Right hepatic vein(B) 1Left lobe of liver2Gastro-oesophageal junction3Aorta4Spine(C) 1IVC2Right renal artery3Right lobe of liver

Radiology pearls

Ultrasound (Fig. 5.29)

Radiology pearls

Hepatic arteriography (Fig. 5.12)

CT angioportography (CTAP)

Hepatic artery embolization

Radiology pearls

Portal venography

Hepatic venography

Radiology pearls

Hepatic scintigraphy

The biliary system (Figs 5.30, 5.31)

The gallbladder

The relations of the gallbladder

Normal variants

Figure 5.30 • The biliary system and its relations.

Figure 5.31 • Variation in the relationship of bile ducts, and hepatic artery at the porta hepatis. (A) In two-thirds of individuals the bile duct is anterior to the right hepatic artery. (B) In one quarter the bile duct passes behind the artery. (C) In 12% the right hepatic artery arises from the SMA and passes behind the bile duct.

Figure 5.32 • Variation in relationship of hepatic artery and portal vein.

Arterial supply

Venous drainage

Bile ducts (Figs 5.30–5.36)

Figure 5.33 • Segmental biliary drainage. (A) Usual configuration. (B) Commonest variations. RAD = right anterior bile duct; RPD = right posterior bile duct; LHD = left hepatic duct; RHD = right hepatic duct; CHD = common hepatic duct.

Figure 5.34 • Ultrasound of porta hepatis: usual configuration of portal vein, bile duct and hepatic artery. 1Portal vein2Common bile duct3Hepatic artery

Variation in the biliary ducts

Radiology pearls

Figure 5.35 • ERCP study of the pancreaticobiliary tree. 1Endoscope2Pancreatic duct3Common hepatic duct4Cystic duct5Left hepatic duct6Right hepatic ducts7Gallbladder8Gas in fundus of stomach9Gas in duodenum10Right hemidiaphragm

Radiological features of the biliary system

Plain films of the abdomen

Ultrasound examination of the biliary system (Fig. 5.34)

Radiology pearls

Contrast examinations (Fig. 5.35)

Radiology pearls

Figure 5.36 • MR cholangiopancreaticogram. Coronally-acquired HASTE images demonstrate parts of the bile duct and pancreatic duct. This is a water-sensitive sequence in which fluid is bright. (A) This section shows the intrapancreatic common bile duct and pancreatic duct. Part of the pancreatic duct is seen in the body of the pancreas. Note – right lobe of liver is prolonged inferiorly in a ‘Reidl's lobe’. (B) The cystic duct confluence with the common hepatic duct is seen.(A) 1Confluence of cystic and bile duct2Right hepatic duct3Left hepatic duct4Pancreatic duct in body of pancreas5Stomach6Gallbladder7Portal vein8Right lobe of liver9Left lobe of liver10Duodenum(B) 1Confluence of pancreatic and bile ducts2Common duct3Pancreatic duct4Gallbladder5Stomach6Duodenum

MR cholangiography (Fig. 5.36)

CT of the biliary tree

Scintigraphy of the biliary system using 99mTc HIDA

The pancreas (Figs 5.36–5.42)

The pancreatic ducts and their development (Figs 5.38–5.40)

Radiology pearl

Variations in pancreatic anatomy

Radiology pearls

Arterial supply of the pancreas (Fig. 5.41)

Venous drainage of the pancreas

Lymphatic drainage

Radiological features of the pancreas

Plain films of the abdomen

Radiology pearls

Figure 5.37 • Pancreatic ducts.

Figure 5.38 • Development of the pancreas: (A) appearance of two ventral and one dorsal pancreatic buds; (B) development of one ventral and one dorsal bud; (C) fusion of the ventral and dorsal buds.

Figure 5.39 • Variation in anatomy of the pancreatic ducts: (A) atrophic accessory duct persists as a tiny accessory duct in 60%; (B) accessory (upper) duct atrophies completely – no connection with duodenum (20%); (C) major and minor ducts open separately and do not communicate (pancreas divisum) (10%); (D) both ducts persist, communicate and open separately (10%).

Hypotonic duodenography

Ultrasound of the pancreas (Fig. 5.42)

Radiology pearl

Computed tomography (Figs 5.2, 5.3, 5.40)

Figure 5.40 • CT pancreas. Images obtained in portal venous phase after injection of fast bolus of contrast. (A) This level shows part of the tortuous splenic artery and the highest parts of the pancreas – the body anterior to the portosplenic confluence and the tail. A short segment of the duct is visible in this case. (B) Note the position of the gastroduodenal artery relative to the common bile duct in the head of the pancreas. Note left renal vein passing between aorta and SMA.(C) The distal pancreatic duct and distal pancreatic ducts are visible. Note how the uncinate process tucks in behind the superior mesenteric vessels. The duodenum also passes between aorta and SMA – note position of third part. Note the combination of opacified blood (from renal veins) and unopacified blood (from lower body) in IVC, because images are taken before the contrast has had a chance to circulate the body fully. After a few more cardiac cycles, the contrast will be homogeneously dense, before washing out of the vessels. 1Pancreatic body2Pancreatic head3Pancreatic tail4Uncinate process5Pancreatic duct6Common bile duct7Hepatic artery8Gastroduodenal artery9SMV10SMA11Duodenum (first part)12Duodenum (second part)13Duodenum (third part)14Left renal vein

Figure 5.41 • Arterial supply of pancreas.

Figure 5.42 • Ultrasound of upper abdomen: transverse image through head and body of pancreas. 1Skin surface2Left lobe of liver3Head of pancreas4Neck of pancreas5Body of pancreas6Splenic vein7Confluence of splenic and superior mesenteric veins to form portal vein8Aorta9Superior mesenteric artery10Fat around superior mesenteric artery11Left renal vein12Inferior vena cava (collapsed)13Right renal vein14Vertebral body

MRI of the pancreas (Fig. 5.36)

Endoscopic retrograde cholangiopancreatography (Fig. 5.35)

Angiography of the pancreas

Venography of the pancreas

The spleen (Fig. 5.46A, B)

Blood supply of the spleen

Variants

Radiological features of the spleen

Plain films of the abdomen

Ultrasound of the spleen

Figure 5.43 • Portal venous system.

Computed tomography (Figs 5.2, 5.3, 5.10, 5.11, 5.46)

Magnetic resonance imaging

Radiology pearls

Scintigraphy

Portography

The portal venous system (Figs 5.43, 5.44)

Superior mesenteric vein

Figure 5.44 • Portosystemic communications.

Inferior mesenteric vein

The splenic vein

The portal vein

Table 5.4 Portosystemic anastomoses

Portosystemic anastomoses (Fig. 5.44)

Radiological features of the portal venous system

Plain films of the abdomen

Radiology pearls

Ultrasound (Fig. 5.34)

Radiology pearl

Computed tomography (Figs 5.2, 5.3, 5.10, 5.11)

Radiology pearl

Magnetic resonance imaging

Portography

Direct portography

Indirect portography

The kidneys (Figs 5.45–5.48)

Figure 5.45 • Structure of kidney.

Figure 5.46 • (A, B) Coronal reformatted CT of the abdomen showing kidneys and their relations. 1Right kidney (lower pole)2Left kidney (upper pole)3Renal pelvis4Left adrenal5Right adrenal6Crus right hemidiaphragm7Crus left hemidiaphragm8Aorta9IVC10Spleen11Liver12Tail of pancreas13Splenic flexure14Psoas muscle15Iliacus muscle16Transversus abdominis muscle17Internal oblique muscle18External oblique muscle19Gluteus maximus muscle20Gluteus medius muscle21Left hemidiaphragm22Hilum of spleen23Fundus of stomach

The relations of the kidneys

Blood supply of the kidneys

Figure 5.47 • Fascial spaces of the retroperitoneum.

Venous drainage

Lymphatic drainage

Fascial spaces around the kidneys (Figs 5.46, 5.47)

Figure 5.48 • Intravenous urogram. The right kidney has three major calyces. The left kidney has two major calyces, and a bifid pelvis. Note the course of the lower ureters. The distal part of the ureter passes behind the bladder. 1Right upper-pole (major) calyx2Right middle (major) calyx3Right lower-pole (major) calyx4Left upper-pole (major) calyx5Left lower-pole (major) calyx6Minor calyx (infundibulum of)7Papilla8Infundibulum9Fornix10Bifid left renal pelvis11Right renal pelvis12Right ureter13Left ureter: vascular impression14Upper pole right kidney15Right psoas outline16Gas in body of stomach17Gas in transverse colon18Intravesical ureter

The development of the kidney

Developmental abnormalities and variants

Radiology pearls

Radiological features of the kidney

Plain films of the abdomen

Intravenous urography (Fig. 5.48)

Ultrasound examination of the kidneys

Radiology pearls

CT and MRI (Figs 5.3, 5.4, 5.46)

Arteriography of the kidneys

Renal venography

Interventional procedures in the kidney

Radiology pearls

Scintigraphy of the kidney

The ureter (Fig. 5.48)

Blood supply of the ureter

The development of the ureter

Developmental abnormalities and variants

Radiological features of the ureter

Plain films of the abdomen

Intravenous urography (Fig. 5.48)

Ultrasound

Computed tomography

MR urography

Radiology pearl

The adrenal glands (Figs 5.11, 5.46)

Arterial supply

Venous drainage

Variants

Radiological features of the adrenal glands

Plain films of the abdomen

Computed tomography (Figs 5.11, 5.46, 5.55, 5.56)

Magnetic resonance imaging

Ultrasound

Adrenal venography

Arteriography of the adrenal gland

The abdominal aorta (Fig. 5.49; see also Fig. 6.11)

Figure 5.49 • Major branches of the aorta. (A) Ventral unpaired branches – the coeliac artery, superior mesenteric artery and inferior mesenteric artery. Lateral paired branches – the lumbar arteries and the common iliac arteries. (B) Other lateral paired branches.

Branches of the abdominal aorta

Radiological features of the aorta

Plain films of the abdomen

Ultrasound

Computed tomography

Magnetic resonance imaging

Angiography (Figs 5.12, 5.20, 5.22, 6.11)

The inferior vena cava

Tributaries of the inferior vena cava

Embryology and variants

Radiology of the inferior vena cava

Chest radiography

Cavography

Ultrasound

Computed tomography

Magnetic resonance imaging

Figure 5.50 • Veins of the posterior abdominal wall.

Veins of the posterior abdominal wall (Fig. 5.50)

Radiological features of the veins of the posterior abdominal wall

CT and MRI

Lymphatic drainage of the abdomen (Table 5.5)

Preaortic nodes

Table 5.5 Normal lymph node size in the abdomen*

Coeliac nodes

Superior and inferior mesenteric nodes

Para-aortic nodes

Retroaortic nodes

Cisterna chyli

Radiological features of the abdominal lymphatics

CT and MRI

Lymphography

The peritoneal spaces of the abdomen (Figs 5.51–5.53)

Development and terminology of the mesentery and peritoneal spaces

Figure 5.51 • Embryological development of peritoneal spaces: (A) fetus at fifth week; (B) fetus at tenth week; (C) maturity.

Figure 5.52 • Peritoneal spaces and ligaments: transverse section.

The lesser sac and associated ligaments (Figs 5.52, 5.53)

Boundaries of the epiploic foramen

Figure 5.53 • Peritoneal attachments to posterior abdominal wall and sagittal sections to show peritoneal spaces. (A) This section passes through the right lobe of liver and right kidney. Note the position of the bare area of the liver, where fluid cannot abut the liver in cases of free intra-abdominal fluid. The right subphrenic space communicates with the right subhepatic space around the front of the liver. (B) This section passes through the liver, stomach, colon with its greater and lesser omenta, and the retroperitoneal duodenum and pancreas. Note that the lesser omentum runs up into the fissure for the ligamentum venosum in the liver. The free lower edge of this contains the vessels running to and from the porta of the liver: hepatic artery portal vein and bile duct. (C) Section through left lobe of liver, stomach with lesser sac behind and colon. Pancreas, duodenum and left kidney are retroperitoneal. Note that the lesser sac extends up to the left subphrenic space. (D) Section through spleen. Note splenorenal and gastrosplenic ligaments.

Recesses of the lesser sac

Ligaments of the lesser sac

Radiology pearls

Subphrenic and subhepatic spaces and associated ligaments

Radiology pearl

Inframesocolic mesenteries and spaces

Radiological features of the peritoneal spaces

Plain films of the abdomen

Ultrasound

Computed tomography (Fig. 5.54)

Figure 5.54 • Axial CT of abdomen. Subject with extensive abdominal fluid. Note the vessels running in the thin mesenteric folds, outlined by fat; and the retroperitoneal location of the ascending and descending colon, the ureters, the aorta and inferior vena cava. 1Ascites2Folds of small bowel mesentery3Small bowel loops4Ascending colon5Descending colon6Transverse colon7IVC8Aorta9Ureter

Cross-sectional anatomy of the upper abdomen

Axial section through upper liver and spleen (Fig. 5.55)

Body wall

The diaphragm

Figure 5.55 • Axial CT, upper liver and spleen (T10/T11 approximately). 1Left portal vein2Left hepatic artery in porta3Fissure for ligamentum venosum4Middle hepatic vein5Right portal vein6Caudate lobe (segment I)7Inferior vena cava8Right adrenal gland9Segment VII10Upper pole of right kidney11Eleventh right rib12Segment II13Segment III14Rectus abdominis muscle15Muscles of chest wall16Stomach with air17Anterior left hemidiaphragm18Left lung19Gastric vessels in gastrosplenic ligament20Spleen21Origin of coeliac axis22Aorta23Left crus of diaphragm24Eleventh thoracic vertebra

Liver

Spleen

Other viscera

Figure 5.56 • Axial CT through porta hepatis (T11 approximately). 1Segment III2Ligamentum teres3Segment IVb4Hepatic artery5Portal vein6Branches of right portal vein7Papillary process of caudate lobe8Segment VI9Upper pole of right kidney10Eleventh right rib11Transverse colon12Stomach13Splenic artery14Part of pancreatic body15Spleen16Coeliac axis17Aorta18Upper pole of left kidney19T11/T12 disc space

Axial section at the level of the porta of the liver (Fig. 5.56)

Body wall

Diaphragm

Liver

Adrenal glands

Spleen

Other viscera

Axial section at the level of the body of the pancreas (Fig. 5.57)

Body wall

Figure 5.57 • Axial CT at level of body of pancreas (T12/L1). 1Neck of pancreas2Duodenum3Gallbladder4Head of pancreas5Inferior vena cava6Right crus of diaphragm7Renal sinus fat8Right renal vein9Right renal artery branch10Stomach11Splenic flexure12Splenic vein13Body and tail of pancreas14Spleen15Superior mesenteric artery16Left renal artery17Aorta18Left kidney19Confluence of splenic and portal veins

Liver

Pancreas

Other viscera

Axial section at the level of the pancreatic head and renal hila (Fig. 5.58)

Body wall

Liver

Pancreas

Kidneys and renal vessels

The aorta and the inferior vena cava

Figure 5.58 • Axial CT at level of pancreatic head (L1 approximately). 1Three layers of anterior abdominal wall2Gallbladder3Gastroduodenal artery4Head of pancreas5Duodenum6Renal vein7Branch of right renal artery8Ureter9Right kidney10Psoas muscle11Thecal sac in spinal canal12Transverse colon13Small bowel loops14Splenic flexure15Superior mesenteric vein16Superior mesenteric artery17Inferior pole of spleen18Left kidney at hilum19Left renal vein20Left renal artery21Renal lobulation22Erector spinae muscle

Figure 5.59 • Axial CT through mid-abdomen (L2/L3). 1Rectus muscle2Transverse colon3Small bowel loops4Mesenteric vessels5Ascending colon6Third part of duodenum7Inferior vena cava8Inferior mesenteric artery9Aorta10External oblique muscle11Internal oblique muscle12Peritoneal fat13Transversus abdominis muscle14Descending colon15Left pole of left kidney16Psoas muscle17Erector spinae muscle18Subcutaneous fat

Other viscera

Axial section below the kidneys (Fig. 5.59)

Body wall

The duodenum

The colon and jejunum

6 The pelvis

The bony pelvis, muscles and ligaments (Figs 6.1–6.7)

Radiology pearl

The sacrum

Figure 6.1 • Bony pelvis: (A) anterior view of pelvis; (B) inner surface of hemipelvis.

The coccyx

The sacroiliac joints

Figure 6.2 • Pelvic muscles: (A) coronal section; (B) viewed from inside the pelvis.

Radiology of the pelvic ring

Plain films

Anomalous lumbosacral anatomy

Differences between male and female pelvis

Cross-sectional imaging

Figure 6.3 • AP radiograph of male pelvis. 1Spinous process of L5 vertebra2Transverse process of L5 vertebra3Spinous process of first sacral segment4Lateral sacral mass5Ilium6Sacroiliac joint7Sacral foramen of S2 vertebra8Spinous process of S3 vertebra9Coccyx: first segment of three10Iliac crest11Anterior superior iliac spine12Anterior inferior iliac spine13Pelvic brim14Ischial spine15Body of ischium16Ischial tuberosity17Ramus of ischium18Inferior pubic ramus19Body of pubic bone20Pubic symphysis21Superior pubic ramus22Acetabulum23Head of femur24Fovea25Neck of femur26Greater trochanter of femur27Lesser trochanter of femur28Intertrochanteric femur

The pelvic floor (Figs 6.5–6.7; see also Figs 6.17, 6.21–6.25, 6.27, 6.28)

Figure 6.4 • CT scan of pelvis: axial section through male bladder. Intravenous contrast has been given. The full bladder displaces small bowel loops superiorly. 1Subcutaneous fat2Rectus abdominis muscle3Iliacus muscle4Psoas muscle and tendon5External iliac vein6External iliac artery7Inferior epigastric vessels8Sartorius muscle9Tensor fasciae latae muscle10Gluteus minimus muscle11Gluteus medius muscle12Gluteus maximus muscle13Piriformis muscle14Obturator internus muscle15Acetabulum16Lower sacral segment: S4 vertebra17Bladder: full of layering urine and contrast18Perivesical fat19Seminal vesicle20Rectum containing air, faeces and contrast medium21Wall of rectum22Perirectal (mesorectal) fat23Perirectal fascia (known as Denonvillier's fascia anteriorly)24Pararectal fat

Radiology of the pelvic floor

Dynamic proctography

Magnetic resonance imaging (Figs 6.5, 6.27, 6.28)

The sigmoid colon, rectum and anal canal (Figs 6.8, 6.9; see Fig. 5.19)

The sigmoid colon

Figure 6.5 • MRI pelvis – coronal section through male pelvis: (A) anterior section; (B) posterior section.(A) and (B) 1Ischium2Transverse perineal muscle3Obturator internus4Levator ani5Attachment of levator to tendinous arch of fascia overlying obturator muscle6Body of uterus7Endometrial cavity8Peritoneum reflected to pelvic side wall9Uterine vessels entering broad ligament (deep to fascia)10Internal iliac vessels11Sigmoid colon12Levator ani contributing to external anal sphincter13Sciatic nerve14Ischiorectal fossa

Blood supply (Figs 5.8, 5.22, 5.23)

Lymph drainage

The rectum

Figure 6.6 • Axial anatomy of the pelvis: (A) CT section through male perineum; (B) MR section through female perineum; (C) Axial diagram of male perineum. 1Pectineus muscle2Obturator externus muscle3Iliacus muscle4Obturator internus muscle5Pubic bone6Ischial tuberosity7Gluteus maximus muscle8Levator ani9Anus10External anal sphincter11Vagina12Urethra surrounded by external urethral sphincter13Sciatic nerve and inferior gluteal vessels14Ischiorectal fossa

Figure 6.7 • Male pelvis: (A) sagittal section showing pelvic floor and urethra; (B) coronal section showing the pelvic floor.

The anal canal (Fig. 6.9)

Figure 6.8 • Rectum: (A) anterior view and blood supply; (B) lateral view showing peritoneal reflections.

Radiology pearl

Blood supply (Figs 5.22, 5.23)

Figure 6.9 • Anatomy of anal canal.

Lymph drainage

Radiology of the sigmoid and rectum

Plain films (see Fig. 5.1)

Barium enema (see Fig. 5.19)

Computed tomography

CT colonography

Magnetic resonance imaging

Dynamic imaging (Fig. 6.28)

Blood vessels, lymphatics and nerves of the pelvis

Overview of the arteries and veins

Internal iliac artery (Figs 6.10, 6.11)

Figure 6.10 • Internal iliac artery and branches.

Branches of the anterior trunk

Branches of the posterior trunk

Radiology pearls (Fig. 6.13)

Figure 6.11 • Aortogram: external and internal iliac branches. 1Abdominal aorta2Lumbar artery3Right common iliac artery4Left common iliac artery5Left external iliac artery6Left internal iliac artery7Inferior mesenteric artery8Median sacral artery9Posterior trunk of right internal iliac artery10Iliolumbar artery (branch of 9)11Lateral sacral artery (branch of 9)12Superior gluteal artery (branch of 9)13Anterior trunk of right internal iliac artery14Obturator artery (branch of 13)15Vesical artery (branch of 13)16Inferior gluteal artery (branch of 13)17Deep circumflex iliac artery

External iliac artery (Fig. 6.11)

Branches

The iliac veins (Fig. 6.4)

Radiology pearl

Radiology of the iliac vessels (Fig. 6.11)

Angiography

Venography

Computed tomography

Magnetic resonance imaging

Ultrasound

The lymphatics

Radiology of the lymphatics

Lymphangiography

Cross-sectional imaging

Important nerves of the pelvis

Figure 6.12 • CT of lower pelvis showing pudendal vessels in pudendal canal. 1Obturator internus muscle2Pudendal vessels in pudendal canal3Dorsal penile branch4Obturator vessels

Radiology

Radiology pearl

The lower urinary tract

The pelvic ureters

The bladder (Figs 6.13, 6.14)

Radiology pearl

Figure 6.13 • CT of median and medial umbilical ligaments: (A) axial image; (B) coronal reformatted image. The medial ligaments are the fibrous remnants of the umbilical arteries; the median ligament is the fibrous remnant of the urachus. 1Medial umbilical ligament2Median umbilical ligament3Bladder4Urachus5Tendinous intersections of rectus abdominis muscle

Figure 6.14 • Male bladder and urethra: (A) lateral view; (B) diagram of prostatic urethra to show ducts.

Peritoneal reflections

Blood supply of the bladder

Lymph drainage

Radiology pearl

Radiology of the bladder

Plain films

Radiology pearls

Contrast studies

Cross-sectional imaging (Figs 6.4, 6.5)

The male urethra (Figs 6.15, 6.16)

Figure 6.15 • Retrograde urethrogram in the male: oblique view. 1Balloon of catheter in navicular fossa2Penile urethra3Bulbous urethra4Membranous urethra5Impression of verumontanum in prostatic urethra6Filling of utricle (not usually seen)7Air bubbles in contrast

Radiology pearl

Radiology of the male urethra (Fig. 6.15; see also section on radiology of the penis)

The female urethra

Urinary continence in the female

Radiology of the female urethra

Contrast studies

Ultrasound

MRI of the female urethra

The male reproductive organs (Figs 6.7, 6.14–6.20)

The prostate gland (Figs 6.16, 6.17)

Figure 6.16 • Prostate gland: zonal anatomy in a young adult. With ageing, the transitional zone hypertrophies, compressing the peripheral zone. The central and transitional zones (central gland) cannot be distinguished radiologically.

Zonal anatomy of the prostate (Fig. 6.16)

Radiology pearls

Figure 6.17 • MRI scan of male pelvis: (A) sagittal image through midline showing urethra; (B) sagittal image to the right of midline showing seminal vesicle. 1Bladder2Proximal urethra3Internal urethral sphincter4Prostate gland5Symphysis pubis6Retropubic fatty space (of Retzius)7Sigmoid colon8Rectum9Anal canal10Coccygeus muscle11Levator ani12Corpus spongiosum13Part of corpus cavernosum14Rectus muscle15Sacrum16Spinal canal containing CSF and sacral nerve roots17Seminal vesicle

The seminal vesicles (Figs 6.14, 6.17B, 6.31)

Blood supply of prostate gland and seminal vesicles

Nerve supply

Lymph drainage

Radiology of the prostate gland and seminal vesicles

Ultrasound

Cross-sectional imaging

The testis, epididymis and spermatic cord (Figs 6.18, 6.19)

The testis

Testicular size

The epididymis

Figure 6.18 • Testis and epididymis: (A) internal architecture; (B) blood supply; (C) transverse section.

The vas deferens

The spermatic cord

Clinical/radiology pearls

Figure 6.19 • Ultrasound of testis: (A) longitudinal image; (B) transverse image; (C) transverse image showing prominent rete testis – a normal variant. 1Skin2Testis3Epididymis4Fluid in scrotal sac5Rete testis

Blood supply

Lymph drainage

Radiology of the testis

Ultrasound (Fig. 6.19)

Radiology pearls

Figure 6.20 • Anatomy of penis: transverse section.

Magnetic resonance imaging

The penis (Fig. 6.20)

Blood supply of the penis

Radiology of the penis (see also section on the male urethra)

Ultrasound

Magnetic resonance imaging

Cavernosography

Radiology pearl

The female reproductive tract (Figs 6.21–6.28)

The vagina (Figs 6.21, 6.23)

Figure 6.21 • Female pelvis: sagittal section showing pelvic floor.

Blood supply

Lymph drainage

The uterus

Ligamentous support of the uterus (Figs 6.21, 6.22, 6.24)

Other uterine supports

Figure 6.22 • Support ligaments of female pelvis.

Figure 6.23 • Uterus and fallopian tubes: coronal section to show blood supply and ureter relative to uterine artery, cervix and vaginal fornices.

Normal variants of the uterus

The uterine tubes

Figure 6.24 • (A) Broad ligament; (B) Sagittal cross section of broad ligament.

Figure 6.25 • Transverse ultrasound of uterus and broad ligament. The broad ligament is outlined by fluid, and therefore can be seen. The right ovary lies in its anterior surface. The broad ligament is attached at the internal iliac vessels. The uterine artery runs in the base of the ligament, within its leaves. 1Free fluid2Uterus – body3Uterus – endometrium4Broad ligament5Ovary6Internal iliac vessels

Blood supply of the uterus and uterine tubes (Fig. 6.23)

Lymph drainage

The broad ligament (Figs 6.24, 6.25)

The ovaries

Blood supply

Lymph drainage

Radiology of the female pelvis

Ultrasound (Fig. 6.26)

Figure 6.26 • Ultrasound of uterus and vagina. (A) Longitudinal image; (B) Transverse image; (C) Endovaginal sagittal image. The ultrasound probe is in the posterior fornix of the vagina, directed anteriorly so that the transducer is parallel to the long axis of the uterus and cervix.(A) 1Bladder2Uterine fundus3Body of uterus4Cervix5Endometrial stripe6Vaginal stripe7Air in rectum(B) 1Bladder2Myometrium – anterior3Myometrium – posterior4Endometrium5Right ovary6Left ovary7Gas in bowel8Skin surface(C) 1Uterine fundus2Endometrium3Opposing endometrial surfaces4Cervix5Nabothian cyst

Figure 6.27 • MRI of female pelvis: (A) transverse T2-weighted image showing lower body of uterus and both ovaries. Note the high signal of endometrium and ovarian follicles; (B) Sagittal section midline.(A) 1Subcutaneous fat2Rectus muscle3Bladder4External iliac vein5External iliac artery6Round ligament7Transversus abdominis muscle8Small bowel loop9Uterus – myometrium10Uterus – endometrium11Ovary containing follicles12Rectum13Free fluid in cul-de-sac(B) 1Serosa (of uterus)2Myometrium3Junctional zone of uterus4Endometrium5Anterior lip of cervix6Cervical canal7Posterior vaginal fornix8Vagina9Bladder10Small bowel loops11Sigmoid12Rectum13Pubic bone14Rectus muscle

Radiology pearls

Figure 6.28 • Sagittal section of female pelvis showing pelvic floor lines. ILC = iliococcygeal line: from inferior pubis to last sacrococcygeal joint, representing levator/coccygeus complex. H line = anteroposterior dimension of levator hiatus, inferior pubis to puborectalis impression at anorectal junction. M line = perpendicular line dropped from ILC line to H line. LP = levator plate, line drawn along iliococcygeus muscle posterior to anorectal junction representing midline raphe.

Magnetic resonance imaging (Figs 6.27, 6.28)

Radiology pearl

Dynamic MR imaging (Fig. 6.28)

Normal findings and measurements (Fig. 6.28)

Computed tomography (Fig. 6.32)

Hysterosalpingography (Fig. 6.29)

Clinical/radiology pearl

Vaginography

Cross-sectional anatomy (Figs 6.30–6.32)

Midsacral level – male or female (Fig. 6.30)

Figure 6.29 • Hysterosalpingogram. 1Body of uterus2Fundus of uterus3Uterine cornu4Isthmus of fallopian tube5Ampulla of fallopian tube6Peritoneal spill of contrast7Cervical canal8Balloon of catheter in cervix9Catheter in vagina

Figure 6.30 • Axial CT of male/female pelvis: mid-sacral level. 1Subcutaneous fat2Bladder3Rectus muscle4Inferior epigastric vessels5Iliacus muscle6Caecum7Gluteus medius muscle8External iliac artery9External iliac vein10Gluteus minimus muscle11Small bowel12Sigmoid colon13Skin14Sigmoid colon15Psoas tendon16Medulla of ischium17Cortex of ischium18Superior gluteal vessels19Internal iliac vessels20Gluteus maximus muscle21Piriformis muscle22Sacrum23External sacral neural foramen

Figure 6.31 • Axial CT of male pelvis: lower sacral level. 1Femoral vein, artery and nerve in femoral sheath2Sartorius muscle3Iliacus muscle4Gluteus medius muscle5Gluteus minimus muscle6Femoral head7Acetabulum8Gluteus maximus muscle9Obturator internus muscle10Branches of internal iliac vessels11Rectus abdominis muscle12Inguinal ligament13Obturator internus muscle14Left seminal vesicle15Obturator internus muscle16Rectum17Perirectal fat18Coccyx

Figure 6.32 • Axial CT of female pelvis showing uterus and ovaries. 1Endometrial cavity2Uterus3Left ovary4Right ovary5Bladder6External iliac vein7External iliac artery8Inferior epigastric vessels9Round ligament10Piriformis muscle11Branches of internal iliac vessels12Sigmoid colon13Inferior gluteal vessels14Gluteus maximus15Gluteus medius16Gluteus minimus

Lower sacral level – male (Fig. 6.31)

Lower sacral level – female (Fig. 6.32)

Section through the perineum – male (Fig. 6.6A)

Section through the perineum – female (Fig. 6.6B)

7 The upper limb

The bones of the upper limb

The scapula (Figs 7.1, 7.2)

Radiological features of the scapula

Plain radiographs

Isotope bone scan

Ossification

Radiology pearl

The clavicle (Fig. 7.3; see also Fig. 7.2)

Figure 7.1 • The scapula: (A) anterior view; (B) posterior view; (C) lateral view.

Figure 7.2 • Axial radiograph of the shoulder. 1Medullary cavity of humeral shaft2Cortex3Head of humerus4Lesser tuberosity5Tip of acromion process6Lateral end of clavicle7Acromioclavicular joint8Clavicle9Glenoid fossa of scapula10Coracoid process of scapula11Acromion process of scapula

Figure 7.3 • The clavicle: (A) superior view; (B) inferior view.

Figure 7.4 • The left humerus: anterior and posterior views.

Radiological features of the clavicle

Chest radiograph

Radiology pearl

Ossification

Radiology pearl

The humerus (Figs 7.4, 7.5; see also Fig. 7.2)

Radiological features of the humerus

Plain radiographs

Figure 7.5 • AP radiograph of the elbow. 1Shaft of humerus2Olecranon fossa3Medial epicondyle4Lateral epicondyle5Olecranon process6Capitulum7Trochlea8Head of radius9Neck of radius10Coronoid process of ulna11Radial tuberosity12Shaft of radius13Shaft of ulna

Radiology pearl

Avulsion of the medial epicondyle

Ossification

The radius and ulna (Figs 7.6, 7.7; see also Fig. 7.5)

Figure 7.6 • The radius and ulna: anterior and posterior views.

Figure 7.7 • AP radiograph of the wrist and hand. 1Distal radius2Styloid process of radius3Distal ulna4Styloid process of ulna5Distal radioulnar joint6Radiocarpal joint7Scaphoid8Lunate9Triquetral10Pisiform11Hamate12Hook of hamate13Capitate14Trapezoid15Trapezium16First metacarpophalangeal joint17Base of fourth metacarpal18Shaft of fourth metacarpal19Head of fourth metacarpal20Fourth metacarpophalangeal joint21Shaft of proximal phalanx, ring finger22Proximal interphalangeal joint, little finger23Middle phalanx, middle finger24Distal interphalangeal joint, index finger25Distal phalanx, thumb26Sesamoid bone27Soft tissues overlying distal phalanx of middle finger

Radiological features of the radius and ulna

Plain radiographs

Radiology pearl

Ossification of the radius

Ossification of the ulna

The carpal bones (Fig. 7.8; see also Fig. 7.7)

Figure 7.8 • Bones of the hand.

Radiological features of the carpal bones

Radiography

Supernumerary bones

Nutrient arteries of the scaphoid

Ossification of the carpal bones

The metacarpals and phalanges

Figure 7.9 • Axial diagram of wrist tendons.

Radiological features of the metacarpals and phalanges

Bone age

The metacarpal sign

The carpal angle

The metacarpal index

Sesamoid bones

Ossification of the metacarpals and phalanges

The joints of the upper limb

The sternoclavicular joint

Type

Articular surfaces

Ligaments

The acromioclavicular joint

Type

Articular surfaces

Ligaments

The shoulder (glenohumeral) joint (Fig. 7.11)

Type

Articular surfaces

Capsule

Synovium

Ligaments

Stability

Radiological features of the shoulder joint

Plain radiographs

Arthrography with or without CT

Figure 7.10 • (A) Contrast outlining the subacromial bursa allowing targeted placement of therapeutic steroid. (B) Shoulder arthrogram showing contrast filling of joint space. (C) High-frequency ultrasound showing supraspinatus tendon attachment to humeral head. (D) Corresponding coronal oblique MRI.(B) 1The biceps sheath2The axillary pouch3The subcoracoid recess(C, D) 1Supraspinatus tendon2Supraspinatus tendon attachment3The suprascapular notch

Subacromial bursography

Ultrasound

Magnetic resonance imaging (Figs 7.11, 7.12)

Relevant anatomy – contributors to stability

The rotator cuff

The coracoacromial arch

Radiology pearl

The glenoid labrum

The bicipitolabral complex

Radiology pearl

The Bufort complex

Radiology pearl

The anterior capsular attachment

The glenohumeral ligaments

Shoulder stability

Marrow patterns

Figure 7.11 • (A) Coronal oblique section through the shoulder joint as seen on coronal oblique MRI scan. (B, C, D) Coronal oblique T1-weighted images from posterior to anterior.(B, C, D) 1Acromion process2Infraspinatus muscle3Deltoid muscle4Teres minor muscle5Quadrilateral space (containing circumflex humeral nerve and vessels)6Triceps muscle (lateral head)7Triceps muscle (long head)8Supraspinatus muscle and tendon9Superior labrum (and long head of biceps muscle anchor)10Suprascapular notch (containing suprascapular nerve artery and vein)11Biceps tendon12Coracoid process13Lesser tuberosity of humeral head14Subscapularis muscle and tendon(E, F, G, H) Direct axial images of the shoulder from superior to inferior. 1Acromioclavicular joint2Deltoid muscle, lateral belly3Supraspinatus tendon insertion4Clavicle5Acromion process6Deltoid muscle, anterior belly7Scapula8Coracoid process9Subscapularis muscle and tendon10Anterior glenoid labrum11Hyaline articular cartilage12Infraspinatus muscle13Long head of biceps tendon and sheath14Transverse humeral ligament15Middle glenohumeral ligament16Posterior glenohumeral joint capsule17Teres minor muscle18Coracobrachialis

Figure 7.12 • Sagittal oblique proton density weighted image. 1Clavicle2Supraspinatus muscle belly3Coracoid process4Glenoid5Subscapularis6Acromion7Infraspinatus muscle belly8Teres minor muscle belly9Deltoid muscle

Figure 7.13 • (A) Acromial shapes, types 1, 2 and 3. (B) A diagram of coronal view of shoulder showing variations in the attachment of the long head of biceps to the superior glenoid (type 1: attachment to glenoid; type 2: attachment to glenoid and labrum; type 3: attachment to labrum). (C) An atial diagram of the shoulder joint showing variations in the attachment of the capsule to the anterior margin of the glenoid (type 1: anterior capsule attachment; type 2: anterior capsule attachment to glenoid; type 3: attachment to medial glenoid).

Figure 7.14 • Axial MR arthrogram shows Bufort complex. 1Thickened middle glenohumeral ligament2Absent anterior glenoid labrum

Figure 7.15 • Sagittal MR arthrogram. 1Superior2Middle glenohumeral ligaments3Inferior glenohumeral ligaments4Supraspinatus tendon5Biceps tendon

Figure 7.16 • Coronal T1-weighted image in a normal adult. 1Epiphyseal subarticular red marrow rests2Metaphyseal red marrow

Radiology pearl

Radiology pearl

The elbow joint (Fig. 7.17)

Type

Figure 7.17 • (A, B) Diagram of the elbow joint. (C) Coronal T1-weighted image of the elbow. (D, E) Direct sagittal T1-weighted images: (D) radial side; (E) ulnar side.(C) 1Radial collateral ligament2Radial head and anular ligament3Supinator muscle belly4Ulnar collateral ligament5Medial epicondyle and common flexor tendon insertion6Coronoid fossa7Coronoid process8Extensor digitorum muscle belly9Flexor carpi radialis10Pronator teres(D, E) 1Olecranon fossa2Triceps tendon3Olecranon process4Trochlea (medial humeral condyle)5Trochlear notch6Pronator teres muscle belly7Biceps tendon8Brachialis tendon9Brachialis muscle belly10Biceps muscle belly11Coronoid fossa12Coronoid process13Flexor carpi ulnaris muscle(F, G) Direct axial proton density weighted images: (F) from level of humeral condyles; (G) to the level of the proximal radioulnar joint. 1Common extensor tendon insertion2Anconeus3Common flexor tendon insertion4Olecranon5Medial epicondyle6Brachialis tendon7Biceps tendon8Flexor carpi ulnaris9Brachial artery, vein and median nerve10Brachioradialis muscle11Radial head12Anular ligament13Ulnar nerve14Radial nerve

Articular surfaces

Table 7.1 Appearance of ossification centres

Capsule

Ligaments

The development of the elbow

Radiological features of the elbow joint

Plain radiographs (see Fig. 7.17)

Radiology pearl

Arthrography

Magnetic resonance imaging (Fig. 7.17)

Relevant anatomy

The ulnar collateral ligament

Radiology pearl

The lateral collateral ligament

Radiology pearl

Biceps muscle and tendons

Radiology pearl

Triceps tendon muscle and tendon

Radiology pearl

Lateral epicondylitis

Medial epicondylitis

Relevant neural anatomy and injury following elbow trauma

Pseudolesions of the elbow

The inferior radioulnar joint (Fig. 7.18)

Type

Articular surfaces

Capsule

The radiocarpal joint (Fig. 7.18)

Type

Articular surfaces

Capsule

Ligaments

The intercarpal joints (see Fig. 7.18)

Radiological features of the joints of the wrist and hand

Wrist biomechanics – stable versus unstable equilibrium

Figure 7.18 • (A) Diagrammatic representation of the wrist; (B, C) coronal T1- and gradient echo T2-weighted images of the wrist.(D) sagittal proton density weighted image. (E, F) Axial proton density weighted images at the level of distal radius and ulna (E); and at the level of the distal pillars of the carpal tunnel (F).(B, C) 1Triquetral bone2Triangular fibrocartilage3Ulna4Radius5Scapholunate ligament6Scaphoid7Lunate8Extensor carpi ulnaris tendon(D) 1Capitate2Extensor tendons3Lunate4Radius5Pronator quadratus6Flexor digitorum profundus tendons7Flexor digitorum superficialis tendons(E, F) 1Flexor carpi ulnaris muscle belly and tendon2Extensor carpi ulnaris tendon3Extensor digiti minimi tendon4Extensor digitorum tendons5Extensor pollicis longus tendon6Extensor carpi radialis brevis tendon7Extensor carpi radialis longus tendon8Lister's tubercle9Extensor pollicis brevis tendon10Flexor carpi radialis distal muscle belly11Flexor digitorum profundus tendons12Hook of the hamate13Hypothenar eminence14Guyon's canal (containing the ulnar nerve artery and vein)15Flexor retinaculum16Median nerve17Thenar eminence18Distal tubercle of trapezium19Flexor carpi radialis insertion20Flexor pollicis longus tendon

Plain radiographs

Scaphoid views

Arthrography

Magnetic resonance imaging (Fig. 7.18)

Relevant anatomy

The scapholunate ligament

Figure 7.19 • (A) The scapholunate angle, (B) the lunatocapitate angle and (C) Gilula's arcs.

Radiology pearl

Lunatotriquetral ligament

Radiology pearl

Triangular fibrocartilage complex (TFCC)

Figure 7.20 • The triangular fibrocartilage complex.

Flexor and extensor tendons of the wrist

Tendon injury at the wrist

Extensor carpi ulnaris tendon

First extensor compartment syndrome – de Quervain's tenosynovitis

Intersection syndrome

Scaphoid injury

Figure 7.21 • Structures of the carpal tunnel and of Guyon's canal.

Vascular integrity of fracture fragments

The carpal tunnel

Guyon's canal

The spaces of the palm of the hand

The intrinsic muscles of the hand

Figure 7.22 • Sagittal image of the digit.

Tendons and soft-tissue anatomy of the digit (Fig. 7.22)

The volar plate

The dorsal hood

Applied anatomy and digital injury

Collateral ligament injury

Extensor tendon injury – mallet finger

Flexor digitorum profundus tendon injury – jersey finger

The muscles of the upper limb

Figure 7.23 • Axial proton density weighted MRI section through the upper arm. 1Biceps muscle – short head (flexor of the elbow)2Biceps muscle – long head (flexor of the elbow)3Brachialis muscle (flexor of the elbow)4Triceps muscle medial head (extensor of the elbow)5Triceps muscle lateral head (extensor of the elbow)6Triceps muscle long head (extensor of the elbow)7Basilic vein (neurovascular bundle)8Brachial artery (neurovascular bundle)9Median nerve (neurovascular bundle)10Cortex of humeral shaft11Medullary cavity12Subcutaneous fat in anterior aspect of the upper arm

Figure 7.24 • Axial proton density weighted MRI scan through the forearm. The scan was obtained with the palm facing up. Extensive fat allows easier visualization of the muscle groups. The flexors are anterior and the extensors posterior. 1Radius2Ulna3Extensor carpi radialis muscle (longus and brevis)4Extensor carpi ulnaris muscle5Extensor digitorum muscle6Extensor pollicis longus muscle7Abductor pollicis longus muscle8Flexor carpi ulnaris muscle9Flexor carpi radialis muscle10Flexor digitorum superficialis muscle11Flexor digitorum profundus muscle12Brachioradialis muscle13Position of radial artery and vein14Cephalic vein

The arterial supply of the upper limb (Fig. 7.27; see also Figs 1.42, 1.43)

Figure 7.25 • Axial section through the upper arm showing muscle compartments: (A) upper humeral level; (B) midhumeral level.

Figure 7.26 • Axial section through the lower arm showing muscle compartments.

Figure 7.27 • Arteries of the upper limb.

Figure 7.28 • Superficial veins of the upper limb.

Radiological features of the arterial supply of the upper limb

Arteriography (see Fig. 1.42)

The veins of the upper limb (Fig. 7.28)

Radiological features of the veins of the upper limb

Venography

Intravenous injection of contrast or radionuclides in dynamic studies

8 The lower limb

The bones of the lower limb

The femur (Fig. 8.1; see also Fig. 6.1)

Radiology pearl

Radiology pearl

Radiological features of the femur (see Fig. 6.1)

Plain radiographs

Figure 8.1 • Femur: anterior and posterior views.

Radiography

Radiology pearl

Sesamoid bones

Blood supply of the head of the femur

Ossification of the femur

Trabecular markings in the neck of femur and bone density

Figure 8.2 • Diagrammatic representation of the trabecular markings of the femoral neck.

Radiology pearl

The patella

Radiological features of the patella

Plain radiographs

Radiology pearl

Dislocation of the patella

Radiology pearl

Ossification

Figure 8.3 • Tibia and fibula: (A) anterior view; (B) posterior view.

The tibia (Fig. 8.3)

The fibula (Fig. 8.3)

Radiological features of the tibia and fibula

Plain radiographs

Ossification of the tibia

Ossification of the fibula

The tibia in adulthood

Radiology pearl

Figure 8.4 • Bones of the foot: dorsal view.

The bones of the foot (Figs 8.4, 8.5)

The talus

Radiology pearl

The calcaneus

Radiology pearl

The arches of the foot

Figure 8.5 • Oblique radiograph of the foot. 1Fibula2Tibia3Talus4Neck of talus5Head of talus6Sinus tarsi7Posterior process of talus8Calcaneus9Sustentaculum tali10Navicular11Cuboid12Medial cuneiform (superimposed)13Intermediate cuneiform (superimposed)14Lateral cuneiform (superimposed)15Styloid process of fifth metatarsal16Shaft of first metatarsal17Head of first metatarsal18Proximal phalanx, first toe19Distal phalanx, fifth toe20Base of fourth metatarsal

Radiology pearl

Radiological features of the bones of the foot (Fig. 8.6)

Plain radiographs

Radiology pearl

Radiology pearl

Figure 8.6 • Radiological features of the bones of the foot: (A) Boehler's calcaneal angle and heel pad thickness; (B and C) orientation of the talus in a child; (D and E) styloid process of the fifth metatarsal: epiphyseal line and fracture; (F and G) sesamoid bones of the foot.

Sesamoid bones

Ossification of the bones of the foot

Coalition of the bones of the foot

Figure 8.7 • Hip joint: coronal section.

Radiology pearl

The joints of the lower limb

The hip joint (Fig. 8.7)

Type

Radiology pearl

Articular surfaces

Capsule

Synovium

Ligaments

Radiological features of the hip joint

Plain radiographs

Figure 8.8 • The infant hip: lines and angles.

Radiography

Arthrography

Figure 8.9 • Ultrasound scan of infant hip: coronal view in standard plane. 1Iliac wing2Acetabulum (iliac part)3Triradiate cartilage4Acetabulum (ischial part)5Labrum of acetabulum6Lower limit of joint capsule as it merges with femoral neck (echogenic focus)7Cartilage of femoral head8Ossific nucleus of femoral head9Gluteal muscles10Skin

Ultrasound of the infant hip (Fig. 8.9)

CT of the hip joint

Magnetic resonance imaging of the hip (Fig. 8.10)

The acetabular labrum

Radiology pearl

Pitfalls

The symphysis pubis (Fig. 8.11)

Radiology pearl

The knee joint (Fig. 8.12)

Type

Articular surfaces

Capsule

Synovium

Figure 8.10 • MRI of the hip: (A, B, C) coronal T1-weighted scans from anterior to posterior (A–C). 1Rectus femoris insertion2Gluteus medius muscle3Iliacus muscle4Iliopsoas muscle belly5Tensor fascia lata6Femoral vessels7Conjoined insertion of gracilis and adductor longus muscles8Adductor longus9Pubic symphysis10Pectineus muscle11Bladder12Uterus13Gluteus minimus14Capsule (ileofemoral ligament)15Vastus lateralis muscle16Obturator internus muscle17Obturator externus muscle18Adductor brevis muscle19Adductor longus muscle20Piriformis muscle21Gluteus maximus muscle22Greater trochanter23Ischium24Conjoined tendon of long head of semimembranosus and long head of biceps femoris25Adductor magnus muscle26Semitendinosus muscle27Inferior gemellus muscle28Quadratus femoris muscle MRI of the hip: (D, E, F) sequential axial T2-weighted scans from superior to inferior. (G) sagittal T1-weighted image of the hip. (H) MR arthrographic images showing labral anatomy in coronal (top left), sagittal (right side) and axial (bottom left) planes. (D, E, F) 1Rectus abdominis muscle2Bladder3Prostate4Rectum5Quadrilateral plate of the acetabulum (and cotyloid fossa)6Sciatic nerve7Coccyx8Piriformis9Anterior labrum10Ileofemoral ligament (anterior fold of the capsule)11Posterior wall of the acetabulum12Obturator externus muscle13Obturator internus muscle14Ischiorectal fossa15Natal cleft16Gluteus medius17Cotyloid fossa18Femoral vein19Femoral artery20Sartorius21Rectus femoris22Iliopsoas23Tensor fascia lata24Adductor longus25Adductor brevis26Quadratus femoris27Gluteus maximus (G) 1Iliopsoas muscle2Iliopsoas tendon3Pectineus4Obturator externus5Anterior labrum6Femoral head7Roof of the acetabulum8Quadratus femoris9Sciatic nerve10Glutei minimus11Gluteus medius12Gluteus maximus

Ligaments

Internal structures (Fig. 8.13)

Figure 8.11 • (A) Symphyseal contrast injection, symphysography, with matching (B) coronal MRI, and (C) axial MR image. 1Normal symphyseal cleft2Normal adductor attachments3Posterior bulge of fibrocartilage4Anterior rectus abdominis and adductor aponeurosis

Radiological features of the knee joint

Plain radiographs of the knee joint (Fig. 8.14)

Arthrography of the knee joint

Figure 8.12 • Knee joint: sagittal section.

Magnetic resonance imaging of the knee (Fig. 8.15)

Relevant MRI anatomy

The menisci

Anatomy

Figure 8.13 • Upper end of the tibia: axial section showing menisci and attachments of the cruciate ligaments.

Meniscal tears

Figure 8.14 • Knee: (A) AP radiograph; (B) lateral radiograph.(A) 1Femur2Patella3Lateral epicondyle4Medial epicondyle5Adductor tubercle6Lateral tibial plateau7Medial tibial plateau8Lateral tibial spine (intercondylar eminence)9Medial tibial spine (intercondylar eminence)10Fused growth plate, proximal tibia11Head of fibula(B) 1Distal femur2Patella3Quadriceps tendon4Epicondyles (superimposed)5Femoral condyle6Tibial spines (superimposed)7Tibial plateaux (superimposed)8Head of fibula9Neck of fibula10Tibial tuberosity

Radiology pearls

Radiology pearl

Figure 8.15 • MRI scan of the knee. Coronal T1-weighted images of the anterior knee (A) and of the posterior knee (B). (C, D, E, F) Sequential sagittal scans from lateral to medial.(A, B) 1Iliotibial band2Lateral meniscus3Gerdy's tubercle4Medial meniscus5Medial collateral ligament (superficial component)6Conjoined tendon7Fibular collateral ligament8Biceps femoris tendon9Popliteus insertion, notch10Anterior cruciate ligament11Posterior cruciate ligament(C, D, E, F) 1Lateral meniscus (posterior horn)2Popliteus tendon3Lateral head of the gastrocnemius4Biceps femoris, muscle belly5Tibial tuberosity6Hoffa's fat pad7Patella tendon8Articular cartilage (of the lateral femoral condyle)9Quadriceps tendon10Intercondylar notch (Blumensatt's line)11Anterior cruciate ligament12Popliteal vessels13Medial meniscus (anterior horn)14Posterior cruciate ligament15Medial head of gastrocnemius16Semimembranosus muscle belly17Vastus medialis muscle belly18Medial meniscus posterior hornMRI scan of the knee: (G) Axial image at the level of the patellofemoral articulation. 1Lateral articular facet of the patella2Lateral retinaculum3Iliotibial band4Biceps femoris muscle5Lateral head of the gastrocnemius muscle6Popliteal vessels7Sartorius muscle8Gracilis muscle9Semimembranosus muscle10Semitendinosus muscle11Lateral head of the gastrocnemius12Vastus medialis muscle13Medial retinaculum

Collateral ligaments

The lateral collateral ligament complex

Radiology pearl

The medial collateral ligament

Radiology pearl

Cruciate ligaments

The anterior cruciate ligament (ACL)

Radiology pearl

Posterior cruciate ligament (PCL)

Radiology pearl

The extensor mechanism

Figure 8.16 • (A) Coronal fat suppressed MRI and (B) sagittal T1-weighted image of the knee showing a discoid lateral meniscus (1).

Radiology pearl

Popliteus tendon

Radiology pearl

Plantaris tendon

Radiology pearl

The tibiofibular joints

The ankle joint (Fig. 8.17)

Type

Figure 8.17 • Ankle: (A) medial view – deltoid ligament; (B) lateral view.

Articular surfaces

Capsule

Synovium

Ligaments

Biomechanics of the foot and ankle

Radiological features of the ankle joint

Plain radiographs

Arthrography

Figure 8.18 • MRI of the ankle: (A) Sagittal T1-weighted image; (B) Coronal T1-weighted image.(C, D) MRI of the ankle: Axial proton density image. (E) Axial oblique proton density image.(A) 1Achilles tendon2Flexor hallucis muscle belly3Tibia4Talus5Posterior subtalar joint6Plantar aponeurosis7Calcaneus8Sinus tarsi and interosseous ligament9Calcaneocuboid articulation10Tibiotalar articulation11Tibialis anterior tendon(B) 1Medial malleolus2Lateral malleolus3Inferior tibiofibular articulation4Talus5Fibulocalcaneal ligament6Tibiocalcaneal ligament7Tibialis posterior tendon8Flexor digitorum longus9Flexor hallucis longus tendon10Abductor hallucis muscle11Flexor digitorum brevis12Flexor digiti minimi13Calcaneus14Peroneus longus tendon15Peroneus brevis tendon16Posterior subtalar joint17Sustentaculum talus(C, D) 1Tibialis anterior tendon2Extensor hallucis tendon3Extensor digitorum tendon4Anterior tibiofibular ligament5Posterior tibiofibular ligament6Peroneus brevis tendon7Peroneus longus tendon8Tibialis posterior tendon9Flexor digitorum tendon10Flexor hallucis longus tendon and muscle belly11Achilles tendon12Anterior talofibular ligament13Posterior talofibular ligament14Talus15Lateral malleolus(E) 1Tibialis posterior tendon2Flexor digitorum tendon3Flexor hallucis tendon4Peroneus brevis tendon5Peroneus longus tendon6Extensor hallucis tendon7Extensor digitorum tendon8Tibialis anterior tendon9Tarsal tunnel10Quadratus plantae muscle11Medial plantar nerve, artery and veins12Lateral plantar nerve, artery and veins13Talus14Sustentaculum talus15Posterior subtalar joint

Radiology pearl

Computed tomography

Magnetic resonance imaging (Fig. 8.18)

Relevant MRI anatomy

The ankle ligaments

The lateral collateral ligament

Radiology pearl

Anterior talofibular ligament

The calcaneofibular ligament

The posterior talofibular ligament

The medial collateral ligament (the deltoid ligament)

The syndesmosis

Radiology pearl

The ligaments of the sinus tarsi

Impingement syndromes

The Achilles tendon

Peroneal tendons

Radiology pearl

Tibialis posterior tendon

Radiology pearl

Flexor hallucis longus

Tibialis anterior tendon

Radiology pearl

The subtalar joint

Radiological features of the subtalar joint

Plain radiography

Computed tomography

Magnetic resonance imaging

Other joints of the foot

The muscles of the lower limb

Figure 8.19 • Axial proton density weighted MRI scan of thigh. 1Medullary cavity of femur2Cortex of femur3Rectus femoris muscle4Vastus lateralis muscle5Vastus intermedius muscle6Vastus medialis muscle7Sartorius muscle8Superficial femoral vessels in adductor canal9Adductor magnus10Biceps femoris muscle (long head)11Semitendinosus muscle12Semimembranosus muscle13Gracilis muscle14Position of sciatic nerve15Deep femoral vessels

Radiology pearl

The arteries of the lower limb (Figs 8.24–8.26)

Medial and lateral circumflex femoral arteries

Four perforating arteries

Figure 8.20 • Axial proton density weighted MRI scan of calf. 1Medulla of tibia2Cortex of tibia3Medulla of fibula4Cortex of fibula5Muscles of anterior tibial compartment6Tibialis posterior muscle7Anterior tibial artery, vein and nerve8Posterior tibial artery, vein and nerve9Medial head of gastrocnemius muscle10Lateral head of gastrocnemius muscle11Soleus muscle12Flexor digitorum longus muscle13Peroneus longus14Popliteus muscle

Figure 8.21 • Axial section of upper thigh.

Figure 8.22 • Axial section of midthigh.

Figure 8.23 • Axial section of midcalf.

Figure 8.24 • Arteries of the lower limb as seen on angiography.

Figure 8.25 • Femoral artery angiogram. 1Common femoral artery2Profunda femoris artery3Superficial femoral artery4Lateral circumflex femoral artery5Perforating artery6Superior vesical artery7Obturator artery8Internal pudendal artery9Inferior gluteal artery

Radiological features of the arteries of the lower limb

Arteriography of the lower limb (Figs 8.24–8.26)

Magnetic resonance angiography

Ultrasound

Figure 8.26 • Femoral angiogram: popliteal arteries. 1Popliteal artery2Descending genicular artery3Medial superior genicular artery4Lateral superior genicular artery5Middle genicular artery6Medial inferior genicular artery7Lateral inferior genicular artery8Anterior tibial artery9Tibioperoneal trunk10Posterior tibial artery11Peroneal artery12Muscular branches

Collateral arteries

The veins of the lower limb (Fig. 8.28)

Figure 8.27 • Coronal lower limb gadolinium-enhanced magnetic resonance angiogram.

Figure 8.28 • Veins of the lower limb as seen on venography.

Radiological features of the veins of the lower limb

Venography

Ultrasound

9 The breast

General anatomy (Figs 9.1, 9.2)

Lobular structure (Fig. 9.3)

Blood supply (Fig. 9.2)

Lymphatic drainage (Fig. 9.2)

Figure 9.1 • Breast: sagittal section.

Clinical/radiology pearl

Radiology of the breast

Mammography (Figs 9.4–9.7)

Ultrasound (Fig. 9.8)

Figure 9.2 • Breast: anterior view demonstrating relationship to chest wall, blood supply and lymph drainage.

Figure 9.3 • Lobular structure of breast.

Figure 9.4 • Mammogram of a moderately fibroglandular breast. (A) Mediolateral oblique view (MLO). (B) Craniocaudal view (CC). The pectoralis muscle should be well seen on the MLO view. The glandular tissue is concentrated mainly in the retroareolar region. There is a retroglandular fatty area between the glandular tissue and the pectoralis muscle on both views. Note the sliver of pectoralis on the CC view, which should be evident on a technically well-executed mammogram. 1Pectoralis muscle2Retroglandular fat3Glandular breast tissue4Nipple5Cooper's ligaments

Figure 9.5 • MLO view of a breast with prominent fibroglandular and stromal elements. There is a moderate amount of fat. The entire breast has the same pattern with no concentrated glandular area or retroglandular fat. Subtle areas of architectural distortion might be difficult to see on this study.

Figure 9.6 • MLO view of predominately fatty breast. Most of the density in this breast is due to blood vessels and fibrous septae. There is a small amount of glandular tissue. Any change or abnormality would be easy to detect in this breast.

Figure 9.7 • MLO view of an extremely dense breast. There is almost no fat in this breast and all of the density is made up of stromal and some glandular elements. A calcified artery is noted bilaterally. A mass could be very difficult to detect mammographically in this breast.

Figure 9.8 • Ultrasound of breast. Composite image demonstrating breast and pectoralis muscle. 1Pectoralis muscle2Subcutaneous fat3Cooper's ligament4Glandular tissue

Magnetic resonance imaging (Fig. 9.9A and B)

Sentinel node mapping (Fig. 9.10)

Radiology pearl

Mammographic patterns (Figs 9.4–9.7)

Age changes in the breast

Radiological significance of breast density and parenchymal pattern

Figure 9.9 • Coronal MRI of breasts. (A) T1-weighted, fat-saturated, gadolinium-enhanced. Note – fat is dark and muscles are bright, enhancing breast tissue is bright. (B) T2-weighted image. Note – fat is bright, fibroglandular tissue is dark.(A) 1Cooper's ligaments2Skin3Subcutaneous fat4Enhancing fibroglandular breast tissue5Retroglandular fat6Sternum7Enhancing vessels8Pectoralis major muscle9Lung(B) 1Cooper's ligament2Fibroglandular tissue3Fat4Pectoralis major muscle5Costal cartilage6Sternum7Heart

Figure 9.10 • Lymphoscintigram of breast. Technetium sulphur colloid has been injected around a tumour in the left breast. Uptake is seen in the first draining node in the axilla. Uptake is also seen in the thyroid gland and liver. 1Radioisotope in tumour2Uptake in sentinel node3Uptake in thyroid gland4Uptake in liver

Index

 


An aparitie 24 Sept. 2010
Autor Stephanie Ryan FRCSI FFR(RCSI) , Michelle McNicholas MRCPI FFR(RCSI) FRCR
Dimensiuni 22.23 x 1.91 x 27.94 cm
Editura Elsevier
Format Paperback
ISBN 9780702029714
Limba Engleza
Nr pag 337

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