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MANUAL OF RADIOLOGY: ACUTE PROBLEMS AND ESSENTIAL PROCEDURES SecondEdition MANUAL OF RADIOLOGY: ACUTE PROBLEMS AND ESSENTIAL PROCEDURES Second Edition Editedby Clifford R. Weiss, MD Fellow,VascularandInterventionalRadiology TheRussellH.MorganDepartmentofRadiologyandRadiologicalScience TheJohnsHopkinsUniversitySchoolofMedicine Baltimore,Maryland Oleg M. Teytelboym, MD Resident/Fellow,NuclearMedicine TheRussellH.MorganDepartmentofRadiologyandRadiologicalScience TheJohnsHopkinsUniversitySchoolofMedicine Baltimore,Maryland Nafi Aygun, MD AssistantProfessorofRadiology TheRussellH.MorganDepartmentofRadiologyandRadiologicalScience TheJohnsHopkinsMedicalInstitution Baltimore,Maryland John Eng, MD AssociateProfessorofRadiology JointAppointmentinHealthSciencesInformatics TheRussellH.MorganDepartmentofRadiologyandRadiologicalScience TheJohnsHopkinsUniversitySchoolofMedicine Baltimore,Maryland AcquisitionsEditor:LisaMcAllister ManagingEditor:KerryBarrett ProjectManager:JenniferHarper MarketingManager:AngelaPanetta SeniorManufacturingManager:BenjaminRivera ArtDirector:RisaClow ProductionServices:LaserwordsPrivateLimited,Chennai,India ©2008byLIPPINCOTTWILLIAMS&WILKINS,aWoltersKluwerbusiness 530WalnutStreet Philadelphia,PA19106USA LWW.com Firstedition,©1997byLippincott-RavenPublishers Allrightsreserved.Thisbookisprotectedbycopyright.Nopartofthisbookmaybereproduced inanyformorbyanymeans,includingphotocopying,orutilizedbyanyinformationstorageand retrievalsystemwithoutwrittenpermissionfromthecopyrightowner,exceptforbriefquotations embodiedincriticalarticlesandreviews.Materialsappearinginthisbookpreparedbyindividualsas partoftheirofficialdutiesasU.S.governmentemployeesarenotcoveredbytheabove-mentioned copyright. PrintedintheUSA LibraryofCongressCataloging-in-PublicationData Manualofradiology/CliffordR.Weiss...[etal.].—2nd.ed. p.;cm. Includesbibliographicalreferencesandindex. ISBN978-0-7817-9964-5 1.Radiology,Medical—Handbooks,manuals,etc.I.Weiss,CliffordR. [DNLM:1.Radiography—methods—Handbooks.WN39M2952008] RC78.M2422008 (cid:1) 616.0757—dc22 2007041348 Carehasbeentakentoconfirmtheaccuracyoftheinformationpresentedandtodescribe generallyacceptedpractices.However,theauthors,editors,andpublisherarenotresponsibleforerrors oromissionsorforanyconsequencesfromapplicationoftheinformationinthisbookandmakeno warranty,expressedorimplied,withrespecttothecurrency,completeness,oraccuracyofthecontents ofthepublication.Applicationofthisinformationinaparticularsituationremainstheprofessional responsibilityofthepractitioner. Theauthors,editors,andpublisherhaveexertedeveryefforttoensurethatdrugselectionand dosagesetforthinthistextareinaccordancewithcurrentrecommendationsandpracticeatthetimeof publication.However,inviewofongoingresearch,changesingovernmentregulations,andthe constantflowofinformationrelatingtodrugtherapyanddrugreactions,thereaderisurgedtocheck thepackageinsertforeachdrugforanychangeinindicationsanddosageandforaddedwarningsand precautions.Thisisparticularlyimportantwhentherecommendedagentisaneworinfrequently employeddrug. SomedrugsandmedicaldevicespresentedinthispublicationhaveFoodandDrugAdministration (FDA)clearanceforlimiteduseinrestrictedresearchsettings.Itistheresponsibilityofthehealthcare providertoascertaintheFDAstatusofeachdrugordeviceplannedforuseintheirclinicalpractice. Topurchaseadditionalcopiesofthisbook,callourcustomerservicedepartmentat (800)638-3030orfaxordersto(301)223-2320.Internationalcustomersshouldcall(301)223-2300. VisitLippincottWilliams&WilkinsontheInternet:atLWW.com.LippincottWilliams& Wilkinscustomerservicerepresentativesareavailablefrom8:30amto6pm,EST. 10 9 8 7 6 5 4 3 2 1 CONTRIBUTORS LauraAmodei,MD AriM.Blitz,MD DirectorofMRI AssistantProfessorofRadiology CharlestonBreastCenter TheRussellH.MorganDepartmentof Charleston,SouthCarolina RadiologyandRadiologicalScience JohnsHopkinsUniversitySchoolof Medicine NafiAygun,MD Baltimore,Maryland AssistantProfessorofRadiology TheRussellH.MorganDepartment PaulD.Campbell,Jr. ofRadiologyandRadiological Resident,DiagnosticRadiology Science TheRussellH.MorganDepartmentof TheJohnsHopkinsUniversitySchoolof RadiologyandRadiologicalScience Medicine JohnsHopkinsUniversitySchoolof Baltimore,Maryland Medicine Baltimore,Maryland BradP.Barnett MedicalStudent ClaireS.Cooney,MD TheJohnsHopkinsUniversitySchoolof Fellow,BodyImaging Medicine TheRussellH.MorganDepartmentof Baltimore,Maryland RadiologyandRadiologicalScience JohnsHopkinsUniversitySchoolof VisveshwarBaskaran,MD Medicine Baltimore,Maryland ChiefResident,DiagnosticRadiology TheRussellH.MorganDepartment ofRadiologyandRadiological AzarP.Dagher,MD Science AnnapolisRadiologyAssociates JohnsHopkinsUniversitySchoolof AnneArundelMedicalCenter Medicine Annapolis,Maryland Baltimore,Maryland MandeepDagli,MD Fellow,VascularandInterventional NormanJ.Beauchamp,Jr.,MD,MHS Radiology ProfessorandChair TheRussellH.MorganDepartmentof DepartmentofRadiology RadiologyandRadiologicalScience UniversityofWashington JohnsHopkinsUniversitySchoolof Seattle,Washington Medicine Baltimore,Maryland SimonBekker,MD Resident,DiagnosticRadiology MichaelW.D’Angelo,MD,MS TheRussellH.MorganDepartment Fellow,MuskuloskeletalImaging ofRadiologyandRadiological TheRussellH.MorganDepartmentof Science RadiologyandRadiologicalScience JohnsHopkinsUniversitySchoolof JohnsHopkinsUniversitySchoolof Medicine Medicine Baltimore,Maryland Baltimore,Maryland v vi Contributors JosephP.DiPietro,MD EdwardH.Herskovits,MD,PhD Resident,DiagnosticRadiology AssociateProfessor TheRussellH.MorganDepartmentof DepartmentofRadiology RadiologyandRadiologicalScience UniversityofPennsylvania JohnsHopkinsUniversitySchoolof Philadelphia,Pennsylvania Medicine Baltimore,Maryland AndrewL.Holz,MD,MBA ResidentFellow,NuclearMedicine W.DeeDockery,MD TheRussellH.MorganDepartment Partner,AmericanRadiologyAssociates, ofRadiologyandRadiological P.A. Science Dallas,Texas JohnsHopkinsUniversitySchoolof Medicine Baltimore,Maryland DanielJ.Durand,MD Resident,DiagnosticRadiology TheRussellH.MorganDepartmentof KarenM.Horton,MD RadiologyandRadiologicalScience AssociateProfessorofRadiology JohnsHopkinsUniversitySchoolof TheRussellH.MorganDepartment Medicine ofRadiologyandRadiological Baltimore,Maryland Science JohnsHopkinsUniversitySchoolof Medicine TimothyS.Eckel,MS,MD Baltimore,Maryland Director,DiagnosticandInterventional Neuroradiology AnnapolisRadiologyAssociates KrishnaJuluru,MD AnneArundelMedicalCenter AssistantProfessor Annapolis,Maryland DepartmentofRadiology WeillMedicalCollegeofCornellUniversity NewYork,NewYork JohnEng,MD AssociateProfessorofRadiology JointAppointmentinHealthSciences SatomiKawamoto,MD Informatics AssistantProfessorofRadiology TheRussellH.MorganDepartmentof TheRussellH.MorganDepartment RadiologyandRadiologicalScience ofRadiologyandRadiological JohnsHopkinsUniversitySchoolof Science Medicine JohnsHopkinsUniversitySchoolof Baltimore,Maryland Medicine Baltimore,Maryland BradleyR.Foerster,MD Fellow,Neuroradiology AlexanderM.Kowal,MD TheRussellH.MorganDepartmentof Resident,DiagnosticRadiology RadiologyandRadiologicalScience TheRussellH.MorganDepartment JohnsHopkinsUniversitySchoolof ofRadiologyandRadiological Medicine Science Baltimore,Maryland JohnsHopkinsUniversitySchoolof Medicine Baltimore,Maryland DavidJ.Grelotti,MD ClinicalFellow DepartmentofPsychiatry GeorgeP.Kuo,MD HarvardMedicalSchool; Resident,DiagnosticRadiology ResidentinPsychiatry TheRussellH.MorganDepartmentof DepartmentofPsychiatry RadiologyandRadiologicalScience MassachusettsGeneralHospitaland JohnsHopkinsUniversitySchoolof McLeanHospital Medicine Boston,Massachusetts Baltimore,Maryland Contributors vii LoralieD.Ma,MD MyriaPetrou,MD ClinicalAsst.ProfessorofRadiology Fellow,Neuroradiology DepartmentofRadiology TheRussellH.MorganDepartmentof TheJohnsHopkinsHospital; RadiologyandRadiologicalScience MedicalDirector TheJohnsHopkinsUniversitySchoolof DepartmentofRadiology Medicine GreaterBaltimoreMedicalCenter Baltimore,Maryland Baltimore,Maryland AimeeLynnMaceda,MD ValerieA.Pomper,MD StaffRadiologist Fellow,BodyImaging DepartmentofRadiology TheRussellH.MorganDepartmentof WashingtonAdventistHospital RadiologyandRadiologicalScience TakomaPark,Maryland JohnsHopkinsUniversitySchoolof Medicine Baltimore,Maryland DouglasE.Ramsey,MD RadiologyResident CathleenF.Magill,MD RussellH.MorganDepartmentof ChiefResident RadiologyandRadiologicalSciences DepartmentofInternalMedicine TheJohnsHopkinsUniversitySchoolof TheJohnsHopkinsUniversity Medicine ChiefResident Baltimore,Maryland DepartmentofInternalMedicine TheJohnsHopkinsBayviewMedical Center HariCharanP.Reddy,MD Baltimore,Maryland Fellow,Neuroradiology TheRussellH.MorganDepartmentof RadiologyandRadiologicalScience SarahMezban,MD JohnsHopkinsUniversitySchoolof Resident,DiagnosticRadiology Medicine TheRussellH.MorganDepartmentof Baltimore,Maryland RadiologyandRadiologicalScience JohnsHopkinsUniversitySchoolof Medicine ChristopherL.Smith,MD Baltimore,Maryland AssistantProfessorofRadiology TheRussellH.MorganDepartmentof JasonOaks,MD,MA RadiologyandRadiologicalScience Resident,DiagnosticRadiology JohnsHopkinsUniversitySchoolof TheRussellH.MorganDepartmentof Medicine RadiologyandRadiologicalScience Baltimore,Maryland JohnsHopkinsUniversitySchoolof Medicine Baltimore,Maryland KevinA.Smith,MD ChiefResident,DiagnosticRadiology TheRussellH.MorganDepartmentof RickW.Obray,MD RadiologyandRadiologicalScience ResidentPhysician JohnsHopkinsUniversitySchoolof DepartmentofRadiology Medicine TheJohnsHopkinsUniversity Baltimore,Maryland Baltimore,Maryland MarcusW.Parker,MD JoshuaSmith,MD Resident,DiagnosticRadiology Fellow,Neuroradiology TheRussellH.MorganDepartmentof TheRussellH.MorganDepartmentof RadiologyandRadiologicalScience RadiologyandRadiologicalScience JohnsHopkinsUniversitySchoolof JohnsHopkinsUniversitySchoolof Medicine Medicine Baltimore,Maryland Baltimore,Maryland viii Contributors JenniferE.Swart,MD KennethC.Wang,MD,PhD Resident,DiagnosticRadiology Resident,DiagnosticRadiology TheRussellH.MorganDepartmentof TheRussellH.MorganDepartmentof RadiologyandRadiologicalScience RadiologyandRadiologicalScience JohnsHopkinsUniversitySchoolof JohnsHopkinsUniversitySchoolof Medicine Medicine Baltimore,Maryland Baltimore,Maryland OlegM.Teytelboym,MD MonicaD.Watkins Resident/Fellow,NuclearMedicine Fellow,Neuroradiology TheRussellH.MorganDepartmentof TheRussellH.MorganDepartmentof RadiologyandRadiologicalScience RadiologyandRadiologicalScience JohnsHopkinsUniversitySchoolof JohnsHopkinsUniversitySchoolof Medicine Medicine Baltimore,Maryland Baltimore,Maryland BenjaminTubb,MD DavidA.Weiland,MD FellowinMagneticResonanceImaging AdvancedMedicalImaging DepartmentofRadiology Denver,Colarado TheUniversityofPennsylvania Pennsylvania,Philadelphia CliffordR.Weiss,MD Fellow,VascularandInterventional D.DarrellVaughn,MD Radiology JeffersonRegionalMedicalCenter TheRussellH.MorganDepartmentof Pittsburgh,Philadelphia RadiologyandRadiologicalScience JohnsHopkinsUniversitySchoolof JensVogel-Claussen,MD Medicine AssistantProfessorofRadiology Baltimore,Maryland TheRussellH.MorganDepartmentof RadiologyandRadiologicalScience JohnsHopkinsUniversitySchoolof Medicine Baltimore,Maryland PREFACE T heManualofRadiologyhasbeencreatedbyTheJohnsHopkinsradiologyresidents and faculty to help radiology residents during night call. Radiology is a massive field, encompassing all organ systems, age groups and patient populations. For any given problemorsuspecteddiseaseprocess,therearemanydiagnosticpathwaystochoosefrom. Anyon-callradiologistneedstobeabletomanageallofthesechallengesefficientlyand effectively.Thesameistrueoftheon-callmedicalorsurgicalresidents,whoarerequesting theradiologicaltests. Thismanualfocusesontheimagingessentialsofthediseaseprocessesmostcommonly encountered by the on-call resident. Using a direct and simple format, each chapter includesabriefdescriptionofpathophysiologyandclinicalpresentation,followedbykey imagingfindings.Themanualemphasizesselectingthebestimagingmodality,choosingthe appropriate protocol, and identifying the key findings needed to establish the diagnosis, detectlife-threateningcomplications,andavoidcommonpitfalls.Asinthefirstedition,we haveincludedacollectionofessentialproceduresandpracticalreferences,whichwehave foundusefulinourdailypracticeasradiologyresidents. The manual has been extensively updated since the first edition and now includes multiplefiguresandimageswhichillustratekeydiseasepresentations,complications,and imaging pitfalls. Multiple new topics have been added, including chapters on cardiac imaging and CNSinfections. Imaging protocolshave been extensively updated to reflect current,state-of-artimaging. This manual is targeted for radiology residents who are starting night call, for medicalandsurgicalresidentswhoarerequestingimagingstudies,andformedicalstudents beginningtheirclinicalrotations. We would like to thank senior faculty of the Johns Hopkins radiology department andparticularlyDr.StanleySiegelmanforhismentoringandlong-standingcommitment toresidenteducation. INVITATION FOR COMMENTS I sincerely invite any suggestions, corrections, criticisms, or other comments about this bookandwouldgreatlyvalueanysuchfeedback.Pleaseaddresscommentstomethrough thepublisherorsendthembyelectronicmailtocweiss@jhmi.edu.Allelectronicmailwill beanswered. CliffordR.Weiss,MD OlegM.Teytelboym,MD NafiAygun,MD JohnEng,MD ix

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Thoroughly updated for its Second Edition, this manual is ideal for residents in training, especially those junior residents learning how to perform procedures and facing the first months of call. The manual encapsulates the core information needed for conducting clinical examinations and determinin
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Thoroughly updated for its Second Edition, this manual is ideal for residents in training, especially those junior residents learning how to perform procedures and facing the first months of call. The manual encapsulates the core information needed for conducting clinical examinations and determinin

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