HOW TO MAXIMIZE YOUR TELERADIOLOGY *RELATIONSHIP*

ELI B. COHEN, DVM, DACVR CLINICAL ASSISTANT PROFESSOR

NC STATE COLLEGE OF VETERINARY MEDICINE

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COMMON IMAGING MISTAKES

(TELE)RADIOLOGIST’S LAMENTS

NO/LACK OF CLINICAL HISTORY

POSITIONING

Rotated/oblique cervical/spinal radiographs

Orthogonal views!

Left lateral view of abdomen*

TECHNIQUE

Quantum mottle

Saturation artifact

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CLINICAL HISTORY

CONTEXT IS CRITICAL!

Image interpretation is a noise limited decision task

Decisions are a cognitive process, heavily reliant on clinical context

Each modality has it’s own sensitivity/specificity

It is often the history which alters differentials (which illness scripts are kept or discarded)

No/incomplete clinical history

Strips the expert of their expertise

Creates image interpreter instead of a clinician consultant

Constructing a ddx list prior to imaging/submission passes the case through a cognitive filter before it gets to the radiologist (inherent double read)

nical conte tttxttt

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TARGET KNOWLEDGE

I’M LOOKING FOR MY CAR…I’M LOOKING FOR MY TWO-DOOR CAR…I’M LOOKING FOR MY ORANGE TWO-DOOR CAR…

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Target Knowledge5

FAN OF EASTERN MEDICINE?

CLINICAL HISTORY - THE FUNNY6

IRONY

CLINICAL HISTORY - THE FUNNY7

COMMUNICATION IS KEY

zzzzzzzz

CLINICAL HISTORY - THE FUNNY8

THE NEW PLANKING?

CLINICAL HISTORY - THE FUNNY

+ + = ????????????

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PUNCTUATION ALWAYS WELCOME

CLINICAL HISTORY - THE FUNNY10

VETERINARY STEPHEN KING

CLINICAL HISTORY - THE FUNNY11

CHICKEN OR THE EGG

CLINICAL HISTORY - THE FUNNY12

IMAGING IN THE 4TH DIMENSION

BACK TO THE FUTURE

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LETTER SOUP (BOWL)

LETTER SOUP (CUP)

CLINICAL HISTORY - THE BAD14

HAIKU?

CLINICAL HISTORY - THE BAD15

WHAT’S THE QUESTION?

CLINICAL HISTORY - THE BAD + SAD16

CLINICAL HISTORY - THE BAD17

CLINICAL HISTORY - THE BAD18

CLINICAL HISTORY - THE BAD19

CLINICAL HISTORY - THE BETTER20

CLINICAL HISTORY - THE BETTER21

CLINICAL HISTORY - THE BETTER22

CLINICAL HISTORY - THE BETTER23

CLINICAL HISTORY - THE GOOD24

CASE 3

WHY COUGH W/ HEART DISEASE?

•Ferasin, L., et al. Risk factors for coughing in dogs with naturally acquired myxomatous mitral valve disease. JVIM, Vol. 27, Iss 2; 2013

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CLINICAL HISTORY - THE BEST

Signalment

Presenting complaint

Pertinent clinical history

Your clinical differentials

Any specific questions you have

“Is there cardiogenic edema/LCHF”

“What’s the round opacity over the 4th rib on the left lateral?”

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COMMON IMAGING MISTAKES

(TELE)RADIOLOGIST’S LAMENTS

NO/LACK OF CLINICAL HISTORY

POSITIONING

Rotated/oblique cervical/spinal radiographs

Orthogonal views!

Left lateral view of abdomen*

TECHNIQUE

Quantum mottle

Saturation artifact

blogs.thegospelcoalition.org

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POSITIONING - NECK

CERVICAL RADIOGRAPHS

If the dens looks great, the rad’s not straight!

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LOOK MA, NO DENS!

POSITIONING - NECK29

POSITIONING - NECK30

POSITIONING - NECK31

POSITIONING - NECK32

POSITIONING - THORAX

COMPLETE EXAMINATION

At least 2-views, 3-4 views should be standard

Left lateral, right lateral, ventrodorsal, dorsoventral

DV if patient is unstable

Different views show different things!

Maximal inspiration

Be aware of position prior to imaging

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POSITIONING - THORAX

CAUDAL LOBES ARE THE MEATIEST!

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POSITIONING - THORAX

EXP INSP

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POSITIONING - THORAX36

POSITIONING - THORAX37

POSITIONING - THORAX38

WHAT’S YOUR DIAGNOSIS?

POSITIONING - THORAX

L

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POSITIONING - THORAX

RR

40

POSITIONING - THORAX41

WHAT’S YOUR DIAGNOSIS?

POSITIONING - THORAX

R

42

POSITIONING - THORAX

L

L

43

POSITIONING - THORAX

L

R

R

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WHY IS THERE DISTANCE BETWEEN HEART AND STERNUM?XR

POSITIONING - THORAX45

POSITIONING - THORAXOSIOSITIONTIONINGING TH- THTHORAXORAXORAXORAXORAXORAXORAXRAXRAXAXAXX46

MEDIASTINAL SHIFT

218044

Volume Loss

POSITIONING - THORAX47

PRE POST

POSITIONING - THORAX48

ATELECTASIS VS. CONSOLIDATION

POSITIONING - THORAX49

DOWN PATHOLOGY RISES

POSITIONING - THORAX50

POSITIONING - THORAX51

POSITIONING - ABDOMEN

COMPLETE EXAMINATION

At least 2-views, 3-views should be standard

Left lateral, right lateral, ventrodorsal

DV useless unless looking at stomach or contrast study

12-24hr fast (rarely happens)

Always surveys before a contrast study

Be aware of prior medications

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GRAVITY + RECUMBENCY + ANATOMY = DXPOSITIONING - ABDOMEN

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POSITIONING - ABDOMEN54

POSITIONING - ABDOMENTEXT

F/B

P

F/B

P

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RIGHT

LEFT

POSITIONING - ABDOMEN

PF

B

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P

BF

RIGHT

LEFT

POSITIONING - ABDOMEN57

POSITIONING - ABDOMEN

RIGHTLEFT

P B

F

58

RIGHT LEFT

F

BP

POSITIONING - ABDOMEN59

POSITIONING - ABDOMEN60

POSITIONING - ABDOMEN

START WITH LEFT LATERAL!

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COMMON IMAGING MISTAKES

(TELE)RADIOLOGIST’S LAMENTS

NO/LACK OF CLINICAL HISTORY

POSITIONING

Rotated/oblique cervical/spinal radiographs

Orthogonal views!

Left lateral view of abdomen*

TECHNIQUE

Quantum mottle

Saturation artifact

www.other-worlds-cafe.com

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low contrast

Diagnostic contrast

TECHNIQUE63

HIGH contrast

Diagnostic contrast

TECHNIQUE64

WHAT INFLUENCES CONTRAST?

Subject Contrast

Density

Thickness

Atomic number

Film/Image Detector Contrast

XR Beam Energy

As kVp increases, object contrast decreases

Fog/Scatter

Increases overall opacity, but decreases contrast

Signal:Noise ratio*

Reduced by: collimation, decreasing kVp, using grids*

Motion*

TECHNIQUE 65

TECHNIQUE - QUANTUM MOTTLETECHNIQUE

PENNIES IN THE HATBOX

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PENNIES IN THE HATBOX

TECHNIQUE - QUANTUM MOTTLE67

TECHNIQUE - QUANTUM MOTTLE

PENNIES IN THE HATBOX

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TECHNIQUE - QUANTUM MOTTLE69

WHAT’S THE FIX?

We need more pennies (photons)!

Primary determinant of photon # = mAs

Need to double mAs to see effect

TECHNIQUE - QUANTUM MOTTLE70

TECHNIQUE - OVEREXPOSURE71

TECHNIQUE - OVEREXPOSURE72

SATURATION ARTIFACT

TECHNIQUE - OVEREXPOSURE73

SATURATION ARTIFACT /

PLANKING

TECHNIQUE - OVEREXPOSURE74

WHAT’S THE FIX?

TECHNIQUE - OVEREXPOSURE

Reduce technique (kVp)

Adjust for thinner/thicker parts of the patient

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CLINICAL HISTORY - POSITIONING - TECHNIQUE

CONCLUSION - THIS IS AN IMPERFECT *RELATIONSHIP*

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FIN

QUESTIONS???

Hx: None provided.

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