Atlas of AnatomyB Y S E C T I O N A L I M A G I N G

User Manual

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Tomás Sempere Durá, born in Elche (Alicante).

He graduated in Medicine and Surgery at Saragossa University and specialized in Radiodiagnosis at Miguel Servet Hospital in Saragossa. Dr. Sempere carries out his scientific and care work at the CT Unit of Joan XXIII University Hospital in Tarragona and is Associate Professor of Human Anatomy at the Rovira i Virgili University.

© 2009, Química Farmacéutica Bayer, S.L.

All rights reserved. No part of this publication may be reproduced, transmitted in any form or by any means, electronic or mechanical, inclu-ding photocopying, recording or any other information retrieval system without written authorization from the owner of the copyright.

ISBN: 978-84-691-7878-2

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To Andrés, my father, for his example.To María Rosa, my wife. This work would not have been possible without her constant love and support.

Table of Contents

Prologues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

CD operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

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Since we started our work at the School of Medicine of the Rovira I Virgili Uni-versity, more than 30 years ago, there has been a continuous collaboration between the Anatomy Unit and the Department of Radiology of Joan XXIII University Hospital in Tarragona . We are convinced that the teaching of hu-man anatomy to future physicians will never be complete if the new imaging techniques for diagnosis are not incorporated into its methodology .

Hence, a great part of such diagnostic techniques have been gradually and timely incorporated into the contents of the subject matters taught by us . This concern led us to create a specific optional subject matter focusing on the study of our body using CT, spiral CT, and volume rendering that is taught by Dr . Sempere .

The work presented here is the culmination of years of tireless work, and its superb selection of images of most imaging techniques is the result of the dual vocation of the author as a specialist in radiology and a lecturer .

This is not a “closed” work, but rather the opposite; because of his professio-nalism, perseverance and rigor, the work of Dr . Sempere presented here is not the end of a project, but its starting point and, like the techniques illustrated, will be subject to constant review and update .

We think that the work done combines in a didactic and rigorous form two very important disciplines in medical training . In pregraduate training it will allow for laying the foundations for correct diagnosis by teaching students to discriminate normal from pathological . It will also allow postgraduates and specialists to consolidate and update the knowledge they already have, the-reby facilitating their clinical work .

Reus, June 2008

Verónica Piera LluchFull Professor of Human Anatomy and EmbryologySchool of Medicine and Health SciencesRovira i Virgili University

Prologues

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It is a pleasure for me, as a radiologist and teacher, to make a review of the work “Atlas of Anatomy by Sectional Imaging” written by Dr . T . Sempere, a co-lleague and a friend for many years . This is however no obstacle for me to make some objective comments on this work written by him .

Understanding anatomy is very important, in itself and because anatomical abnormalities suggest anatomical variants or presence of disease . The book cited is finally issued after much thought and meditation and many hours of work, thanks to the dedication of the author .

The advent of computed tomography, and more recently of its spiral modality, has substantially improved the anatomical understanding of all body organs . In addition, multiplanar (MPR) and volumetric (3D and volume rendering) re-constructions have provided a new way to visualize anatomy that we could only dream of when we looked at the drawings of classical anatomists .

Dr . Sempere, in his dual condition of specialist in radiodiagnosis at the Joan XXIII University Hospital in Tarragona and lecturer at the School of Medicine of the Rovira I Virgili University, has gathered more than 10,000 images from more than 500 patients in this atlas .

The contents is superbly structured based on the different anatomical organs of the body, and each section provides submenus with visualization of images by the different techniques with which they were obtained . Legends in the images designating each anatomical structure make anatomical understan-ding and learning pleasant, easy and, to a certain extent, challenging .

In my view, this atlas is essential for medicine undergraduates and highly use-ful for education of residents in the specialty and also, why not, for radiologists or other specialists who have sometimes doubts about anatomical structures in sectional techniques .

Dr. A. Olazabal ZudaireHead, Department of Radiodiagnosis, HUGTIP, BadalonaFull Professor of Radiology and Physical Medicine,Barcelona Autonomous University

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Human anatomy is one of the basic sciences in medical studies since its incep-tion . Since then, the sources used to advance in understanding of the human body have substantially changed .

Without prejudice to the so-called classical methods of anatomical understan-ding, advancement of this at the same pace as some medical disciplines and adequate discrimination between a healthy state, its variants and pathology require incorporation of the most recent techniques as sources of anatomical understanding since the very start of medical training .

Since the advent of X rays to the present day, techniques for visualization of the human body have become essential tools for the diagnosis and treatment of countless diseases, and provide healthcare professionals with a previously unsuspected information about human anatomy .

This is what has occurred at our university over the past decades . All human anatomy contents taught during the degree studies include the correspon-ding section of radiographic anatomy .

Anatomical information is essential in medicine studies, but becomes indis-pensable for training our future specialists in imaging diagnosis . Modern me-dicine, like old medicine, needs to make a good diagnosis, plan an adequate treatment, establish a prognosis, or control a course . Understanding of ana-tomy is a key factor for achieving these goals .

The work presented therefore reflects the experience gained both as univer-sity lecturer (Unit of Human Anatomy, School of Medicine of Rovira i Virgili University) and specialist physician (Joan XXIII University Hospital in Tarrago-na) in the training of pregraduates, postgraduates, and specialists in imaging diagnosis .

The work addresses the study of the chest, abdomen, head and neck, muscu-loskeletal system, circulatory system, and nervous system . Each section inclu-des images obtained using different techniques (conventional X-rays, com-puted tomography, magnetic resonance imaging, and ultrasonography) and is completed by the appropriate three-dimensional study, virtual endoscopy, and volume rendering, which is the true axis of the work .

Volume rendering represents a study method highly relevant for understan-ding sectional anatomy because it allows for perfect orientation of all structu-res in the different spatial planes . Its nice combination of the section with the

Preface

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three-dimensional view makes its use attractive and illuminating .

I hope the reader may benefit from the effort and enthusiasm devoted to pre-pare this work, which is also open to incorporation of new technologies and to any suggestions that may help improve its contents or format in the future .

Tarragona, June 2008

Tomás Sempere Durá

Correspondence with the author:atlasdeanatomiaseccional@gmail .com

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Atlas of Anatomy by Sectional Imaging is issued in electronic format in a DVD-ROM .

Images have been obtained from 530 subjects from among those attending our department in the 2000-2007 period based on the type of examination, age, sex, and morphological characteristics . Subjects who could have changes in the normal organization of their anatomy were excluded .

Our study was performed using the following:

• Tomograph CT TWIN FLASH (PHILIPS)

• Tomograph CT SOMATOM Emotion 6 (SIEMENS)

• MRI equipment MAGNETOM Symphony 1T MRI (SIEMENS)

• Ultrasound system Toshiba NEMIO 20

• Workstation Silicon Graphics O2 (PHILIPS)

• Workstation SYNGO MMWP VE 23 (SIEMENS)

The work addresses the study of the chest, abdomen, head and neck, mus-culoskeletal system, circulatory system, and nervous system . Each section provides images obtained using different modalities, including conventional X-rays, computed tomography, magnetic resonance imaging, and ultrasono-graphy . Study of each section is completed with the three-dimensional, virtual endoscopy, and volume rendering techniques .

This anatomical work includes a total of 10,560 images . In each of these, the most relevant elements have been tagged with legends . For volume rende-ring, because of its simultaneous condition of sectional and three-dimensional technique, only the elements included in the sectional plane are indicated .

Images have been tagged using the anatomical terminology model .

Methodology

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Main menu of organs and systems

• Select with the mouse the system corresponding to the organ to be visua-lized (mp-1) and the relevant organ menu will be displayed (mp-2) .

• By clicking on the button of the selected organ (mp-2), the Navigation Screen will appear, allowing for visualization of all examinations available for such organ .

CD operation

mp-1 mp-2

mp-1: Menu of systems .

mp-2: Menu of organs corresponding to the selected system (in mp-1) .

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Navigation screen

• In the Examinations menu (pn-2), the types of examinations available for the selected organ will appear . By clicking on the type of examination, icons of examinations of that type will be loaded (pn-3) . This example shows 4 volume rendering examinations .

• By clicking on one of the icons (pn-3) the first image of the examination selected will be loaded, as will the list of anatomical points (pn-4) .

• The navigation buttons (pn-9) may be used to navigate through the images and/or cross sections of the examination .

• If the mouse pointer is positioned on an anatomical point in the image (in blue), the corresponding descriptive text or legend (pn-6) will light up .

• By clicking with the mouse an element from the list of anatomical points (pn-4), the legend on the corresponding point in the image will also light up .

• If the Hide button (pn-5) is clicked, anatomical points on the image will di-sappear . However, the area occupied by such points will remain sensitive to the mouse, so that when image is explored with the pointer the points and legends in the pointed area will light up .

pn-1pn-11pn-3 pn-10

pn-2

pn-5

pn-4

pn-8 pn-9

pn-7

pn-6

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pn-1: Return to menu .

pn-2: Menu for selecting the types of examinations available for the organ being visualized . Possible examinations include: Conventional X-rays, volume rendering, 3 dimensions, magnetic resonance imaging, ultra-sonography, virtual endoscopy, and MIP .

pn-3: Icons of available examinations of the type selected in the menu (pn-2) . This example shows 4 volume rendering examinations . The yellow box indicates the currently selected examination .

pn-4: List of anatomical points on the current screen image . If an element in this list is clicked with the mouse, the legend will light up on the point in the image . Points in the image appear in blue

pn-5: Button to hide/visualize points on the image . Points are sensitive to the mouse pointer, so that when one is pointed, the corresponding legend will automatically light up . When points are hidden, the co-rresponding area will remain sensitive to the mouse to light up their legends

pn-6: Text legend on an anatomical point .

pn-7: Title of the image/examination being visualized .

pn-8: Data on the patient and the examination being visualized

pn-9: Image navigation buttons (Previous – Next) .

pn-10: Current system: Current organ .

pn-11: Current type of examination .

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Tomás Sempere Durá. Radiologist . Joan XXIII University Hospital, Tarragona .Associate Professor . Unit of Human Anatomy and Embryology .School of Medicine and Health Sciences, Rovira i Virgili University .

Work reviewed by:

Prof. Dr. Verónica Piera LLuch. Full Professor of Human Anatomy and Embryology .School of Medicine and Health Sciences, Rovira i Virgili University .

Collaborators

Dr. Jesús Palao Errando. Radiologist . Pius Hospital, Valls .Associate Professor . Unit of Human Anatomy and Embryology .School of Medicine and Health Sciences, Rovira i Virgili University .

Dr. Luis Martín Muñoz. Radiologist . Joan XXIII University Hospital, Tarragona .Associate Professor . Radiology and Physical Medicine .School of Medicine and Health Sciences, Rovira i Virgili University

Dr. Diasol Villa Viñas. Radiologist . Joan XXIII University Hospital, Tarragona .

Dr. Joan Pere Vives Abelló. Radiologist . IDI Joan XXIII . Joan XXIII University Hospital, Tarragona

Dr. Jordi Guarinos Oltra. Cardiologist . Hemodynamist . Joan XXIII University Hospital, Tarragona .

Dr. Jordi Mercé Klein. Cardiologist . Joan XXIII University Hospital, Tarragona .

Dr. Mónica Larios Sánchez. Resident in radiology . Joan XXIII University Hospital, Tarragona

Dr. Silvia Rosa Calero. Resident in radiology . Joan XXIII University Hospital, Tarragona .

Dr. Cristina Delgado Ricote. Resident in radiology . Joan XXIII University Hospital, Tarragona .

Dr. Cristina Gómez Miranda. Resident in radiology . Joan XXIII University Hospital, Tarragona .

Authors

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Acknowledgment

This work has been supported by Bayer Schering Pharma and recognized and declared of scientific and educational interest by the Spanish Society of Ra-diology (SERAM) .

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To Drs . Ana Ramos, Ana Magarolas, Alfonso Guedea, Francesc Larroca, and Francisco Avilés for their support in labeling of the work .

To Dr . Natalia Rodríguez and José María Rodríguez Sánchez T .E .R . for contri-bution of images .

To Philips Ibérica Cuidados de la Salud and particularly to Andrés Cano, appli-cations technician, and engineers from Philips Ibérica for their professiona-lism and help .

To Toni Ribes, telecommunications engineer, for solving difficulties of any kind .

To Eduard and Roger, from Propuestas Informáticas, for their good work .

To the Department of Radiology of Joan XXIII Hospital in Tarragona and the Unit of Human Anatomy of the School of Medicine .

To the Institut de diagnòstic per la imatge . IDI Hospital Joan XXIII .

To Mark Morrison and Desiderio Diez for their confidence and friendship .

To Martí Soler, Elisenda Moncasi, and Griselda Margall, from Bayer Schering, for their personal support .

To Bayer Schering Pharma, with which I have collaborated these years, for their work in support of teaching and their confidence in and support to my person, with my special gratitude to David García for promoting and coordi-nating this project .

To my medicine residents and students .

To my family .

Acknowledgments

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ULTRAVIST® 150/240/300/370 Composition: Ultravist® 150, 240, 300, 370: 1 ml contains 0.312 g, 0.499 g, 0.623 g, 0.769 g iopromide in aqueous solution. For diagnostic use! Indica-tions: Ultravist 240/300/370: For intravascular use and use in body cavities. Contrast enhancement in computerised tomography (CT), arteriography and venography, intravenous/in-traarterial digital subtraction angiography (DSA); intravenous urography, use for ERCP, arthrography and examination of other body cavities. Ultravist 150: for intraarterial digital subtraction angiography (DSA), checking the patency of a dialy-sis shunt. Ultravist 240: also for intrathecal use. Ultravist 370: especially for angiocardiography Ultravist 150/300/370: not for intrathecal use. Contraindications: There are no absolute contraindications to the use of Ultravist. Undesirable effects: Intravascular use. • Immunological Anaphylactoid reactions/ hypersensitivity. (uncommon) Anaphylactoid shock (including fatal cases) (rare). • Endocrine. Alteration in thyroid function, thyrotoxic crisis. • Nervous, Psychiatric: dizzi-ness, restlessness, paraesthesia / hypoaesthesia, confusion, anxiety, agitation, amnesia, speech disorders, somnolence, unconciousness, coma, tremor, convulsion, paresis / paralysis, cerebral ischaemia/ infarction, stroke, transient cortical blindness • Eye. Blurred/disturbed vision (uncommon), conjunctivitis, lacrimation (rare) • Ear. Hearing disorders. • Car-diac. Arrhythmia Palpitations, chest pain / tightness, bradycardia, tachycardia, car-diac arrest, heart failure, myocardial ischemia/ infarction cyanosis. • Vascular. Vasodilatation (uncommon), Hypotension, hypertension, shock Vasospasm, a thromboembolic events (rare) • Respiratory. Sneezing, coughing (uncommon), rhinitis, dyspnea, mucosal swelling, asth-ma, hoarseness, laryngeal / pharyngeal / tongue / face edema, bronchospasm, laryngeal/pharyngeal spasm, pulmonary edema, respiratory insufficiency, respiratory arrest (rare). • Gastrointestinal. nausea (common), vomiting, taste distur-bance (uncommon), throat irritation, dysphagia, swelling of salivary glands, abdominal pain, diarrhoea (rare) • Skin and subcutaneous tissue. Urticaria, pruritus, rash, erythema (uncommon), angioedema, mucocutaneous syndrome (e.g. Stevens-Johnson’s or Lyell syndrome) (rare) • Renal and urinary. Renal impairment (uncommon), Acute renal failurea (rare) • General disorders and administration site conditions. heat or pain, sensations, headache (common), malaise, chills, sweating, vasovagal reactions (uncommon), pallor, body temperature alterations, edema, local pain, mild war-mth and edema, inflammation and tissue injury in case of extravasation (rare). Intrathecal use. Based on experience with other non-ionic contrast media, the following undesirable effects may occur with intrathecal use in addition to the undesirable effects listed above: • Nervous, Psychiatric. Neuralgia, meningism (common). Paraplegia, psychosis, aseptic meningitis, EEGchanges (rare). • General disorders and administration site conditions: Micturition difficulties uncommon. back pain, pain in extremities, injection site pain. Headache, including severe prolonged cases, nausea and vomiting occur commonly. The majority of the reactions after myelography or use in body cavities occur some hours after the administration. ERCP: In addition to the undesirable effects listed above, the following undesirable effects may occur with use for ERCP: Elevation of pancreatic enzyme levels (common), pancreatitis (rare). Usein other body cavities. The possibility of pregnancy must be excluded before performing hysterosalpingography. Inflammation of the bile ducts or salpinx may increase the risk of reactions following ERCP or hysterosalpingography procedures. Low osmolar water-solu-ble contrast media should be routinely used in gastrointestinal studies in newborns, infants and children be-cause these patients are at particular risk for aspiration, intestinal occlusion or extraluminal leakage into the peritoneal cavity. Special warnings and special precautions: Caution is advised in patients with: hypersensitivity or a previous reaction, bronchial asthma, latent hyperthyroidism or goiter, severe cardiac or cardiovascular diseases; very poor general state of health, severe renal insufficiency, severe liver dysfunction in case of severe renal insufficiency, metformin therapy, symptomatic cerebro-vascular diseases, cerebral convulsive disease, myeloma ore paraproteinaemia, pheochromocytoma, autoimmu-ne disorders, myastenia gravis, alcoholism, homocystinuria, pregnancy. Instructions for Use/Handling: Ultravist should be warmed to body temperature prior to use. Contrast media should be visually inspected prior to use and must not be used, if discoloured, nor in the presence of particulate matter (including crystals) or defective containers. Date of revision of the text: October 2006. Please note! For current prescribing information refer to the package insert and/or contact your local Bayer Schering Pharma organisation. Bayer Schering Pharma AG, 13342 Berlin, Germany

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Atlas of AnatomyB Y S E C T I O N A L I M A G I N G

Bayer Shering Pharma AGBusiness Unit Diagnostic Imaging13342 Berlin, Germany

www.diagnostic-imaging.bayerscheringpharma.dewww.bayerscheringpharma.de

G.D

I.12.

2009

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