Imaging

Modalities in IR
By: Jacob Fleming, Jared Sokol, Sanna Herwald

Introduction
The field of Interventional Radiology (IR) depends on medical imaging technology. With recent advances
in the imaging tools available to physicians, there are ever-expanding possibilities for interventional
radiologists to treat and cure diseases. By using minimally-invasive methods, IR physicians have turned
surgical tasks that once required large incisions and an overnight hospital stays into outpatient
procedures that cause minimal discomfort to the patient. Here we will review the most common
imaging modalities utilized by interventional radiologists and the advantages and disadvantages of each
method.

Radiograph
In 1895, Wilhelm Röntgen discovered the X-ray and took the first radiograph of his wife’s left hand. He
noticed that X-rays passed through human soft tissue, but not bone or metal. This was the birth of
radiology, and Röntgen was awarded the first Nobel Prize in Physics.

Radiography utilizes electromagnetic radiation, especially X-rays, to visualize the internal components of
the human body. When an X-ray beam is directed towards an area of interest, some radiation is
absorbed and some is transmitted according to the composition of the tissue. The transmitted radiation
is captured on a digital detector and processed into an image that represents the tissue. This method of
capturing the radiation “shadow” of a structure is also called projection radiography. Projection
radiography can quickly reveal abnormalities in soft and hard tissues at mid-level resolution.

For the patient, radiographs are a painless imaging modality that takes minutes to complete. X-rays are
a form of ionizing radiation, meaning that they contain sufficient energy to dislodge electrons from an
atom, thereby creating an ion. Ionizing radiation may cause DNA damage and increase future cancer risk
(International Commission on Radiological Protection, 2007). Fortunately, simple radiographs subject
the patient to extremely small levels of ionizing radiation, comparable to several days of background
radiation, and thus have a minimal associated risk. Projection radiography is an import tool for the
diagnostic radiology, but is less-frequently used for IR procedures.

Fluoroscopy
Fluoroscopy uses X-rays to create a real-time, live image of the human body, and is one of the most
important imaging modalities of interventional radiologists. Unlike a simple radiograph that takes a
static image, fluoroscopy allows for the visualization of both structure and movement. The beating of
the heart, the motion of swallowing, and the placement of a catheter can all be visualized using
fluoroscopy. In the modern IR suite, X-ray beams are projected towards the patient, and are either
absorbed by or transmitted through the patient. The transmitted beams then collide with a flat panel
detector that converts the radiation into electrical signals, which in turn are converted into a live
fluoroscopic image. Interventional radiologists usually operate the fluoroscopy machine with a foot
pedal, turning it on and off when necessary.
Contrast agents are frequently used to enhance the utility of fluoroscopy. Interventional radiologists use
iodinated contrast to visualize the vascular system to visualize the digestive system. Iodinated contrasts
consist of iodine molecules bound to either an ionic or organic (non-ionic) compound, are delivered
intravenously, and are offered in different osmolarities. In some patients, the addition of contrast can
lead to usually reversible acute kidney injury (Aspelin et al., 2003, Rudnick et al., 2006, Solomon et al.,
2006). An alternative contrast agent that has little nephrotoxicity is carbon dioxide (Shaw & Kessel,
2006), which can be used alone or paired with iodinated contrast. Importantly, carbon dioxide may be
neurotoxic if used near the cerebral circulation, so its use as a contrast agent should be restricted to
below the diaphragm (Schreie et al., 1996).

Fluoroscopy is usually the imaging modality of choice for many IR procedures, such as catheter-directed
thrombolysis, IVC filter placement, and endovascular aneurysm repair. Unfortunately, fluoroscopy
subjects the patient to more ionizing radiation than a simple radiograph. Furthermore, fluoroscopy also
poses a risk for cutaneous radiation reactions (Balter, 2010). Therefore, fluoroscopy should be used in
moderation to protect both the patient and the medical team.

Computed Tomography (CT)

Computed tomography (CT) uses multiple X-ray scans to create a three-dimensional image that can
be viewed as cross sections. Patients lie on a motorized table that moves through a circular X-ray
source. The X-ray source rotates around the patient and produces many fan-shaped beams
between 1 mm and 20 mm in width. In Axial CT, which is commonly used for head scans, the table
remains stationary while the X-ray source rotates to create a slice. After that slice is complete the
table moves for the next slice. In helical CT, which is often used for body scans, the motorized table
and the X-ray source both move continuously to produce a helical scan (Brenner & Hall, 2007). For
either type of CT, a computer compiles the scanned information into a three-dimensional image
which can either be viewed in cross section or reconstructed into rotatable 3-D images. Like in
fluoroscopy, CT may use contrast to highlight certain regions of interest, such as the vasculature or
the digestive system. CT offers excellent image quality and multiple views, and is an extremely
important tool for interventional radiologists.

Diagnostically, CT scans are used both before and after IR procedures to identify pathologies,
delineate patient anatomy, and evaluate the success of a procedure. More recently, CT scans can be
performed during IR procedures in order to confirm and plan instrument placement relative to
patient anatomy. While useful, CT does pose a risk to the patient; A normal chest CT scan delivers
70 times as much radiation as a chest radiograph, is equivalent to two years of natural background
radiation exposure (Lin, 2010), and the ionizing radiation from CT scans is estimated to cause 1.5-
2% of all cancers in the United States (Brenner & Hall, 2007).

Magnetic Resonance Imaging (MRI)

Magnetic Resonance Imaging (MRI) is a powerful diagnostic modality that generates serial slices of
the patient’s anatomy, similar to CT. Nonetheless, MRI and CT differ in several ways. Most
importantly, MRI does not utilize ionizing radiation, and therefore does not pose an increased risk
of cancers or radiation burns. Instead, MRI uses magnetic fields and low-energy radiofrequency
bursts to obtain images based on the proton densities and magnetic properties of the tissue. This
diagnostic technique was first proposed in 1971 by Raymond Damadian, who considered the use of
nuclear magnetic resonance (NMR), a common technique in organic chemistry labs, to distinguish
tumors from normal tissue (Damadian, 1971). Thereafter, Paul Lauterbur produced the first image
based on NMR (Lauterbur, 1973). Now, after several decades of research and development, MRI
has become one of the most important diagnostic modalities in radiology.

MRI images depend on a tissue’s magnetic properties (instead of its radiolucency, as in plain X-ray,
fluoroscopy, and CT), and therefore offers exquisite soft tissue resolution superior to that of CT.
Thus, MRI is a more sensitive modality for many diagnoses, including brain tumors, acute ischemic
stroke, and subtle fractures difficult to detect on X-ray or CT. Furthermore, MRI is a useful option in
patients for whom radiation is a major concern, such as pregnant women. Nonetheless, MRI does
have some downsides. An MRI scan takes much longer than a CT scan and requires the patient to
remain still, and thus MRI is subject to many imaging artifacts. In addition, MRI scans involves loud
equipment that most patients find displeasing, are relatively expensive, and cannot be used in some
patients, such as those with most types of cardiac pacemakers.

Because of time limitations, MRI is not commonly used during IR procedures, but is often used in
pre-operative planning of interventions. In particular, magnetic resonance angiography (MRA)
produces images of the vasculature that can guide interventions. MRA can be used in certain
patients who are contraindicated for contrast agents and patients with larger body habitus for
whom CT would provide lower quality images (Mauro, 2008).

Positron Emission Tomography (PET)

Positron Emission Tomography (PET) scans differ from almost every other imaging modality
because PET images are generated from radiation emitted from inside the patient’s body, rather
than from outside it. Also, unlike other modalities, it provides information primarily about the
patient’s physiology, rather than anatomy. Pharmaceuticals labeled with radioactive isotopes are
given to the patient either orally or intravenously, and these molecules become localized to areas of
high metabolic activity. The molecules undergo a form of decay that emits a positron. The positron
quickly interacts with an electron (its antiparticle) and annihilates, producing gamma rays that are
detected by a ring-shaped detector similar to that of a CT scanner. Algorithms calculate the point of
incidence of the gamma rays to determine where the positron was emitted, and thus provide a map
of where the radiopharmaceutical decayed (Moore, et al, 2010).

One of the primary uses of PET is for assessment of cancer treatment. Using the above principles,
pharmaceuticals such as 18-F fludeoxyglucose (FDG) are administered to the patient and
preferentially taken up by tumor cells, producing a map of the metabolically active-tumor. A
disadvantage of PET is its poor visualization of normal tissue anatomy, and therefore PET is often
coupled with CT. Like CT, PET imposes a large dose of radiation, but in patients with diagnosed
malignancy, the diagnostic and therapeutic benefit of PET generally outweighs the radiation risk.
Ultrasound (US)
Ultrasound (US) is unique among imaging modalities for multiple reasons. First, it does not use any
ionizing radiation or magnetic fields; instead, an US transducer produces sound waves that echo off of
patient tissues back to a detector to produce an image. Second, and importantly, US uses highly
portable equipment that allows for use in emergent and bedside procedures. Third, US produces a
dynamic, moving image that must be adjusted by the operator in order to be useful.

In IR, US can be used as the primary modality in bedside interventions, such as fine needle aspiration of
thyroid masses. This is a safe and quick way to biopsy tissue in the outpatient setting, and it has high
diagnostic yield (Screaton et al, 2003). US is also used in many common hospital procedures such as
thoracentesis and paracentesis. Because these interventions may be required emergently, the
portability of US is crucial. Additionally, for complex vascular interventions, US can be used as an adjunct
for gaining initial access into the jugular or femoral vein (Mauro, 2008).

Limitations of US include its operator-dependent nature, and the production of images that are not
intuitive to an outside interpreter. Also, US does not provide useful visualization in areas containing a
large volume of gas, such as the lungs.
 Summary

Modality Uses in IR Limitations

Simple Radiograph (X- Pre-procedural planning Uses small levels of ionizing radiation
ray)

Fluoroscopy Intra-procedural visualization of Uses ionizing radiation (acivate via foot

anatomy, esp. vasculature pedal only when necessary)

CT Pre-procedural planning, CT Uses high-dose ionizing radiation; some

angiography (w/ or w/o contrast), patients may have allergies or adverse
intra-procedural 3-D evaluation of reactions to contrast agents
anatomy and instrument placement

MRI Pre-op planning (MRA) Slow, expensive, loud, subject to imaging

artifacts; cannot be used in patients with
certain implanted medical devices

PET Limited use in IR; useful in evaluation Uses high-dose ionizing radiation; poor
of cancer treatment anatomical detail and may need to be
paired with CT (additional radiation)

Ultrasound Bedside procedures (FNA, Highly operator-dependent; image

thoracentesis, paracentesis); locating disrupted by large volumes of gas
vessels for access in vascular
procedures

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