Dunnick, 5th: Anatomy and Procedures Flashcards
The kidney is divided into an outer cortex and an inner medulla by the ____ at the base of each pyramid
Arcuate artery
Columns of cortical tissue sometimes descend between the medullary pyramids and are often referred to as a ____
Column of Bertin
Or septal cortex
Large column of Berthin is most common at the junction ofthe superior and middle thirds of the kidney.
The following make up the intrarenal collecting system, except:
a. Calyces
b. Infundibulum
c. Pelvis
d. Proximal ureter
e. All of the above are part of the intrarenal collecting system
d. Proximal ureter
It is the space around the collecting system and contains a variable amount of fat, along with branches of the renal artery, vein, and lymphatics
Renal sinus
The following structures are located within the anterior pararenal space, except:
a. Tail of the pancreas
b. D2-D4 of the duodenum
c. Ascending and descending colon
d. Hepatic and splenic arteries
a. Tail of the pancreas
The calyx is the cup-shaped portion of the intrarenal collecting system and the rim of the cup is the ____
Fornix
The long axes of the kidneys are deviated approximately ____ degrees from the spine, with the top of the kidneys closer to the spine
20
The perirenal space is defined by what fascia?
Gerota’s fascia
The following are part of the extraperitoneal space, except:
a. Space of Retzius
b. Rectovesical space
c. Presacral space
d. Perirectal space
e. All of the above are extraperitoneal spaces
b. Rectovesical space
Rectovesical space is intraperitoneal
RETROVESICAL SPACE is extraperitoneal
Which of the following statements are false:
a. The right adrenal lies above and anteromedial to the upper pole of the right kidney and best seen on axial immediately posterior to the inferior vena cava (IVC) just below the liver
b. The left adrenal is also above and anteromedial to the upper pole of the ipsilateral kidney and lies posterior to the pancreas
c. The right adrenal typically has an inverted Y appearance, whereas the left tends to resemble a three- pointed star
d. In patients with renal agenesis or ectopy, the ipsilateral adrenal gland has a linear shape
b. The left adrenal is also above and anteromedial to the upper pole of the ipsilateral kidney and lies posterior to the pancreas
The left adrenal is also anteromedial to the ipsilateral kidney but usually seen AT THE SAME LEVEL AS THE UPPER RENAL POLE and lies posterior to the pancreas
Adrenal gland
a. Normal weight
b. Normal width
a. 5g
b. 3-6 mm up to 1 cm
Arterial supply of the adrenal gland comes from what arteries?
a. Superior portion: Superior adrenal artery from inferior phrenic artery
b. Middle portion: Middle adrenal artery from aorta
c. Inferior portion: Inferior adrenal artery from renal artery
Which of the following is false regarding the drainage of the adrenal glands:
a. Each adrenal is drained by a single central vein (adrenal vein)
b. The right adrenal vein directly enters into the anterior aspect of IVC
c. Ocassionally, the right adrenal vein may join an accessory hepatic vein before entering the IVC
d. The left adrenal vein enters the inferior phrenic vein before joining the left renal vein
e. The right adrenal vein is shorter and has smaller caliber than the left
b. The right adrenal vein directly enters into the anterior aspect of the IVC
POSTERIOR aspect of the IVC
Narrowest portion of the ureter
Ureterovesical junction
The ureters enter the bladder obliquely and course submucosally for about ____ before terminating at the lateral margin of the trigone as ureteral orifice
2 cm
The predominant vessel supplying the distal ureter is ____
Inferior vesical artery
Proximal ureter: Renal artery
Mid ureter: Aorta, lumbar, gonadal and iliac arteries
Muscle of the urinary bladder
Detrusor muscle
Between the ureteric orifices is a muscular ridge, known as the ____, which forms the base of the trigone
Interureteric ridge
Venous drainage of urinary bladder
Primarily drains into hypogastric (internal iliac) veins
Auxiliary veins connect the vesical venous plexus to the hemorrhoidal veins that drain into the intervertebral venous plexus. This is the route of vesical venous drainage when the IVC is blocked.
Lymphatic drainage of the urinary bladder
External and iliac lymph nodes
Normal length of the prostatic urethra
3.5 cm
The prostatic urethra is approximately 3.5 em in length, passes through the prostate gland, and ends at the superior aspect of the urogenital diaphragm
A longitudinal ridge of smooth muscle extends from the bladder neck to the membranous urethra on the posterior wall of the posterior urethra. This longitudinal smooth muscle bundle swells just proximal to the membranous urethra to form a 1-cm-long ovoid mound on the urethral floor called ____
Verumontanum (colliculus)
A small depres- sion in the verumontanum is known as the UTRICLE
This the portion of the urethra which marks the change in epithelial lining from transitional epithelium to stratified columnar epithelium
Membranous urethra
Prostatic urethra: Transitional cells
Rest of the urethra: Stratified columnar cells
External meatus: Stratified squamous cells
This is the narrowest part of the urethra
Membranous urethra
SHORTEST AND NARROWEST SEGMENT
1 cm in length, passing through the urogenital diaphragm
Proximal landmark: Distal end of the verumontanum
Distal landmark: Tip of the cone of the bulbous urethra
What urethra will you find the following structures:
a. Opening of the prostatic and ejaculatory ducts
b. Cowper’s glands
c. Opening of the Cowper’s glands
d. Glands of Littre
a. Prostatic urethra
b. Membranous urethra
c. Bulbous urethra
d. Anterior urethra (Bulbous and penile urethra)
This is the widest and most inferior portion of the urethra
Bulbous urethra
The bulbous urethra begins at the inferior aspect of the urogenital diaphragm and extends to the angulated penoscrotal junction
Landmark that which divides the anterior urethra into bulbar and penile urethra
Penoscrotal junction
The distal 2 cm of the penile urethra is slightly dilated and known as the ____
Fossa navicularis
These glands secrete mucus during sexual stimulation
Glands of Littre and Cowper’s glands
A small, striated musculotendinous sling of the bulbocav- emous muscle extends from the anterior and lateral surfaces of the proximal bulbous urethra. This structure is known as the ____ and may circumferentially indent muscle contracts proximal bulbous urethra on dynamic retrograde urethrography.
Musculus compressor nuda
This finding, sometimes called “Cobb’s collar: should not be mis· taken for a true stricture.
Name the finding and specific structure this represents
Cobb’s collar
Musculus compressor nuda
It lies around the bladder neck and is the primary muscle of passive urinary continence
Internal sphincter
PASSIVE URINARY CONTINENCE
Bladder neck: INTERNAL sphincter
Below the verumontanum in the distal one third of the proximal urethra and surrounding membranous urethra: INTRINSIC spincter
ACTIVE URINARY CONTINENCE
Membranous urethra: EXTERNAL sphincter
Length of the female urethra
4 cm
Normal dimensions and weight of testis
4-5 x 3 x 2.5 (L x W x B)
10-14 g
Contents:
1. 250-400 LOBULES containing convoluted TUBULES > Spermatozoa + Sertoli cells
It is a tiny oval sessile body, lies at the upper e:nd of the testis adjacent to the head o f the epididymis
Appendix testis
(Hydatid of Morgagni)
A vestigial remnant of the mollerian duct
Name the pointed structure
Mediastinum testis
Tail of the epididymis is connected to what structure
Vas deferens
Total length: 35 to 45 cm
In the pelvis, the vas deferens follows the lateral pelvic wall, curving first superoposteriorly and then inferomedially. It crosses superficial to the external iliac vessels and the ureter.
As the vas deferens crosses the ureter, it becomes convoluted and dilated, increasing in diameter from 2 to 3 mm up to 1 cm, forming the ampulla of the vas deferens.
Name the pointed structure
Rete testis
The channels of the rete testes progress to the proximal end o f the mediastinum, where they again coalesce into a number of ducts that perforate the tunica albuginea and enter the head o of the epididymis, which is closely applied to the upper testis.
The more slender body of the epididymis runs along the posterolateral aspect of the testis, and the tail is continuous with the vas deferens. In essence, the epididymis is a long and very convoluted tubule.
The distal ampulla and excretory duct of the seminal vesicle on each side join to form an ____
Ejaculatory duct
Normal length and diameter of seminal vesicles
Length: 5 cm
Diameter: 2 cm
The posterior surface of the seminal vesicle lies on ____, which separates it from the rectum
Denonvilliers fascia
The prostate is also separated from the rectum by Denonvilliers fascia.
Normal weight of prostate gland
up to 20g
The glands in this zone can undergo hypertrophy and form fibro- adenomata, resulting in typical benign enlargement of the prostate, or BPH
Transitional zone
The transitional zone represents only 5% of prostatic volume and is found around the midprostatic urethra.
Identify the structures labeled 1 through 5
Identify the structures labeled 1-4
Identify
This zone occupies the superior and central portion of the gland, and is also subject to hypertrophy
Central zone
It comprises the bulk ofthe prostate gland and is the site where most carcinomas and infections occur
Peripheral zone
The peripheral zone occupies al- most the entire posterolateral portion of the prostate and the prostatic apex. cupping the central prostate like a baseball glove around a baseball. The prostate is covered by a :fibrous capsule.
Fascia of the penis from outside in
Dartos fascia > Buck fascia > Tunica albuginea
Upper normal limit of mean ovarian volume in:
a. Premenopausal women
b. Postmenopausal women
a. Up to 20 cc
b. Up to 10 cc
Arterial supply of the ovaries:
Venous drainage of the ovaries:
a. Arterial supply: Ovarian artery, adnexal branch of the uterine artery
b. Venous drainage: Ovarian vein
(L): Ovarian vein > Renal vein
(R) Ovarian vein > IVC
Normal length of the fallopian tube
10 cm
Identify the pointed structures
Arrow: Isthmus
Arrowhead: Ampulla
What imaging modality best depicts the uterus?
MRI (T2W sequence)
Width of the endometrium:
a. Premenopausal, proliferative phase
b. Premenopausal, secretory phase
c. Postmenopausal
a. 4-8 mm
b. 8-16 mm (double)
c. 4 mm
What phase of the menstrual cycle will you see the trilaminar appearance?
Proliferative phase
(Late)
Hyperechoic (uterine cavity) - Hypoechoic (inner functional layer) - Hyperechoic (outer basal layer)
Identify the pointed structure
Junctional zone of inner myometrium
What phase of the menstrual cycle?
Secretory phase
Normal length of the inguinal canal
4 cm
Contains the spermatic cord (testicular artery, genitofemoral nerve, and vas deferens) or the round ligament of the uterus
It consists o f a series of uriniferous tubules, each of which is associated with a group of blood vessels to form primitive glomeruli.
Mesonephros
Stages of kidney development:
1. PRONEPHROS (3rd week AOG): tubules > excretory duct > cloaca // pronephros involutes
2. MESONEPHROS: Uriniferous tubules + vessels = primitive glomeruli > mesonephric duct/wolffian duct > excretory duct > cloaca // mesonephric duct involutes but remnants persist
3. METANEPHROS (5th week AOG): Ureteral bud, metanephric blastema
Ureteral bud influences metanephric blastema > nephrons
Ureteral bud > Collecting system
https://www.youtube.com/watch?v=-qLog_tbMlU
https://www.youtube.com/watch?v=YELuuFhVF9U
The uriniferous tubules develop from a pair of laterally placed mesodermal structure known as the ____
Nephrogenic cord
This refers to the diverticulum in the mesonephric duct which eventually becomes the renal urinary collecting system
Ureteral bud
The tissue that surrounds the ureteral bud and is derived from the caudal end of the nephrogenic cord is called ____
Metanephric blastema
Origin of the nephrons
Metanephric blastema
Between the fourth and eighth weeks, the developing kidneys migrate in a cephalad diredion out of the pelvis to assume their adult position opposite the ____ vertebra. During the course o f this migration, each kidney rotates ____ about its longitudinal axis. so that each renal pelvis faces medially.
L2, 90 degrees
It serves as the precursor of the vas deferens, the seminal vesicles, and the ejajculatory ducts in males
Mesonephric duct
It is the dilatation of the endodermal hindgut formed after fetal flexion and anterior movement of the allantois into the body stalk
Cloaca
Shortly after theformation of the wolffian ducts, a second pair of ducts develop lateral to the wolffian ducts. These ducts develop from coelomic evaginations
Mullerian ducts
The following represent the vestigial remnants of the atrophied Mullerian ducts in males, except:
a. Utricle in verumontanum
b. Appendix testis
c. Appendix epididymis
c. Appendix epididymis
The following are formed from the vesicourethral portion of the ventral bladder:
a. Lateral and posterior bladder walls
b. Bladder trigone
c. Internal sphincter
d. Proximal urethra
e. AOTA
e. AOTA
Origin of the fallopian tube down to the upper vagina and proximal urethra
Mullerian ducts
Urogenital sinus: Pelvic or phallic
a. Anterior urethra, glands of Cowper and Littre, corpora cavernosa, corpora spongiosum
b. Distal prostatic urethra, membranous urethra, urogenital diaphragm
c. Distal urethra and the vestibule
d. Clitoris, the labia major and minor, and the hymen
a. Phallic
b. Pelvic
c. Pelvic
d. Phallic
By the end of the ____ week sex distinction has occurred, and this is apparent anatomically by the ____ week
6th, 12th
The testis is guided through the IC and into the acrotu:m by an attached cord- like structure known as the ____ which is derived from peritoneal folds attaching distally t o the inguinal crest.
Gubernaculum
To evaluate patients with hematuria, the following diagnostic test is not recommended:
a. Stonogram
b. CT urogram
c. IVP
d. All of the above are recommended
c. IVP
Which of the following statements are false?
a. Bowel preparation is unnecessary if tomography is used or if the clinical situation is urgent
b. Because intravenous contrast adminis- tration may rarely produce vomiting, solid food should be withheld after midnight before the examination
c. Clear liquids should be encouraged to avoid dehydration but these should be restricted for an hour or two before the examination to ensure an empty stomach.
d. Essential views include a precontrast or scout view, a number of delayed excretion views in the posteroanterior (PA) position, and, when possible, thin section tomography to minimize interference from overlying bowel gas
d. Essential views include a precontrast or scout view, a number of delayed excretion views in the posteroanterior (PA) position, and, when possible, thin section tomography to minimize interference from overlying bowel gas
ANTEROPOSTERIOR (AP) position, not PA view
Which of the following statements is false?
a. The preliminary or scout radiograph should extend from the diaphragm to the symphysis pubis
b. Oblique scout films or tomograms may be obtained to distinguish renal calcifications from extrarenal demities and artifacts
c. Two or three films of the entire abdomen should be made between 5 and 15 minutes after injection of contrast medium to see the collecting systems, ureters, and bladder.
d. One of the contraindications to anterior abdominal compression is ureteral obstruction
a. The preliminary or scout radiograph should extend from the diaphragm to the symphysis pubis
UPPER RENAL POLES
Contraindications to abdominal compression include an abdominal aortic aneurysm, ureteral obstruction, recent abdominal surgery, and abdominal stoma.
Identify the pointed structure
Compression device
Which of the following statements are false
a. An average renal length equal to three to four vertebralbodies is normal
b. The average length of the left kidney is approximately 0.5 cm greater than that of the right kidney
c. Size discrepancies are likely to represent abnormalities if the right kidney is more than 1.0 cm longer than the left or if the left kidney is more than 1.5 cm longer than the right
d. The renal hilum is usually at the same level of the L2 or L3 vertebral body
c. Size discrepancies are likely to represent abnormalities if the right kidney is more than 1.0 cm longer than the left or if the left kidney is more than 1.5 cm longer than the right
Size discrepancy is likely represent abnormalities if:
a. R > L by 1.5 cm, or
b. L > R by 2.0 cm
A prominent bulge on the lateral border of the left kidney represents a normal variation because of molding by the adjacent spleen and has been called a ____
Dromedary hump
In older patients, the calyces and renal pelvis may be compressed by the accumulation of fat in the renal sinus. This condition, termed ____
Renal sinus lipomatosis
The ureter is most anterior where it passes anterior to which structure/s?
Iliac vessels
This procedure does not rely on the kidneys ability to excrete contrast materials:
a. IVP
b. CT urogram
c. Retrograde pyelography
d. None of the above
c. Retrograde pyelography
Complications of retrograde pyelography
a. The pyelocalyceal system may be overdistended, so that contrast escapes from small ruptures in the fornices into the renal sinus; this is known as ____
b.. If the contrast then opacifies the renal vein or lymphatics, it is known as ____
c. Contrast injected under high pressure into the collecting system may also flow retrograde into the renal tubular lumina, and this is known as ____
a. Pyelosinus backflow
b. Pyelovenous or pyelolymphatic backflow
c. Pyelotubular backflow
Static cystography is performed to assess the following pathologies, except:
a. Suspected bladder rupture
b. Vesical fistula
c. High-pressure vesicoureteral reflux
d. All of the above are indications for static cystography
c. High-pressure VUR
STATIC if low pressure VUR
Voiding cystourethrography is used to diagnose HIGH-pressure VUR and to evaluate the urethra
In cystography, using a Foley catheter, ____ is instilled into the bladder, and radiographs in the AP, oblique, and lateral positions are obtained
300 to 400 mL of contrast material
(20% to 30% weight per volume)
A ____ is also obtained and is considered a mandatory part of a trauma cystogram, as small amounts of contrast material extrasation may be hidden behind a distended bladder
Postdrainage view
The following statements are true about VCUG:
a. In female patients, AP/PA radiographs of the urethra are adequate.
b. In male patients, the voiding films should be obtained in a 45° oblique position, so that the entire length of the urethra is demonstrated
c. If reflux is present, the highest level of that rellux should be documented on spot radiographs.
d. All of the above
d. AOTA
Identify the study
Ileal conduit study or LOOPOGRAM
To perform a loopogram, an appropriate Foley catheter (generally between a 20- and 26-French) is inserted into the stoma and the balloon is inflated to a volume of 5 to 8 mL within the stoma. Contrast material is then instilled through the Foley catheter by gravity infusion (preferred) or hand injection.
What study can demonstrate the following structures:
a. Anterior urethra
b. Posterior urethra
a. Retrograde urethrography
b. Voiding urethrography
Retrograde urethrography demonstrates the anterior urethra. Even if contrast is injected under sufficient pressure to traverse the posterior urethra the posterior portion will not distended because the sphincters are contracted. To demonstrate the porterior urethra, voiding urethrography should be performed.
To perform retrograde urethrography, the distal urethra should be occluded by a small Foley catheter. A 12- or 14-French Foley is inserted into the urethra until the deflated balloon just disappears inside the meatus; the balloon is inflated with 1 to 2 mL of saline so that it distends in the fossa navicularis (Fig. 3.7). Inflation should be performed slowly and carefully and terminated as soon as mild traction on the catheter does not remove it from the urethra. The catheter should be flushed to remove air bubbles before insertion into the meatus.
In females, retrograde urethrography is performed using this special catheter
Double-bubble catheter
A modification of standard color Doppler ultrasound, called ____ offers extended dynamic range (albeit at the loss of directional information) and can demonstrate tissue perfusion that a standard color Doppler image might not visualize
Power Doppler
Formula for bladder volume on ultrasound
0.7 x (W x H x D)
Such estimation ofbladder volume is accurate within approximately 20%, which is considered acceptable; it is most often used to estimate postvoid residual volumes
T/F: Prostate UTZ is no longer used as a purely diagnostic modality and has not been found to be sufficiently sensitive or specific to screen for prostate cancer.
True
It is useful to detect seminal vesicle masses and cysts. It can also be used to diagnose less common prostate conditions, such as abscesses, cysts, and utricular abnormalities
Prostate ultrasound is performed with an intrarectal probe. Thmsducers are high frequency (often 7 MHz) and should be able to provide both transverse and longitudinal images from the same probe.
Transvaginal probes usually operate within the ____ range
5- to 7.5-MHz
During transvaginal ultrasound, positioning the transducer head in this structure often permits visualization of the uterine fundus and body
Vaginal fornix
Withdrawing the transducer head slightly may permit better visualization of the lower uterine segment and cervix.
____ has become the primary imaging technique for diagnosing testicular and other scrotal abnormalities
Ultrasound
In scrotal ultrasonography, a high-frequency (____), short-focused transducer should be used.
7.5- to 12-MHz
Two locations to survey when testis is not in normal positions
Inguinal canal, retroperitoneum
It is now the primary imaging modality for most urinary tract pathology including tumors, cystic disease, trauma, vascular abnormalities, nephrolithiasis, obstruction, postoperative complications, congenital anomalies, and certain metabolic diseases
CT
What are the phases of a typical renal protocol?
a. Precontrast
b. Corticomedullary phase (15 to 30 seconds after injection)
c. Generalized nephrographic phase (60 to 90 seconds after injection)
d. Excretory phase (180 to 300 seconds after injection)
Two phases are typically omitted in assessment of renal masses for radiation dose reduction in some institutions:
1. Corticomedullary phase
2. Excretory phase
An adrenal protocol will usually include a delayed series of images to assess contrast “washout,” an important criterion for differentiating metastases from adrenal adenomas. A dose of 100 to 150 mL injected at 2 to 4 mL per minute is appropriate, as is a delay of ____ from the onset of the injection.
50 to 60 seconds
To investigate hydronephrosis, renal trauma, and congenital anomalies, postcontrast images usually suffice.
a. When searching for small masses, therefore, a second series of images obtained ____ minutes after injection is useful.
b. To evaluate intraluminal soft tissue masses in the collecting system, scans obtained at least ____ minutes after contrast injection, during which time the collecting system should be opacified, are useful
a. 1.5 to 2
b. 5
For noncontrast CT for renal colic, thin (no more than ____) contiguous slices should be obtained from the ____ to the ____.
5 mm
Upper renal poles, bladder floor
PRONE position may be done if it is not clear whether a small calcification is a ureterovesical junction stone or a stone that has passed into the bladder
Low dose stone protocol: lower kvP or MAs
-not useful for very tiny calculi
The following are indications of CT cystography:
a. Bladder rupture
b. Bladder leaks
c. Fistula
d. All of the above
d. AOTA
True about CT cystography except:
a. CT cystography may be performed in place of standard cystography for the evaluation of suspected bladder rupture, leaks, or fistulae.
b. To perform a CT cystogram, the bladder is filled with 300 to 500 mL of diluted (5% to 8%) contrast material through a Foley catheter
c. Filling the bladder with excreted contrast can also provide sufficient bladder distention to reliably exclude a leak
d. Five- to 10-mm-thick axial images of the pelvis are then obtained.
e. Neither precontrast nor drainage images are necessary.
c. Filling the bladder with excreted contrast can also provide sufficient bladder distention to reliably exclude a leak
Must know:
1. 300 to 500 mL of contrast (5% to 8%)
2. Filling the bladder with excreted contrast cannot provide sufficient bladder distention to exclude a leak
3. 5- to 10-mm axial cuts
4. No need for precontrast and drainage images
Study of choice for evaluation of hematuria
CT urogram
CT urography is an imaging study of the urinary tract in which the axial images and contrast resolution of CT are combined with coronal plane images of the urinary tract in a fashion reminiscent of a conventional urogram
Phases of CT urography
a. Precontrast: low mA, 5- to 10-mm increments
b. General nephrographic phase (renal parenchyma): 90 to 120 seconds after contrast injection
c. Excretory phase: 8 to 12 minutes after contrast injection
These images will be reconstructed into three-dimensional (3D) maximum-intensity-projection (MIP) and/or volume-rendered images of the collecting system as well as into two-dimensional (2D) coronal images for the detection of urothelial abnormalities
To minimize radiation dose, a “split-bolus” technique may be used in which a second bolus is given ____ before excretory phase imaging in order to ‘“combine” nephrographic and excretory phases into one set of images.
90 seconds
Active oral and/or intravenous hydration to induce a sustained diuresis may help to fill the collecting system
Others have advocated the administration ofa short-acting diuretic (i.e., furosemide) for this purpose
True about CT angiography of renal arteries, except:
a. A fast bolus of contrast is required; 120 mL (or more) administered at 4mL per second is a commonly used dose
b. For young, healthy patients, a delay of 20 seconds from the beginning of injection to the beginning of scanning is appropriate. This delay may be increased to 30 or more seconds for patients who are elderly or have reduced cardiac output, or for imaging pelvic vessels.
c. A 2-mm collimation or less should be used; for donor evaluation, the scanned region should extend from the most superior upper renal pole to the most inferior lower pole in order to include all sites of possible accessory renal vessels.
d. All of the above are true
d. AOTA are true
In pelvic CT, scan timing may be designed to optimize arterial and early parenchymal enhancement of pelvic structure: 150 mL of ____ contrast should be administered at 2 mL per second, with the pelvic scans beginning ____ after initiation of the injection. If venous opacification is required, images obtained ____ after administration of contrast are useful
60%
50 or 60 seconds
2 or 3 minutes
When a lipid-containing adenoma is suspected, gradient-echo images with time-to-echo (TB) values chosen to make lipid and water signals in phase with additive signal (multiples of ____ milliseconds at 1.5 T) and out of phase with loss of signal (odd multiples of ____ milliseconds at 1.5 T)
In phase: 4.2 ms
Out of phase: 2.24 ms
Adrenal adenoma: T1W gradient echo
Sequence used in static MR urography
Thin slab single-shot fat spin-echo (SSFSE) sequence
Coronal plane of collecting system
Thick slab SSFSE and respiratory gated 3D fast relaxation fast spin echo (FRFSE) can be reconstructed to provide MIPs images of the entire urinary tract
Static MR urography: T2W-based
Excretory MR urography: T1W-based
Excretory MR urography is typically performed using a 3D gradient-echo sequence with fat suppression in the coronal plane (Fig. .3.19). Sequences are used for this purpose:
a. LAVA (liver acquisition with volume acceleration)
b. VIBB (volumetric interpolated breath-hold examination)
c. FAME (fast acquisition with multiphase EFGRE (enhanced fast gradient echo))
d. THRIVE (Tl-weighted high-resolution isotropic volume examination)
e. All of the above
e. AOTA
True about prostate MRI, except:
a. Field strength: 1.5 T with endorectal coil
b. An inflated balloon that contains the coil must be seated against the anal verge and prevented from moving into the rectosigmoid by a stop placed around the device at the perineum
c. The coil must be oriented in a transverse plane and be facing the anterior rectal wall
d. All of the above are true
c. The coil must be oriented in a transverse plane and be facing the anterior rectal wall
CORONAL plane
MUST KNOWS:
1. 3- to 4-mm thick images, contiguous or separated by no more than 1 mm
2. T2W-based (spin-echo or fast spin-echo) images in 3 orthogonal planes are used
3. Gradient echo images lack sufficient spatial resolution
What zone of the prostate is affected?
Peripheral zone
Transverse T1-weighted images in prostate MRI can visualize the following, except:
a. Periphery of the prostate
b. Neurovascular bundles
c. Postbiopsy bleeding in the gland or in the lumina of the seminal vesicles
d. Urethra
d. Urethra
Coils used for scrotal MRI
Circular surface coils
Scrotal MRI protocol
1. Axial T1W images
2. Axial, coronal and sagittal T2W images (SE or FSE)
3. 3 to 4 mm thick, small fields of view (14 to 16 cm)
4. If for testicular perfusion assessment, do it with contast and with fat saturation
Identify the pointed structure
Epididymis
In pelvic MRI, indicate what views is neccesary for the given situation:
a. When the morphology of the endometrial cavity is to be investigated, as in patients with uterine duplication anomalies, an ____ view in which the slices are parallel to the long axis of the uterus, and in which at least one slice contains both cornua, is of value.
b. Often useful to demonstrate the uterine zonal anatomy, urethra, vagina, and rectovaginal septum
c. Useful to assess pelvic sidewall invasion by gynecologic malignancies and to delineate the pelvic floor musculature.
a. Oblique
b.Sagittal
c. Coronal
The right gonadal vein enters the inferior vena cava below the level of the ____, usually at ____
Renal vein, L2 or L3
The following are contraindications to HSG, except:
a. Pregnancy
b. Actively menstruating women
c. PID
d. Recently undergone uterine or tubal surgery
e. All of the above are contrainditions to HSG
e. AOTA
Indications to performing HSG, except:
a. Primary and secondary infertility
b. Repeated spontaneous abortions
c. Suspected congenital abnormalities or evaluating uterine synechiae
d. Preoperative planning for myomectomy or postoperative evaluation of tubal anastomosis
e. Evaluate postmenopausal bleeding
e. Evaluate postmenopausal bleeding
The examination is usually not used to evaluate postmenopausal bleeding; in this circumstance, examination of endometrial tissue obtained by endometrial biopsy or curettage is usually necessary
To avoid imaging pregnant patients, the HSG should be limited to the interval that begins at the end ofactive menstrual bleeding and that does not extend beyond ____ days after the onset of menses.
10
In HSG, congenitally small endometrial cavities or those occluded by synechiae may require no more than 3 or 4 ml to be completely filled, whereas cavities enlarged by intramural fibroids may require several dozen cubic centimeters before they and their tall.opian tubes are completely opacified.
Identify the pointed structure
Uterine veins
Contrast may enter uterine veins (Fig. 3.22) in patients who have uterine mural abnormalities (such as fibroids or adenomyosis), in patients with tubal occlusive disease in whom the endometrial contrast pressure is elevated, and even in normal patients.
Radiopharmaceutical useful for evaluation of renal perfusion as well as for imaging the kidneys and urinary tract
Technetium-99m-diethylenetriaminepentaacetic acid 99mTc-DTPA)
Approximately 90% of an injected dose of DTPA is excreted within 4 hours
Normally used for radionuclide calculation of the GF.R
Because DTPA is cleared so rapidly from the kidneys, it is not suitable as a cortical imaging agent
Radiopharmaceutical useful for is evaluation of renal cortex when little information about the excretion of the material is desired
Technetium-99m-dimercaptosuccinic acid (99mTc-DMSA)
It is cleared from the kidney slowly. Approximately 50% of the injected dose remains in the renal cortex 6 hours after injection.
Radiopharmaceutical is suitable for imaging patients with impaired renal function
Techmetium-99m-mercaptoacetyltriglycine (99mTc-MAG3)
Phase of contrast enhancement where the aortocaval attenuation difference is:
a. at least 30 HU
b. Between 10-30 HU
c. < 10 HU
a. Bolus phase
b. Non-equilibrium phase
c. Equilibrium phase
Give the timing of the three distinct phases of contrast enhancement of the kidneys that can be seen after a bolus of contrast medium has been administered by a mechanical injector:
a. Corticomedullary phase
b. Nephrographic phase
c. Excretory phase
a. 15 to 60 s
b. 80 to 120 s
c. > 120 s
Vicarious excretion or excretion of contrast via the biliary tree and small bowel routes may be seen in CT how many hours after administration of contrast?
15 to 48 hours
The greatest single factor affecting the quality of the urogram is ____
Dose of contrast administered
It is the number of particles in the solution per kilogram of water
Osmolality
In general. the larger the molecular weight ofthe agent, the lower the osmolality.
It is a property describes the relative adhesiveness of the molecules of the contrast medium for one another and is important because the viscosity of the contrast determines how rapidly the contrast may be injected
Viscosity
The viscosity of contrast media decreases with increasing temperature.
The unit of viscosity is the poise
Adverse reactions to contrast media
a. Those that mimic an allergic response to contrast media
b. Those thought to be secondary to a direct toxic effect of the contrast media
a. Idiosyncratic or anaphylactoid effects
b. Chemotoxic effects
The following are considered moderate idiosyncratic reaction, except:
a. Faintness
b. Generalized urticaria
c. Tachycardia
d. Facial edema
c. Tachycardia
Classificatons of idiosyncratic reactions:
1. Mild: minor effects, no treatment required
2. Moderate: transient and not life-threatening, treatment required
3. Severe: life-threatening, intensive therapy required
Large clinical trials have demonstrated significantly fewer ad.vuse reactions to the intravenous administration ofnonionic oon- trast media than coo:venti.onal ionic contrast media.
The greatest single predictor of an untoward reaction
History of previous reaction to administration of contrast media
However, only 15% to 20% of those patients will have an adverse reaction to a subsequent contrast injection
A history of a severe reaction to oontrast media is considered a contraindication to reexamination in all but the most urgent cases.
The only independent risk factors associated with a statistically important increased risk of reaction include the following, except:
a. History of prior contrast medium reaction
b. Asthma
c. Old age
d. History of allergy to food or drugs
c. Old age
In general, patients at greatest risk are in the older age groups and have significant pre-existing disease.
MUST KNOWS:
1. For severe reactions, the incidence appears to be slightly higher when larger doses ( > 20 g of iodine) are used.
2.
After intravenous injection of contrast medium, there is a rapid increase followed by a rapid decrease in plasma concentration of contrast. By how much of the decrease in contrast concentration due to excretion of the contrast by the kidneys represents the diagnostic opacification of the urinary tract during urography because it is during this period that glomerular filtration of the contrast medium is at its maximum? It is therefore within the first few moments after injection that the nephrogram, representing contrast within the renal tubules, is at its peak intensity.
12%
Although the majority (88%) of the rapid decline is due to equilibration of the contrast throughout the ECF.
The degree of opacification of the urinarytract is not a function of the concentration of the contrast medium in the urine alone, but it is the total amount of contrast (urinary contrast con- centration times the volume of urine produced) on which opacification depends. Thus, opacification depends on the total number ofiodine atoms in the path ofthe X-ray beam rather than on their concentration in the urine.
Factors that which the intensity of the nephrogram is directly related to, except:
a. Amount of contrast
b. Concentration of contrast
c. Speed of administration
d. Route of administration
d. Route of administration
Time required to excrete 100% of the administered dose
24 hours
Although the rate of excretion of contrast medium is greatest in the first 10 minutes after injection, it falls logarithmically thereafter.
Most contrast reactions occur within the first ____ minutes after injection of the contrast medium
10
In humans, the primary manifestation of contrast overdosage is:
Neurotoxicity, including the induction of fseizures
The following are included in the recommended protocol for treatment of contrast extravasation, except:
a. Elevation of affected extremity above the heart
b. Warm compress
c. Ice packs (15- to 60 min applications three times per day for 1-3 d)
d. Close observation for 2-4 h with release from department after physician evaluation of the patient if symptomatic
b. Warm compress
Acute renal dysfunction associated with contrast material is usually nonoliguric and in the typical case, the serum creatinine peaks in ____ days and returns to baseline values within ____ days
Peak: 3 to 5 days
Returns to baseline: 7 to 10 days
