An LA Times Article on imaging techniques for the brain and body....

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The California Cure
Picturing the Inside Story
by Shaun L. Samuels, M.D.
The California Cure Don’t feel bad if you don’t have a thorough, or even passing,
understanding of how the images from a diagnostic test you’ve
The Land of Sunshine
received were produced. The dirty little secret is that few doctors
Sheryl Crow Bares All know how they’re made, either. Most radiologists had it down long
Q&A: Rich Carmona and enough to pass the physics section of their board exam, after which ADVERTISEMENT
Christie Hefner the knowledge rapidly evaporated.
All are to be forgiven. It’s a mind-bogglingly complex world awash in
Innovators physics, the kind of stuff where calculus is thrown around like most of
Hans Keirstead, Ph.D. us tweet or instant message. Preposterous amounts of data are
acquired, processed and reconstructed in microseconds, and
Dennis Slamon, M.D.
astonishing images pop up on a screen as if by magic.
Fouad Kandeel, M.D.
It isn’t magic, of course, but the result of decades of bone-crushingly
Emeran Mayer, M.D. detailed work, done by those who have mastered the theoretical and
Robotics at the City of Hope engineering sides of producing imaging equipment. Lots of Nobel
Prizes went out for this stuff, and probably a few dozen more were
Leonard Rome, Ph.D
deserved for the select few who from the beginning believed these
Sue Smalley, Ph.D. things could ever work in any practical way. The following is a
Meditation Myth Busting ridiculously brief compendium of some of the imaging modalities in
wide use, how they came about, what they are used for and some of
Ed Phillips, M.D.
their pitfalls. For those who love to pepper their conversation with
SickDay Comes to L.A. buzzwords that convey a deeper knowledge than they possess, there’s
Tim Miller, M.D. something for you, too.
Stuart Siegel, M.D.
MRI
Soram Khalsa, M.D.
Brief History
Michael Phelps, M.D. Pioneered in the 1970s. Originally called NMRI, the N stands for
nuclear, which gave people the heebie-jeebies. Paul Lauterbur and Sir
Personal Stories Peter Mansfield shared the 2003 Nobel Prize in Physiology or
Head Case: Paco McCauley Medicine for its development.
Best Foot Forward: Dana Davis Physics
So dizzyingly complicated, this small space won’t do. Sad to say, we
Sweet Dreams: Fred Roberts
are but bags of water trapped in different tissues: kidney, brain, liver,
Breast Intentions: Laura Ziskin etc. H2O contains hydrogen atoms, which act like magnets and align
Unsure Cure: Seth Greenland like iron fillings in a magnetic field, and they spin at a speed
proportional to the strength of the magnetic field. Still with me? So, if
Future of Medicine you put someone into a magnet, and you vary its strength, you get the
hydrogen spinning at different speeds in different parts of the body. If
Making Medicine Personal
you then flatten these neatly aligned atoms with an electromagnetic
Saving Face punch, they each tend to stagger back to their feet at different rates,
Picturing the Inside Story realigning with the magnetic field, depending on the tissue they are in.
The result can be “encoded,” as it were, by that variable-
Quantum Leaps
magnetic-field principle. Astonishing, really. The tissue contrast
Safe House produced is unparalleled and can be enhanced by giving the patient a
contrast agent.
Particularly Good For...
• Central nervous system (brain, spinal cord)
• Musculoskeletal (knee, shoulder, spine)
Precautions
• Metallic foreign bodies (especially in the eye)
• Pacemakers/AICDs (MRI messes them up)
• Claustrophobics (that magnetic tube is snug)

2. • Poor kidney function (using contrast agent)
Terms that sound cool or oddly suggestive
K-space, Larmor frequency, spin echo, susceptibility, chemical shift,
gradient coil, large bore, time-of-flight, wrap around
CT
Brief History
Another thing we can thank the Beatles for. Godfrey Hounsfield, who
shared the 1979 Nobel Prize in Physiology or Medicine for his role in
developing CT, had been a researcher at EMI, the record label for the
Fab Four. With the money that came in from their world-altering
success, EMI took a flyer and funded Hounsfield’s independent
research.
Physics
Using the same electromagnetic waves that produce plain X-rays and
mammograms, CT involves shooting those X-rays from a source
rotating around the patient. (Those who’ve seen a CT scanner
recognize the doughnut-shaped gantry which houses the source and
detectors.) It’s no accident that the scanner is covered with an
innocuous, putty-colored molding. Patients might freak watching
these elements whirring around them at alarming speed. Just hearing
it can be a bit unnerving. By sending out a fan-shaped beam and
incorporating multiple detectors opposite it on the circular gantry, the
scanner acquires a cross-sectional density map. A computer collects
all the data and reconstructs image “slices” as the patient moves
smoothly through the scanner. Many thought that MRI would sound
the death knell for CT...but superfast acquisition times have kept CT
very much in play.
Particularly Good For...
• Abdominal and pelvic imaging
• Imaging of coronary arteries
• Imaging of lungs
• Imaging of large blood vessels (especially with contrast
enhancement)
Precautions
• Radiation dose (especially in younger patients who require frequent
scans to follow a particular disease)
• Poor kidney function (using contrast agent)
Terms that sound cool or oddly suggestive
Multidetector row, beam hardening, slip ring, rotate-rotate,
stationary-rotate, partial-volume averaging, maximum-intensity
projection, multiplanar reconstruction
PET
Brief History
A repository of terminology right out of the existentialist handbook.
The core principles are annihilation, decay and coincidence. The
basics of positron emission were elaborated in the 1950s, primarily at
the University of Pennsylvania and Washington University School of
Medicine. The imaging has steadily improved in the decades since.
Physics
Unlike the purely anatomic information of CT and MRI, PET actually
maps out tissue metabolism. The common fuel of cells is sugar in the
form of glucose. In a cunning bait-and-switch, unsuspecting cells,
thinking they’re getting the straight stuff, take up a compound called
18FDG, fluoro-deoxyglucose. That fluoro part is radioactive and emits
a positron, the positively charged antiparticle to the electron (don’t
ask). That positron is inherently unstable, and when it meets the
electron, both are annihilated, an altogether trippy event in which
they cease to exist and emit in their place two gamma rays, super-
high-energy waves. These waves shoot off in roughly opposite
directions and can be recorded by gamma detectors. When these
detectors get a simultaneous signal, the coincidence can be mapped
and the origin of the event relatively closely pinpointed. Hence,
tissues of high metabolic activity, such as many types of cancer, show
up as hot spots on a scan. Similarly, areas of decreased metabolic
activity, as in certain brain disorders, show up as cold spots.
Particularly Good For...

3. • Cancer detection
• Cancer surveillance, monitoring of treatment
• Brain diseases and disorders such as dementia
Precautions
• Radiation dose (especially combined with CT)
Terms that sound cool or oddly suggestive
Scintillation, avidity, radionuclide, backscatter, pick-off process,
positronium, expectation maximization
Plain X-ray / Mammography
Brief History
The insight of Wilhelm Röntgen, winner of the first Nobel Prize in
Physics in 1901, is legendary. He was passing electric current through
a vacuum tube and noticed fluorescence coming from a square of
coated cardboard attached to the tube. Röntgen was intrigued. He
passed another current through the tube, only to notice a glow coming
from a similarly coated piece of cardboard a few feet away. He
concluded that an invisible ray, which he coined “X-ray,” must
account for this light show and the science of roentgenology
(radiology) was born.
Physics
X-ray is way out there on the electromagnetic spectrum, past visible,
past ultraviolet—very high energy. These waves pass through solids
and can interact in a variety of ways with them, as Röntgen discovered
when he famously produced a film of his wife’s hand, bones and
wedding ring visible. The upshot is that some get absorbed and some
pass through, and this can be measured in a standard plain-film X-ray
image. Parts of higher density absorb more X-rays and appear white;
the less dense (for example, where there’s air) appear darker. While
this used to be recorded on special film, it’s now typically detected
digitally and stored electronically, to be viewed on a workstation.
Don’t patronize it as quaint: It still boasts the best spatial resolution of
any of its fancy-schmancy imaging descendants such as the CT.
Hence, for mammography, it can pick up extremely tiny
microcalcifications (about a tenth of a millimeter) that can be crucial
in detecting early cancer. And in terms of sheer numbers, more plain
X-rays are obtained than any other imaging study. So there.
Particularly Good For...
• Detecting fractures in all bones
• Assessing spine alignment and disk spaces
• Screening chest
• Mammography
• Detecting intestinal obstructions
Precautions
• Any single X-ray involves an extremely small amount of absorbed
X-rays. Radiologists generally adhere to the ALARA concept with
regard to radiation dose: As low as reasonably achievable.
Terms that sound cool or oddly suggestive
Compton scatter, Mach effect, Bremsstrahlung, rare earth screen
Ultrasound
Brief History
Sonar schmonar: You want really cool stuff, take a look at the current
state of ultrasound, another technology to emerge, albeit indirectly,
from the war effort. Sonar came out of World War I, and as early as
the 1940s, researchers were demonstrating that in addition to
detecting submarines many leagues under the sea, high-frequency
sound waves could be used to ping tissues a few centimeters deep. The
major advances in the technology were multinational in origin,
coming from Europe, Asia and the U.S. All of this emerged from the
discovery in the late 1800s (by Madame Curie’s husband and brother-
in-law, Pierre and Jacques, no less) of an unusual property some
substances displayed called piezoelectricity.
Physics
The wickedly high frequency used for ultrasound imaging is produced
using a piezoelectric crystal (not something, despite the funky name,
they were taking at Woodstock). The substance has the remarkable
characteristic that when one applies voltage to it, it vibrates. Even

4. crazier, the same substance, when vibrated, generates voltage. An
exquisitely choreographed sequence of pulses of electricity is applied,
sending ultrasound waves into the tissues. Just as sound waves echo
off walls, ultrasound waves bounce off tissues, especially at interfaces
between different tissues. As the reflected waves arrive back at the
transducer, they vibrate the very crystal that produced the waves. The
voltage created can be detected, and, depending on when the wave
comes back and from what direction, a map can be created, which
translates into phenomenal 2-D (even 3-D and 4-D) images. It all
happens at such a fast rate that the images are seen in “real time,”
creating a movie where a heartbeat can be seen or the motion of blood
detected. And there are essentially no adverse biological effects. Nifty,
to say the least.
Particularly Good For...
• Obstetrics, the progress of fetal development
• Abdominal imaging, especially solid organs and gallbladder
• Blood vessels, especially carotid arteries and veins of the leg, which
can be interrogated for blockages
Precautions
• At diagnostic frequencies, ultrasound is safe, another plus for
obstetric imaging
Terms that sound cool or oddly suggestive
Ring-down, reverberation, comet tail, defocusing, range ambiguity,
posterior enhancement, probe
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