Download The Benefits of Dual-Energy Subtraction Radiography of the Chest

July 2013
JOURNAL OF THE CALIFORNIA SOCIETY OF RADIOLOGIC TECHNOLOGISTS
Plus
AND
The Benefits of Dual-Energy
Subtraction Radiography of
the Chest
Page 22
csrt.org
Introducing: The C-Arm and
Its Importance in the
Operating Room
Page 26
THE
TECHNIGRAM
JOURNAL OF THE CALIFORNIA SOCIETY OF RADIOLOGIC TECHNOLOGISTS
CONTENTS |
JULY 2013
FEATURES
INTRODUCING: THE
C-ARM
ASRT STUDENT
LEADERSHIP ACADEMY
BY SHAY TURNER
BY AZIZA FASSIL
PAGE 26
PAGE 19
OSTEOARTHRITIS
BY VINNY SHARMA
PAGE 36
CONTENTS
4
7
8
10
President’s
Message
BY LORENZA
CLAUSEN
National
Legislative News
BY LORENZA
CLAUSEN
The Tragedy…
BY JAY HAISCHER
Resume Writing
Tips
BY DIANE GARCIA
22
32
38
Benefits of Dual
Energy
Subtraction
Radiography…
BY LINDA MA
Forensic
Radiography
BY JOSH
SORENSON
Treatment of
Intracranial
Aneurysms…
BY JOSEPH CHOO
ON THE COVER: ASRT
headquarters in
Albuquerque, NM.
JULY 2013 | The Technigram | 2
THE
TECHNIGRAM
JOURNAL OF THE CALIFORNIA SOCIETY OF RADIOLOGIC TECHNOLOGISTS
EDITORIAL
EDITOR-IN-CHIEF
Rich Lehrer, RT [email protected]
CONTRIBUTING WRITERS
Rachelle Campbell, RT [email protected]
Lorenza Clausen, RT [email protected]
Diane R. Garcia, RT [email protected]
Jay Haischer, RT [email protected]
Roxanne Munyon [email protected]
Aziza Fassil, SRT
Linda Ma, SRT
Nav Rajan, SRT
Vinny Sharma, SRT
Josh Sorenson, SRT
Shay Turner, SRT
Abby White, SRT
Amanda White, SRT
ART & PUBLISHING
Cody Doan, RT [email protected]
Customer Service Please call 1-415-278-0441 or email us at [email protected].
Advertising The Technigram provides a specific topic delivered to a highly targeted audience. To find
out more about The Technigram advertising opportunities, please contact us at 1-415-278-0441 or
email us at [email protected].
JULY 2013 | The Technigram | 3
PRESIDENT’S MESSAGE
President’s Message |
July 2012
June is the time for graduation. RT programs across the state and throughout the United States are
sending off their new graduates to start their professional careers. As I reflect back on all of the
students that have contributed to the goals of the CSRT, I feel great pride in knowing that we have
contributed to their future as CRTs.
This month the ASRT held its 2013 Educational Symposium and Annual Governance and House of
Delegates Meeting in Albuquerque. 60 enthusiastic students were selected to participate from all over
the country. This is the third offering of the Student Leadership Development program; begun as a new
initiative during the ASRT presidency of James Temme, RT, from Nebraska.
The goal of this program is to educate and inspire future leaders of affiliates and ultimately of the
ASRT. Students are a great resource by bringing enthusiasm and a fresh perspective to those of us out
longer in the professional world. Our own initiative, the CSRT Student Committee, has brought its own
rewards since beginning more than four years ago.
David Poon, CRT, our first committee chairperson, is the current CSRT President Elect. Mary Hart, CRT,
followed him and is our current Secretary-Treasurer and past recipient of an RT in DC scholarship.
Roxanne Munyon, our immediate past chair is a newly graduated student, multiple scholarship
recipient and plans to continue working with the CSRT in other capacities. Cody Doan, CRT, is our
current webmaster, but began so while a student RT, two years ago.
All of them have brought new ideas and a passion to help move the CSRT continually forward. And so it
is to our educators that I ask to promote participation with the affiliate and the national organization.
The Student Leadership Development Program is a great opportunity for students to learn about the
profession that they will be a part of, network with
fellow RTs and students and all the while help
provide their patients with the quality and safety
they deserve.
Students are a vital component to our profession.
The CSRT will continue to maintain focus on
students. After all, they are the future of the
profession.
Lorenza Clausen, RT
President, CSRT
[email protected]
President Lorenza Clausen
addresses the ASRT Board
of directors in the open
forum.
JULY 2013 | The Technigram | 4
Upcoming Events |
RTEC Meeting
The Latest and Greatest 6
Saturday, September 7, 2013
Sutter Cancer Center
2801 L Street, Sacramento, CA 95816
RTCC Fall Meeting
Wednesday, October 23, 2013
1500 Capitol Avenue
Sacramento, CA 95814
Friday, November 8, 2013
South San Francisco Conference
Center
255 S Airport Blvd, South San
Francisco, CA 94080
74th Annual Conference
Medical Imaging: From Acquisition
to Innovation
Saturday, November 9, 2013
South San Francisco Conference
Center
255 S Airport Blvd, South San
Francisco, CA 94080
CSRT 2013 Annual Conference Topics of Presentation
Anatomy of a Lawsuit in Imaging Departments
- Ted Vanderlaan, JD, RT(R), CRT
MRI for Radiographers and other Non Physics Majors
- David Nelson, MD
How We Think: Psychological Challenges in Radiology and a Potential Solution
- Peter Marcovici, MD
Cone Beam CT
-Gurminder Sidhu, BDS, DDS, MS
The Radiologic Technologists Role in the Evaluation and Treatment of Acute Myocardial
Infarction
- Christopher Steelman, M.S., R.T. (R)(CI), RCIS
JULY 2013 | The Technigram | 5
RTEC |
Latest and Greatest 6 Schedule of Events
7:00-8:00
7:45-8:00
8:00-8:50
Registration & Continental Breakfast
Welcome & Announcements
Lithotripsy and Imaging
-Lionel Foster, MD
9:00-10:30 Do You Have the Vision to Improve Your Image?
-Shawn McKenzie, MPA
10:30-10:45 Break
10:45-11:45 Dose Reduction in Healthcare Today
-Neil Singh, MBA, RT(R), CRT
11:45-12:45 Lunch
12:45-1:45 Dental Radiography
- Michael M. Rice, DDS
1:45-2:45
Health Effects of Low Level Radiation
- Keith Diehl, BA, RT(R)(MR), CRT
2:45-3:00
Break
3:00-4:00
C-Arm and Radiation Safety in the OR
- Greg Sadler
Radiologic Technology Educators of California
The 50th Annual Conference will be held this year on Friday November 8, 2013 at the South
San Francisco Conference Center. Educational sessions will be focused on topics of interest
to current and future educators. Students are welcome to attend.
Presenters are from various perspectives including a radiologist, neurologist, technologists
and the community. Speakers from JRCERT and RHB will also be invited.
Registration opens Summer 2013 and Golden Apple Applications will be emailed to the
Program Directors August 1st.
Join educators educating the community we serve!
6-7.5 CEU’s Pending
From the Editor’s Desk:
Synopsis of activities from the ASRT HOD and Educational Conference 2013
By Rich Lehrer and Rachelle Campbell
JULY 2013 | The Technigram | 6
Legislative News |
National Legislative News- July 2013
Now halfway through the new session's first year, the CARE bills were both reintroduced in late
March. The MARCA bill, also from 2012, was also reintroduced. SB 642 has 5 cosponsors. HR 1146 has
29 cosponsors, including newly elected Congressman Ruiz from California. HR 1148 has 32 cosponsors
for MARCA; the most ever for this bill.
This year, as was announced at RT in DC, there will be a new strategy seeking to add an amendment
with CARE language to Medicare related bills. It is hoped that through this alternative, it may provide
an additional opportunity for passage. Recently, Congressman Whitfield (Kentucky) sent a request for
the bill to be scored by the Congressional Budget Office (CBO). The GAO, Government Accountability
Office, recently published its latest report, stating the need for medical imaging education standards.
You can read the report here (Medicare Imaging Accreditation) or on our website announcements
section.
Other recent activity saw Michigan and its affiliate sponsor its own RT lobby day. The March on
Lansing brought more than 300 RTs together to educate state legislators and request state licensing
standards be implemented. Michigan is still one of the states without educational and licensing
standards. Michigan is currently working on introducing its licensure bill. North Carolina held theirs in
March and Missouri is also working on its event to be held in their state.
Over the next year, ASRT will be assisting other affiliates in holding similar events to educate its
lawmakers about the profession. CSRT is looking into planning its own RT at the Capitol and begin
educating our lawmakers about medical imaging. Look for more information to come as the year
progresses. Anyone interested to work on this project is encouraged to contact me or our office.
Finally as it was reported in the last issue, the
introduced bills in Maine regarding Fluoroscopy
licensure exemptions for MAs and RCIS CV
specialists, were held up in committee and did
not proceed through to passage. Thanks to a
large response from the medical imaging
community, the Maine affiliate was able to
organize a grassroots outpouring of opposition
to defeat that attempt.
More information is always available on the
CSRT website at www.csrt.org.
Lorenza Clausen relaxing in the ASRT Director’s Office.
Lorenza Clausen, RT
Legislative Co Chair
JULY 2013 | The Technigram | 7
The Tragedy… |
The Tragedy Surrounding Recognition of the RCIS Credential to Conduct
Fluoroscopic Duties in the Cardiac Catheterization Lab
By Jay Haischer, MHA, ARCRT, CRT (R)(F)(IV), VA-BC
Chair, CSRT Legislative Committee
The medical use of ionizing radiation, while offering great benefits to patients, also contributes
significantly to radiation exposure. When complex procedures are performed or repeated to the same
patient, high doses of radiation occur because of long fluoroscopy times and numerous images.
Review any studies on patient dosimetry in Interventional Cardiology and there is great variability of
patient exposure to radiation. Some of the factors contributing to this are complexity of the procedure,
operator (physician) experience, level of operator training in radiation safety and protection, and the
type, performance and operation of equipment used. On average, Coronary Angiography corresponds
to a radiation exposure to the patient of 300 chest x-rays, stent placement 1000 chest x-rays and RFA
1500 chest x-rays. Given these exposures, ONLY properly and highly trained operators should be
allowed to conduct Radiography/Fluoroscopy during a cardiac catheterization.
TItle 17 in The California Code of Regulations also known as the Radiologic Technology Act, was
created by the California Legislature to protect the citizens and patients of California from unnecessary
exposure to ionizing radiation and to ensure proper education/training/credentialing of persons
defined by Title 17, subchapter 4.5 as a Certified Radiologic Technologist (CRT). Included with Title 17
is language that describes what a properly trained Radiologic Technologist who holds a Fluoroscopy
permit can do while the supervising physician is conducting Fluoroscopy.
“A radiologic technologist fluoroscopy permit issued by the Department shall be required of
ANY technologist who exposes a patient to X-rays in a fluoroscopic mode, or who does one or
more of the following during fluoroscopy of the patient:
a. Positions the patient
b. Positions the fluoroscopy equipment.
c. Selects exposure factors.” (Title 17, CCR §30450)
Recently, an online call for assistance was distributed to all cardiology professionals authored by the
Alliance of Cardiovascular Professionals (ACVP), to recognize and authorize the Registered
Cardiovascular Invasive Specialist (RCIS) credential for conducting the same duties prescribed by Title
17 for Radiologic Technologists. ACVP has provided contact information for California Legislators to
their members and are attempting to modify current legislation. ACVP mentioned in their call that the
standard credential obtained as a SECONDARY certification by the American Registry of Radiologic
Technologists (CV) is controversial and does NOT properly test the knowledge and skills to perform
adequately in the Cardiac Catheterization lab. ACVP states that the RCIS credential is the ONLY one
recognized and supported to supply competency in all areas of Cardiac Catheterization. Title 17,
California Code of Regulations specifies the education and training required to obtain licensure to
conduct Radiographic and Fluoroscopic procedures in California. No other technologist credential has
the education, training or proper knowledge in equipment operation to operate fluoroscopic
equipment safely and effectively.
JULY 2013 | The Technigram | 8
The Tragedy… |
On 4/17/2013 the Radiologic Technology Certification Committee (RTCC) held its biannual meeting in
Los Angeles. ACVP, their various speakers some who hold the RCIS credential, a JD credentialed
attorney and a MD credentialed Cardiologist presented their case to gain committee support. The goal
of the ACVP is to amend or redefine the language in Title 17 so as to grant the RCIS one or more of the
duties described above as presently required by a Radiologic Technologist holding a Fluoroscopic
permit. After numerous questions and comments from committee members and the audience, it was
discovered that the Cardiologist wanted ANYONE in the suite to be able to conduct the duties
prescribed by Radiologic Technologists holding a Fluoroscopy permit.
This is a dangerous scenario for the citizens and patients of our state, a fact mentioned by several
radiography program directors, health physicists and former committee members in attendance.
Despite the voice or caution and concern, there is currently a motion approved and seconded by the
committee to entertain changes in the duties prescribed by Title 17 exclusively for Radiologic
Technologists. CSRT takes exception to this motion, as the intent is to recognize the RCIS credential
and therefore bypass the California Radiologic Technology Act and the PRIMARY certification of the
California CRT.
We have 6 months before the next meeting of the RTCC to garner support to deny this motion.
The ASRT has recognized the RCIS credential as equivocal to the (CV) credential POST primary
certification. CSRT hopes that the ASRT will support our efforts to contain this and other credentialing
agencies from gaining support and acceptance to conduct radiologic technology procedures. We are
concerned as our profession is placed in a compromised position where lesser-trained personnel are
attempting usurp our profession. Additionally, passage of this legislation sets a precedent for other
instances of occupational erosion.
CSRT appreciates feedback that agrees or disagrees with our stated position. We need the support of
our profession to stop this encroachment on our domain. Please feel free to comment or request
further information from:
California Society of Radiologic Technologists
575 Market Street
Suite 2125
San Francisco, CA 94105
JULY 2013 | The Technigram | 9
RESUME WRITING TIPS FOR NEW GRADS
It is graduation time!
Resume Writing Tips |
By Diane Garcia
You are finally finishing a radiologic technology program and after you receive
your ARRT certification, obtain your CRT license, and then take and pass the fluoroscopy permit exam
you will be ready to start job hunting. How many of you have already begun to write your resume?
Here are some tips to help make your resume stand out.
Think of the hundreds of resumes that cross an HR manager’s desk in each hospital every week. It’s
truly a mountain of paperwork they’d rather bypass. The job market can be tight and being what it is,
recent grads are cranking out resumes using the same accepted industry standard formats. There is
nothing wrong with that, but there are subtle ways to make your resume stand out from the rest.
One way is to be word wise. That means dumping the standard weak words and “amping” your resume
with power words. You will want words that will catch a recruiter’s or HR manager’s eye. An applicant
will want words that will stop a keyword scanning program and shift your resume into the “take a
second look” category. First, you have to know the words that you need to dump. They include:
1.
2.
3.
4.
5.
Strong
Exceptional
Good
Excellent
Outstanding
6. Effective
7. Driven
8. Motivated
9. Seasoned
10. Experienced
That’s right…..don’t use the word experienced if you are a new graduate. You are not yet experienced
in radiography, you are educated. Your time in the hospitals, to date, does not include working
independently. You were always supervised and someone else took responsibility for everything you
did. To be experienced, you need to have had full responsibility for everything you do and that has not
happened yet. At this point, you are Entry Level ready. There is still so much more to learn and refine.
Those 10 words are self-aggrandizing. Your references may use them to describe you, but if you use
them, it sounds like you are patting yourself on the back. They simply lack objectivity. They are
qualitative and cannot easily be linked to quantitative appraisals of your accomplishments.
It’s much better to use the hot words that can be connected to specific areas of your performance
during your educational process. These will catch a recruiter’s or HR manager’s eye. They’ll also be
flagged by keyword programs, giving your resume a “second read.” They include:
1.
2.
3.
4.
5.
Improved
Developed
Researched
Created
Increased
6.
7.
8.
9.
Reduced
Accomplished
Won
Exposure [to] (instead of experienced in)
JULY 2013 | The Technigram | 10
Resume Writing Tips |
When using these keywords, try to link them with specific facts. This adds credibility to the words and
will draw the attention of recruiters, HR managers and most recently, applicant tracking software.
It is an unfortunate fact of life that most companies and hospitals now use some type of applicant
tracking software. This software looks for keywords that match specific job requirements. Some
companies digitize the hundreds of resumes they receive on a daily basis, store them in a database,
search for candidates using keywords and then create interview call lists. The bottom line: If your
resume lacks the right combination of job-specific keywords, it will end up in digital limbo, never to be
seen again until a programmer purges the file. I know, it’s brutal and impersonal, but such is the world
we live in.
Here are some suggestions on the types of keywords to include in your resume. They should be job,
task and industry specific:
•
•
•
•
•
•
•
•
•
•
•
Job Titles
Product or Equipment Names
Technical Terms
Industry Jargon & Medical Terminology
Software/Hardware Packages used in different modalities or the HIS or RIS systems
Job-specific Buzzwords
University or College Scholarships and/or Awards
Certifications and Degrees
o Fluent in foreign language
o Specialized computer training or computer languages
Hospital and Company Names
Past business affiliations
Professional Organization membership and participation
Creating an effective resume that will get noticed these days and it takes a bit of work. It takes much
more than just listing your accomplishments. You also need to highlight the extra things you have been
involved in during your educational process. These extra-curricular activities show an employer that
you are not only interested in a job, you value this profession as a career choice so much that you
volunteer your time to make the profession better for everyone!
Now go out there and land your first job! After that, you can upgrade your resume and use the word
EXPERIENCED!
JULY 2013 | The Technigram | 11
From the Student Committee…
From the Student Committee |
By Nav Rajan
Student Committee Chair
CSUN BSRS Student
The responsibility of Student Chair was recently passed along to me.
It is a great honor to represent
the students across the state. As the immediate past chair, Roxanne did a great job and I know that I
have some big shoes to fill. I have been a member of the Student Committee since I started my RT
program in the Fall of 2012. I still remember wanting to be a member before I was even an RT student.
I tried to volunteer for the Annual Conference in Stanford a few years back. Unfortunately, I was not an
RT student and was not allowed to attend. It was then that I promised myself and Mr. Castillo that I
would be back and make sure I stayed involved throughout my career. It is incredibly gratifying to be
in this position. We have made a lot of progress this last year, working on the video project, setting up
new fundraisers and scholarships, as well as our RT to DC trip. It has been a pleasure to interact with
the Board as well as the students across the state. Our unison is what has brought me to this juncture
as a student.
My hope as the new Chair are to make sure we complete the web-video. When I signed on to the
committee, the video was something Roxanne really wanted to see completed. As in the past years
there were many hiccups along the way. Together, Roxanne and I devised a plan, and fortunately I was
able to reach out to a colleague in the industry. I am pleased to report that the video is becoming
reality, together the Student Committee will get this video done within my term.
As Chair, I would also like to reinforce the importance of being involved within your local society, the
CSRT. It is important not only as a student but as a professional RT to stay involved. I would like to
elaborate and educate the students on how the CSRT can help with future employment as well as how
having a strong union among RT's can also help job creation and strengthen the field as a whole.
Finally, the Student Committee has some excellent dedicated members this year that I am looking
forward to interacting with and getting feedback from these dedicated few. Roxanne has kindly stayed
on as a liaison and we are very lucky to have her, it shows her dedication to the profession and the
CSRT. The new members have already started to step-up and take responsibility which is gratifying.
The students of today are the future RT's of tomorrow and I look forward to working with all of you to
reach our common goals.
JULY 2013 | The Technigram | 12
RT in DC 2013
RT in DC 2013 |
Amanda White, SRT
Prior to applying for the RT in DC grant I thought I knew all there was to know about the CARE bill and
I thought I understood the importance of such a bill. Turns out I didn’t know half of what there is to
know about the CARE bill! I knew that it was a very important bill that I wholeheartedly supported,
but it’s not until you’re thrown into the middle of the politics in Washington DC that it all really begins
to make sense. Now more than ever I realize how important my support is to what used to seem like
such an easily achievable goal…equal education and credentialing nationwide for Radiologic
Technologists.
Everyone that I spoke with regarding to the CARE bill support it. This was true of each and every
individual that I meet with on Capitol Hill. This is why I find it so hard to believe that the CARE bill has
yet to pass. What I learned while in Washington DC is that it is hard to get any bill passed by Congress,
in fact last year marked historic lows for the number of bills passed! So, when I was beginning to get
discouraged that the CARE bill may never get passed, I reminded myself that very few bills regardless
of the subject matter get passed so it is more important now than ever to support this bill.
Visiting Capitol Hill was a wonderful experience and unlike anything I’d ever done before. I will say
that heading to Washington DC I was extremely nervous. I wasn’t sure what to expect from the
individuals working on Capitol Hill and what their reactions would be to what I was presenting and if I
even fully understood what I would be presenting. The main reason for my nervousness was that I’d
prepared myself to discuss the CARE bill with these individuals and ask for their support. I’d prepared
a whole book with pictures of radiographs, radiation burns and also material to show the extent of my
educational program. The problem was that shortly before leaving for DC I was informed that this
year RT in DC would be done a little different than years past. The ASRT had decided to take a
different approach in accomplishing the goal of equal education and credentialing for RT’s. My
apprehension was soon put to ease after a day of mentoring that made me clear as to what I was there
to do. This year there is no CARE bill as of yet so, what was I asked to do? I was asked to meet with
legislators to ask that they support our decision to add amendatory language to already pre-existing
bills for instance; any bill relating to Medicare reimbursement. So long as Medicare is only reimbursed
if the radiologic procedure is performed by a qualified individual we are that much closer to achieving
our goal. This is the new approach and as it turns out the research and preparation I’d done prior to
leaving for DC was all still very valuable information. Everything that I had to present was very well
accepted by everyone that I meet with.
That day on Capitol Hill was one very hectic day and one I will never forget. It involved much running
around from building to building to make it to all of the meetings that we had scheduled. California
has a huge number of Representatives which left us very busy for the day! I was kindly surprised at
how pleasant everyone was on The Hill. I was not expecting it to be such an enjoyable experience but
it is an event that I would recommend for every Radiology Technologist to attend. It was a significant
event for me to show me just how crucial it is to be actively involved in supporting my field. Without
JULY 2013 | The Technigram | 13
From the Student Committee |
our involvement we may never reach the goal that we all so deeply need. By accomplishing this goal
not only will we greatly improve patient care and safety within the field but we will also greatly reduce
the amount of money needlessly spent within the field. It feels wonderful to have been a part of such a
remarkable event and feel as though I was able to help first hand in improving the field of radiologic
technology. Now more than ever I’m driven to continue the fight for equal education and credentialing
nationwide. Thank you to the CSRT and the ASRT for such a phenomenal experience.
From the Student Committee…
By Roxanne Munyon
Past Student Committee Chair/Board Liaison
As my formal education in medical imaging comes to a close, so does my time as the Student
Committee Chair. My journey to this profession is, in short, nothing I had envisioned. I never imagined
that I would learn so much not only about imaging but also about myself. I have learned not only how
to take diagnostic images and critique them, but also about radiation safety for myself and my patients,
anatomy, pathology etc. What I have also learned is that I am good with people, with patients, I am
compassionate and I am a leader. I have learned that I am a critical thinker, I am a grown up. I accept
responsibility for my mistakes and shortcomings, and I strive to do better.
I am honored to be a part of the CSRT and to have served as the Chair for the Student Committee. The
Committee’s goals have been to increase the presence of the CSRT in the various programs throughout
the state and increase student involvement in the society. Creating an atmosphere where students are
welcome and realize the importance of the CSRT will hopefully encourage continued involvement after
graduation. I look forward to seeing how the Committee will continue to grow.
Nav Rajan from CSUN’s imaging program has stepped up to become the new Chair. I feel very
confident in his abilities to get things accomplished. While we were in Washington D.C. this past March
lobbying for the C.A.R.E bill his professionalism was very evident in the way that he conducted himself
and spoke on the need for the C.A.R.E bill. We made a good team while visiting representative’s offices.
Although my term of Student Committee Chair has come to a close, this does not mean my involvement
is over. I look forward to more learning and professional development within the CSRT and in medical
imaging.
JULY 2013 | The Technigram | 14
On to Washington!
On to Washington! |
By Roxanne Munyon
An important legislative issue regarding Consistency, Accuracy, Responsibility and Excellence in
Medical Imaging and Radiation Therapy which is known as the C.A.R.E bill has been on Capitol Hill for
the last 12 years. For those 12 years, Radiologic Technologists (RT’s) from around the country have
been lobbying legislators, encouraging them to set minimum standards of education for those who
work with ionizing radiation. The American Society of Radiologic Technologists (ASRT) and California
Society of Radiologic Technologists (CSRT) sponsor RT’s and RT students to attend an important event
called RT’s to DC where RTs have the opportunity to lobby Congress on behalf of all patients in the
United States.
I applied for the CSRT, RT to DC scholarship. When I received the news that I had won and I would
attend the 2013 event, I was very excited! Since beginning my education in diagnostic imaging I have
been interested in what the professional societies do for the profession. I have learned so much by
becoming involved with the CSRT. This organization helps to promote our profession. Its main focus is
keeping California’s patients safe from the misuse of radiation as well as keeping their eye on all
California legislative changes to our profession. The CSRT is also instrumental in keeping California’s
educational standards high. The ASRT fights for patient rights regarding radiology, our professional
standards and careers on a national level. These are just some examples of what the CSRT and the
ASRT do for its members there are many, many more issues they tackle on behalf of Radiologic
Technologists throughout the country.
Preparing for my trip to Washington D.C. entailed collecting letters of support from the constituents of
California. I started on this journey, which many RTs and students have done before, by enlisting the
help of other students and faculty from my college. I asked for their support as well as that of friends
and family. The support was overwhelming! When I journeyed to Congress, I was armed with many
letters written by constituents from around the country to their Congressional Representatives. I
knew that I would be meeting RT’s from other states so I enlisted the help from EVERYONE I knew!
These letters expressed their concern for the lack of educational consistency and asked for their
support for the C.A.R.E. bill.
In the days prior to my departure, I made appointments with four Congressional Representatives. I
was actually surprised at how easy it was to do this and how personable each Congressperson’s staffer
was on the phone. My mentors and colleagues from the CSRT, six in total, whom I would accompany to
Washington D.C., were very organized. As time approached to make the trip, more and more meetings
with the Representatives were on the schedule. All in all, the six of us had arranged 20 appointments.
When I arrived in Washington D.C., there was much to do to prepare for our day on Capitol Hill. The
day before was filled with informative meetings about the history of the C.A.R.E. bill, Medicare reform,
entitlement reform and other relative legislation. Although the C.A.R.E. bill has had widespread bipartisan support, getting it passed through Congress has not happened yet. This time, for the 113th
Congress, a new strategy was being applied and we spent the afternoon learning about its intricacies.
An individual bill is difficult to pass. The strategy this time was to have the language of the C.A.R.E. bill
JULY 2013 | The Technigram | 15
On to Washington! |
inserted into any federal bill that pertains to Medicare, sequestration, the debt ceiling or entitlement
reform. As well as having another C.A.R.E. bill submitted to the Congress. We are hoping this strategy
will work this time.
As I walked around the city in the late afternoon, organizing my thoughts after our informational
meeting, I was stopped by a reporter and interviewed by the local news station about my thoughts
regarding sequestration and how I felt about what it would do to jobs in my profession. Much to my
relief, I had some thoughtful remarks to make on the subject as I had just spent a good part of the day
learning about how this kind of government action would affect our profession. The ASRT does an
excellent job of educating all of us and I now felt very informed and ready to face the Congressmen and
women with whom I had appointments. This interview with the reporter proved to be a great test run.
Tuesday morning I awoke early in anticipation of the day‘s event. After a quick breakfast and checking
in with other RT’s and students from around the country, the six of us set off for the Hill. Our first
meeting was at 9:00 am with the Legislative Assistant (LA) for Representative Bass. It was great to
have Lorenza Clausen, President of the CSRT, there with me. She has seven years of experience coming
to Capitol Hill. Once that meeting was over, I felt confident I could conduct a productive meeting with
the other scheduled Representatives. Nav Rajan, a student from California State University,
Northridge (CSUN), and I headed off to Congresswoman Nancy Pelosi’s office. We literally ran through
the underground tunnels of the Capitol and took the “members only” subway to the LA’s office. Nav and
I were a good team as we explained to the LA, the need for minimum standards of education for
imaging professionals. It was fun discovering our way through each of the buildings that house our
Representatives and seeing other white labs coats (representing the ASRT) along the way! We had just
enough time in between meetings to run in and watch the House of Representatives in action! What a
great experience.
After that amazing opportunity, some of us met up again in Representative Jackie Speier’s office. It was
a twist of luck! Just as I was finishing up speaking with her LA Erin Ryan, Ms. Speier came out of her
office and introduced herself to all of us. It was great to be able to meet my Representative. She was
personable and spent time with us. She is well aware of the C.A.R.E. bill objectives and has always
been very supportive of the efforts of the ASRT.
After we all gave each other “high 5’s” for actually meeting a Representative, which is rare, we paired
off again to attend the rest of our individual meetings. I headed off with Pasadena City College Student,
Amanda White, and we met with the LA’s from the offices of Representative McKeon and
Representative Sanchez.
Meeting and talking with each of the Representatives is very important, but it is an additional bonus
meeting with those on important committee’s such as the Ways & Means committee and Energy &
Commerce committee. Amanda White landed a meeting with Representative Linda Sanchez, a member
of the Ways & Means committee. She and I went to meet with her LA, Tim Del Monico. Tim had
experience with our cause and had great advice for the best possible strategies for this important
legislation. There were five students in all from California, Alex Guiterrez , Alex Render-Leos Nav
Rajan, Amanda White and me representing CSUN, Pasadena City College and City College of San
Francisco. Together we went into Representative Henry Waxman’s office, a member of the Ways &
JULY 2013 | The Technigram | 16
On to Washington! |
Means committee. Representative Waxman was a strong supporter of Mammography Quality
Standards Act (MQSA) and we are hoping to gain him as a Co-sponsor of the C.A.R.E. bill legislation.
Some of our meetings were conducted in beautiful offices and some were in the hallways. However, no
matter where the meeting was held I found all the office staffers to be gracious, personable and helpful.
Many were very familiar with the C.A.R.E. bill and were receptive to the new strategy. The day was
long, but time flew by. We ended back at the hotel, regrouping and then meeting up for dinner. It was
an eventful, educational and fun day. It is my hope that this 113th Congress can work together and
pass this meaningful, important legislation.
As our time in Washington came to a close, much to our surprise, a few people got caught in a winter
storm which snowed us in and closed the airports. After all the excitement of Capitol Hill, everyone
was ready to go home but some found it necessary to find later flights and extend their stay in this
fabulous city. I was one of them. It gave me just enough time to see and explore a few more of the
amazing sights that are part of America’s tapestry of history. I was able to then see the Supreme Court,
the Library of Congress, Union Station to name a few places as well as seeing the National Monuments
at night.
I offer my sincere gratitude to the CSRT and the ASRT for providing this memorable experience for me.
I will never forget this wonderful opportunity to be a part of the legislative process, walk among the
halls of Congress, meet my own Representative, and satisfy my curiosity about what our professional
organizations do for our profession. I will never again question how important they are to my new
career. RT to DC was an experience of a lifetime!
JULY 2013 | The Technigram | 17
ASRT Student Leadership
ASRT Student Leadership |
By Abby White, SRT
Northwestern Memorial Hospital School of Radiology
Chicago, IL
So how was my experience and time in Albuquerque at the Delegates meeting? .....Awesome! I couldn't
believe how many amazing people I met within just a few days. One of the most positive aspects of the
whole thing was my mentor (Rachelle Campbell) and how she guided me through everything that I
may not have understood at the time. I am 9 months into my 21 month program at Northwestern
Memorial Hospital in Chicago, so there were some
things about the Delegates meeting and how the
process works that were confusing at first, but after
attending the conference everything is coming
together. I didn't realize how much of a networking
opportunity this was until I started meeting and
talking with others in the profession from all over
the nation.
ASRT Student Leadership winners Abby White (IL),
Dan Focarelli and Christina Sung (CA).
The classes offered to the students were
educationally outstanding. I found out and learned
more about how I could continue my education with
my profession after I become an RT. I love learning
and if it were possible, I would stay in school my
entire life.
Knowing that I can continue my
education to no ends was marvelous news to me.
The way I felt going into this leadership program and the way I felt coming out was completely
different. Coming in I felt a little scared not knowing what to expect but when I left, I felt like a totally
different person. I am now educated and on top my game. My confidence
level was significantly higher and I felt more as if I could help lead my
classmates into becoming the best technologists possible. I felt
encouraged, even obligated to tell my classmates that they don't have to
stop once they are done with our program but they should keep going to
enhance their careers and personal growth. There are so many
opportunities that are available for every type of person and I want my
classmates to succeed. I also had many ideas collected from students and
educators on how their programs are run to share with my own program
director and clinical coordinator. So how will this experience fit into my
career? In every way possible.
I left Albuquerque having what are surely some of the best life long
friends. When you spend 18 hours everyday for 5 days of professional
and social experience with the other students, you feel like you have
JULY 2013 | The Technigram | 18
ASRT Student Leadership Academy |
known them for years. I hope to stay in touch with everyone I met and keep them as close friends for
the rest of my life.
Having experienced this, it opened my eyes for new places to go and different directions to take. More
doors have opened and I now realize that these would be amazing people to work with. This is what I
want my career to encompass.
ASRT Student Leadership Academy
By Shay Turner, SRT
Covenant Medical Center's School of Radiography
Waterloo, Iowa
My name is Shaytra Turner, but I
prefer to be called Shay. As of
June 24th 2013 my venture as a
second year will commence via
Covenant Medical Center's School
of Radiography in Waterloo,
Iowa! Although I was technically
a first year student, it rocked my
world
being
accepted
to
represent my state at the ASRT
Student Leadership Program in
Albuquerque, New Mexico. What
an incredible honor to be the only
representative of Iowa in 2013! I The newly remodeled ASRT headquarters in Albuquerque, NM
had so much anticipation going
into this program. As mother of a three-year-old who just returned to school to try and provide better
for my family and provide a positive example for my son, I never imagined that such a short but jampacked week could immediately pluck me from my timid shell!
The events began immediately, every event was teeming with information I could hardly take notes as
quickly as the speakers presented it! There was so much I wanted to take in, I didn't want to forget a
single aspect, I wanted to bring it back and share it with anyone who would listen. It wasn't just the
bountiful information that intrigued me, it was the information which was relayed to all of us. The
speakers had such knowledge and passion! They could not wait to talk to people, hear what we had to
say and then evolve upon it, reflect upon it, stretch every idea or possibility so far that we ourselves
became more passionate about the profession of Radiography. And when the speakers or even just
another student or mentor-whomever!-saw this, it 'filled their bucket' just a little. By the end of any
conversation, regardless of if it had lasted 30 seconds or an hour, we walked away from one another
with a hop in our step and a twinkle in our eye.
JULY 2013 | The Technigram | 19
ASRT Student Leadership Academy |
ASRT Student Leadership winners Shay
Turner, Dan Focarelli, Christina Sung and
Abby White
So, here I am eighteen pages of notes later and more
passionate about my future than ever before. What did I
actually learn? That's what everyone keep asking me. “Shay,
did you really learn anything? Would you ever attend another
meeting?” The answer is yes to both, and let me tell you,
that's a yes with zest. Reigned in by the plethora of facts and
outpouring of knowledge that those who have served the
field of Radiography for decades longer than I've been alive, I
could not have walked away from any meeting more
prepared for my future than I am now. I have been so
accurately educated on the ethics, the principles, the mission
of this profession there is no turning back now! I want to and
am going to use this information to ignite the fire in those
within the profession who are just beginning or whose flame
is smoldering, let's intensify those flames and show the world
what we are made of! This is a career about caring for others
as well as one another!
So let us prove we care, we are not just button pushers, we
are an educated and well-rounded team of individuals whose
career is based upon the very motto, “Once certified, forever
learning, evolving and developing.” This is accomplished by attending these very meetings, being part
of programs, developing our skills while
volunteering our time and committing ourselves
to the excellence that has preceded us and the
excellence we are engaged in creating.
This synopses of my impression seems to have
morphed into more of an 'Inspiration in the field
of Radiography' paper, but when I reflect upon all
that I learned and took away from the ASRT
Student Leadership Development Program and
all that it enveloped, I always find myself circling
back to passion. No career can be great and
forever evolving and improving without passion.
I am so proud and honored to be working hard to
be a part of a profession that fully embraces such
a fiery passion.
JULY 2013 | The Technigram | 20
2013 ASRT Student Leadership Delegate |
2013 ASRT Student Leadership Delegate
By Christina Sung, Cal State University Northridge
I
had an absolute blast as a Student Delegate representing California! I
learned a lot and met so many people. As I watched Sandra Hayden
fulfilling her duties during the first and second business meetings, I kept
thinking that I would love to be Speaker of the House one day. Even my
fellow student delegates agreed that I would make a great Speaker of the
House. The trip to get elected seems totally doable, I just have to be
willing to make the time, effort and sacrifices.
I enjoyed our trip to ASRT Headquarters Grand Re-opening Gala. It is
absolutely beautiful out there framed in the high desert with spectacular
views!! I took pictures of myself sitting at Sal Martino’s (ASRT CEO) desk,
sitting across from Myke Kudlas (ASRT Chief Academic Officer) in his
office, and the beautiful pictures and displays throughout the new
building.
I already know that I want to talk to the class behind mine about my
experiences and why they should apply and go to next year’s Annual Governance and House of
Delegates meeting. This was such an incredible opportunity for me to learn about the other programs
out there. Some of my new friends do not have program directors who are so active or who are willing
to fight for their students at clinical sites like my program director and clinical coordinators. Note: New
appreciation and thanks. For many students, this was their first conference that they had
attended....and they are second year. A few were shocked to know that I have attended many
conferences and could point out which speakers were my favorites.
I think that the Student Leadership
Development Program is a wonderful
opportunity for all students to attend. I feel
like I have made some lifelong friends in
Albuquerque, NM. I was so sad to see a few
of them leave. Thank God for emails, text
messaging, and Facebook!! I’ve already
emailed, called, texted and connected on
Facebook with many of the other student
delegates.
I honestly cannot think of any negatives
about this experience. There were so many
positives and so many memorable moments Attendees: Lorenza Clausen, Mary Hart, Christina Sung, Rachelle
for me that I am glad to have applied for this Campbell, Dan Focarelli, Rich Lehrer.
program. I am already looking at applying to the ASRT Leadership Academy in the next year or so. If I
want to become the Speaker of the House, I have to start somewhere, right?
JULY 2013 | The Technigram | 21
Benefits of Dual-Energy… |
Benefits of Dual-Energy Subtraction Radiography of the Chest
By Linda Ma, SRT – City College of San Francisco
Chest x-rays are one of the most common radiographic exams and arguably one of the most important
exams in helping with the diagnoses of patients. Chest x-rays provide scores of vital information about
the heart, lungs and vessels. However, chest x-rays are limited in that it only provides a twodimensional view of the chest. Due to the projection of standard chest x-rays, bony anatomy such as
ribs or clavicles could obscure subtle lesions of the lungs if the nodules lie superimposed underneath
the bony structures. Conversely, when rib x-rays are taken, soft tissues of the lungs could obscure
small masses or hairline fractures of the bony structures. To visualize the lung and soft tissues of the
chest, a high kV exposure is used to produce a long scale of contrast. To emphasize the bony anatomy
such as the ribs, another exposure is taken at a lower kV to produce a short scale contrast. As a result,
two exams must be done to obtain all the information. Now, advances in computed and digital
radiography technology enable dual-energy radiography (exposure at two different energy levels),
offering a powerful tool for depicting abnormalities in the chest (Pal, 2006).
There are two types of dual-energy radiography systems that have been developed for clinical use.
The first type uses a single high energy exposure directed at two aligned computed radiography (CR)
imaging plates separated by a copper filter. The front imaging plate would record the low energy
information. The copper filter would absorb the low energy photons, leaving only high energy photons
to strike the second imaging plate which would then record the high energy information. With a single
exposure, this “sandwich” detector could record two different images at two different energy levels
simultaneously (Ogden, 2011). Because the two images are acquired at the same time, temporal
registration of the two images is very good; “essentially eliminating any artifacts due to patient
motion” (Ogden, 2011).
The second type of dual-energy radiography system is a dual exposure system in which a digital
radiography (DR) flat panel detector with a fast readout records two sequential exposures, the first at
60 kVp and the second at 120 kVp. Because two different exposures are performed separately, the
energy separation is larger, yielding a higher signal-to-noise ratio (SNR) (Ogden, 2011). According to
Davidson (2007), “Statistical fluctuations of exit photon intensities exist when an x-ray beam of
homogeneous intensity irradiates a uniform object.” The SNR is higher in a dual exposure system
because the exit intensity of the beam (signal) is coming directly from the x-ray tube source; therefore,
“the exit intensity is high [and] the fluctuations are relatively small compared to the x-ray intensity”
(Davidson, 2007). With a higher SNR, there is less mottle in the appearance of the image and the
quality of the image is greatly improved.
Regardless of whether a single exposure sandwich detector system or a dual exposure flat panel
detector system is used, the benefit of dual-energy subtraction radiography is the superior ability to
differentiate between soft tissue and bone to discover potentially cancerous nodules (Forrest, 2007).
Because the images obtained from a dual energy system provide information that emphasizes both the
soft tissue and the bony structures, a computer subtraction algorithm could be used to subtract either
the bone or the soft tissue from the standard image. From a standard dual-energy chest radiograph,
JULY 2013 | The Technigram | 22
Benefits of Dual-Energy… |
the operator could eliminate the bony structures to obtain a soft tissue-only image of the chest. A
tissue-only image of the chest is beneficial in that it will solve the problem of having overlying bones
that often hide subtle soft-tissue nodules in the lung. For example, a standard image is compared with
the bony ribs subtracted from the image below. The tissue only image clearly depicts a soft tissue
lesion in the right upper quadrant of the lung which could have been missed in the conventional image.
Similarly, creating a bone-only image is beneficial in visualizing “bone lesions such as primary bone
tumors and rib fractures become more conspicuous” (Pal, 2006). With a standard image, overlying soft
tissue may have caused doctors to miss hairline fractures or subtle bone structure anomalies. For
example, “removing the soft-tissue components and emphasizing the bony structures might allow the
discrimination of soft versus calcified lesions” as evident in the bone only image below (Ogden, 2011).
The lesion near the cardiac knob is visible in the standard image of the chest to the left; however, with
manipulation using dual-energy subtraction, it is apparent that the lesion is calcified because the lesion
is no longer seen in the tissue-only rendition of the radiograph in the center and clearly emphasized on
the bone-only image on the right.
“Dual-energy subtraction also improves the visualization of cardiac calcifications and other vascular
diseases” (Pal, 2006). In the example below by Ogden (2011), several nodules can be seen in the
standard image to the left. By examining the tissue-only image in the middle and comparing it to the
bone-only image to the right, the soft tissue nodules depicted only in the tissue-only image could be
discriminated from the calcified lesion visualized only in the bone-only image. “The lesions in the heart
JULY 2013 | The Technigram | 23
Benefits of Dual-Energy… |
region in the bone-only image…indicates the presence of calcium-containing lesions [or] these might
be due to calcium deposits in the vasculature” (Ogden, 2011).
According to Forrest (2007), a radiologist in Florida explained the importance of detecting these
lesions early, "If it weren't for dual-energy subtraction imaging, we would not have seen those
(lesions) until they got bigger, and then you're running into problems with the patient, because the
cancer has been growing." Another doctor in Cleveland also noted the benefits of dual-energy
radiography, "There is no doubt that you see calcium in coronary arteries in dual-energy that you don't
see off a standard x-ray. At the very least…the detection of calcium should prompt a radiologist to alert
a referring physician to the possibility of coronary artery disease in a patient with chest pain” (Forrest,
2007).
Unfortunately, with all new technologies, the benefits do not come without some tradeoffs. There are
some disadvantages with each dual-energy radiography system that are important to note. The
drawback of the single exposure CR dual-energy system is the lower signal-to-noise ratio (SNR) due to
the small separation of energy between the two images (Ogden, 2011). According to Davidson (2007),
“When the exit intensity is low, the fluctuations are relatively large compared to the x-ray intensity.
The SNR is therefore low.” A low SNR means increased quantum mottle which means a grainier
appearance of the image. Consequently, due to the lower SNR, the resulting image has a lower image
quality when compared to a dual exposure system. In addition, CR has lower detector efficiency when
compared to the flat-panel detector (Ogden, 2011).
Although the dual exposure DR system has better image quality due to a high SNR, the dual exposure
system suffers from a time delay between the two exposures. This time delay of up to 230
milliseconds of acquisition and read out time of the flat panel detector could result in voluntary or
involuntary motion from the patient that could cause a motion artifact on the images (Ogden, 2011).
According to Pal (2006), a time “delay between the two exposures can cause artifacts, which appear as
black or white lines, and are most obvious on the bone-selective images.” An example of a motion
artifact is clearly shown in the bone-only image below on the right. This motion artifact is most likely
due to cardiac motion (Ogden, 2011).
JULY 2013 | The Technigram | 24
Benefits of Dual-Energy… |
Furthermore, because two exposures are taken, there is the issue of increased patient dose. According
to Forrest (2007), a dual-energy chest x-ray exam may result in approximately 5% more radiation to
the patient when compared to conventional film-screen chest radiography. However, "given the
benefits of the (dual-energy) technology, [the extra] 5% amount of radiation is very well worth it”
(Forrest, 2007). As with any new technologies, continual research, trials and errors, feedback, and
improvements could help to decrease the aforementioned limitations of dual-energy subtraction
radiography.
With the numerous benefits offered by dual-energy subtraction radiography, the pressing question
that remains is: “why isn't dual-energy subtraction used more frequently?” (Forrest, 2007). One reason
may be that when this technology was available almost 20 years ago (Forrest, 2007), many hospitals
have not yet adopted digital systems so adding this new technology would demand a drastic change in
cost and protocols. Fortunately, dual-energy subtraction radiography is more accessible now that so
many hospitals have converted to using CR and DR systems. Nevertheless, like with any new changes,
implementing a modification in routine protocol and procedures of clinics and hospitals requires cost,
time, and adjustment. According to a director of cardiothoracic imaging in Cleveland, “one reason [for
the delayed acceptance of dual-energy imaging] is that busy radiologists may not want to add to their
already voluminous workload. Like anything, there is a learning curve; you have to look at a few more
images" (Forrest, 2007). The required change in workflow for the radiologists and other personnel in
the imaging department may be one of the main reasons not all hospitals have adopted this new
technology. With increasing knowledge of the added benefits associated with the use of this technique,
dual-energy subtraction radiography of the chest may eventually become a routine protocol in
hospitals in the future.
References
Davidson, R. A. (2007). Digital radiography and its limitations. (p. 62). Retrieved from
http://ses.library.usyd.edu.au/bitstream/2123/1932/5/05Chapter4.pdf
JULY 2013 | The Technigram | 25
Introducing: The C-Arm… |
Forrest, W. (2007, February 22). Dual-energy digital x-ray still looking for acceptance. Retrieved from
http://www.auntminnie.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=74720
Ogden, K. (2011). Dual energy radiography acquisition and processing. Informally published
manuscript, Radiology, Upstate Medical University, Syracuse, NY, Retrieved from
http://www.upstate.edu/radiology/education/rsna/radiography/dual/
Pal, S. (2006, February 24). Dual-energy subtraction x-ray offers powerful tool for depicting thoracic
abnormalities. Retrieved from http://www.auntminnie.com/index.aspx?
Introducing: The C - Arm and Its Importance in the Operating Room
By Aziza Fassil - City College of San Francisco
During my first day rotation into operating room, I wasn’t aware of anything because I was exploring
the activity in the room. Everyone had certain responsibility which needed to be accomplished to make
the surgery run smoothly form the surgeon to the circulating nurse including, of course, the x-ray
technologist.
I noticed the necessity of X-ray technologist in the OR suite which is making the workflow go
easy. Because the x ray technologist is responsible of using the C-arm machine that can be used to
acquire high-quality images to assist during pre-, intra-, and postoperative procedures. The images
can provide useful information about preoperative planning (if performed in the OR),
intraoperatively how the reduction and fixation can be guided, and postoperatively, to check the
quality of fixation. Without the guidance with an x-ray imaging during the surgery, many things may go
wrong. The surgeon must decide whether to operate again or leave the fixation as is. Revision surgery
at this time carries an increased risk of complications, such as sepsis, thromboembolic disease, and
anesthetic complications. There is therefore a tendency for surgeons to accept the suboptimal result in
order to avoid potential complications. There is also the problem of explaining to the patient why
he/she needs a second operation and why the problem was not detected at the time of the first
surgery.
Because of the importance of C arm in OR, not only the preoperative films taken under anesthesia in
the OR provide valuable and accurate information, but also at the end of a surgical procedure, the Carm can be used to screen the quality of the reduction and fixation. Therefore, I am more interested in
knowing the development of mobile C-arm systems from the first surgical systems to modern systems
such as the BV Pulsera with 3D rotational imaging.
The introduction of the image intensifier in the mid 1950’s opened up new perspectives in surgery
and interventional radiology. The mobile C-arm stand for use in surgery was developed by C.H.F.
Müller GmbH (the German Philips Medical Systems organization) and launched commercially in 1955.
It was the first system to be based entirely on the use of the image intensifier (Figure 1).
JULY 2013 | The Technigram | 26
Introducing: The C-Arm… |
Figure (1).The BV20 (1955)
The image intensifier and the X-ray tube were fixed opposite each other
on a semi- circular bow mounted on a mobile stand containing the
control desk. The bow could be rotated in a “propeller” movement and
could also slide through a sleeve, giving a virtually unlimited choice of
projections. In addition to fluoroscopy, the system could also be used for
conventional radiography by means of a cassette clipped to the front of
the image intensifier. The whole system formed a self-contained unit that
could be used anywhere in the hospital and required no connections to
other equipment. The principal application of the C-arm system was in
the operating room, and the device was generally referred to as a
“surgical system”, but it had several other applications, including the
examination of patients in bed.
Before the introduction of the BV20 “BV” as
the abbreviation of “Bildverstärker” (the German
for
“image
intensifier”), the only device available for X-ray examinations during
surgery was the “Cryptoscope” a hand-held viewer with a fluorescent
screen virtually unchanged since 1896 (Figure 2). The light intensity of
this device was very poor, requiring a period of dark adaptation. To
compensate, high X-ray doses were used, with the surgeon standing
unprotected in the X-ray beam. Detail studies required radiography on
film, resulting in delays while the films were developed.
In 1958, the BV20 was fitted
with an industrial TV chain. Fig 2: The hand-held
The addition of a television fluoroscope: virtually
camera
to
the
image unchanged from 1896 to 1956
intensifier was almost as
great a step forward as the introduction of the image
intensifier itself. With the original design, only one person
could view the image, and this was often from an awkward
position, with the viewer relaying information to the
surgeon while lying on the floor. With TV, the whole
surgical team could watch the X-ray image: the surgeon
The BV20 in use for nailing of the femoral neck was better informed and could perform the operation
“BV 20” Combination of Image Intensifier and
faster. The BV20 with TV was an instant success. The first
Television in Casualty Surgery
TV chain had no automatic gain control, requiring
continuous adjustment of the X-ray tube current, and was housed in a bulky separate cabinet.
However, within a short time, Philips developed a special transistorized TV chain, with automatic gain
control, that could be built into the mobile control unit of the BV20 (Figure 3).
JULY 2013 | The Technigram | 27
Introducing: The C-Arm… |
Further refinements
By 1960, a combination of technical
advances and feedback from the
medical profession had led to several
major improvements. The original bow,
consisting of two curved tubes, had
been replaced by a solid curved C-arm,
increasing the stability of the imaging
assembly, while the position of the
imaging components was adjusted to
improve the counterbalancing. A
horizontal displacement movement was
Fig 3: image intensifier/TV systems
also added, allowing the beam to be
moved in the transverse direction without moving the stand itself. The imaging components
themselves were also upgraded. The older 5" image intensifier was replaced by a more advanced 6"
version, and the original 75 kV 20 mA tank unit was replaced by the compact 90 kV 20 mA Practix tank
unit.
BV21
In 1966, new regulations in Germany and the United States required
substantial modifications to the BV20 design. In the first place, there
were more stringent requirements for asepsis and for use in the
presence of flammable gases. In the United States, there was an
additional demand for positioning the image intensifier under the
table. The new system was provided with a separate mobile stand
for the control desk and monitor, and all electrical components were
provided with a gas- and vapor-tight housing. The mechanical design
was improved with a smooth-running sleeve for the C-arm, an
increased range of movements, a sturdier mobile base, and neater
cabling. A new TV chain was introduced in which the automatic gain
control was replaced by automatic regulation of the X-ray tube
current. To meet the specific demands of the German market, a
Fig 4: BV 21
version was introduced in which the tube voltage was also
regulated. The American demand for positioning the image intensifier under the table increased the
minimum height of the C-arm, creating problems in the rest of the world, where hospital beds and
operating tables did not always have the necessary clearance. Accordingly, a separate version of the
BV21 was manufactured for the American market.
BV22
In the early 1970’s, a series of new technological developments led to the decision to undertake a
second major redesign of the BV system: the BV22 (Figure 4). The most obvious improvement was the
JULY 2013 | The Technigram | 28
Introducing: The C-Arm… |
possibility of replacing the lens optics between the output of the image intensifier and the camera tube
with a direct fiberoptic coupling, resulting in a much more compact construction in order to eliminate
internal reflections, with a consequent improvement in contrast, and no problems with focusing.
Other, equally significant changes were the development of a new, advanced TV chain, and a
significantly improved image intensifier design with a highly sensitive cesium iodide input screen.
A useful feature for the surgeon is the ability to rotate the X-ray image to match the orientation of the
body, regardless of the position of the image intensifier. In earlier BV systems this was achieved by
rotating the TV camera, but this could not be done with the fixed fiberoptic coupling. This remotecontrolled rotation had the added advantage of eliminating the problem of maintaining sterility when
rotating the camera above the operating table. The BV22 also had provision for the Scopofix: a
simple video disc recorder that allowed the last image of a fluoroscopic series to remain
displayed on the screen, so that the surgical team could examine details without subjecting the patient
to further radiation.
BV25
From 1976 a new generation of surgical C-arm units: the BV25
(Figure 5). The BV25 was intended to incorporate all the experience
gained in 25 years of mobile C-arm development, and rapidly became
the BV25 set the industry standard until well into the 1990’s, but its
success also led to a demand for specialized versions with a larger
image intensifier: the BV212 with a 12" field of view, introduced in
1994, and the BV300 with a choice of 12" or 9" field of view
introduced in 1996.
The new generation
At the end of the 1990’s, a further major upgrade took place. It was
decided that the BV range would be continued in three versions, each
meeting a specific need, and in 2001 Philips introduced the new BV
family:
Fig 5: BV 25
• BV Libra
• BV Endura
• BV Pulsera
All three systems comprise a mobile stand carrying the C-arm and X-ray controls, and a mobile view
station with advanced digital image handling and processing capabilities. A Modality Performed
Procedure Step validates that scheduled examinations have taken place, while a Storage Commit
feature ensures that images cannot be erased from the mobile view station before they have been
completely and correctly transferred to the hospital image storage system.
JULY 2013 | The Technigram | 29
Introducing: The C-Arm… |
Fig 6: The BV Libra
BV Libra
Fig 7: The BV Endura
Fig 8: The BV Pulsera
This is compact system for routine procedures, such as orthopedic exams and basic angiography with
subtraction and re-masking (Figure 6). A 9" triple-mode image intensifier provides the input for
Charge Coupled Device (CCD) technology, with a patented anamorphic lens to provide maximum
resolution with an outstanding level of coverage and detail visualization.
BV Endura
The BV Endura (Figure 7) is available with a choice of a 9" or 12" triple-mode image intensifier. The 9"
version can handle all routine procedures, while the 12" version provides greater all-round coverage
for special and interventional procedures, including stenting, grafting and abdominal exams. It can be
used with the latest storage and archiving features, including memory stick, DVD and Advanced DICOM
functionality.
BV Pulsera
The BV Pulsera (Figure 8) is a mobile C-arm system specifically designed for interventional
procedures. Like the BV Endura, it is available with a choice of a 9" or 12" triple-mode image
intensifier, but has the added benefit of a high output rotating anode X-ray tube. Typical applications
include:
• Cardiovascular exams
• Bolus Chase exams
• Neurosurgical exams
• Urological exams
• Cholangiography
• Pain management
• Orthopedic exams
JULY 2013 | The Technigram | 30
Introducing: The C-Arm… |
The high output is sufficient to penetrate virtually any patient, showing fine details even in the
steepest projections, while the pulsed exposure mode at up to 25 frames per second produces superb
image contrast and eliminates movement artifacts in cardiovascular examinations. One of the most
demanding cardiovascular procedures is the implantation of biventricular pacemakers, where the
combination of long fluoroscopy times and visualization of fine details requires the utmost in heat
management.
The Future
The BV Pulsera 3D-RX (Figure 9) combines the properties of the standard
BV Pulsera with a motorized “propeller” movement of the C-arm, providing
a sweep of over 200° in 3 seconds for high-quality 3D image acquisition.
The system is fitted with a 12" (31 cm) image intensifier for acquisition of
sufficiently large volumes. The images are displayed on one of the high
brightness monitors on the mobile viewing station, enabling optimal
intraoperative guidance. During the scan, a large series of X-ray projection
images is acquired. The images are corrected for mechanical focus shift and
electromagnetic distortion. The series of projection images is reconstructed
into a 3D volume. The image data set is acquired using the standard cardio
X-ray mode of the BV Pulsera. The effective dose per scan is estimated to be
Orthopedic surgery: wrist
0.1 to 0.2 mSv at normal image quality, which is the setting used for the
patient study. This corresponds to a background radiation dose of about one
month. The resulting images provide a three-dimensional view of the region of interest, and can also
yield CT-like cross-sections.
The C-arm is an excellent tool for obtaining this information,
never the less it has some disadvantages, including image
distortion, radiation exposure, and the need for timeconsuming adjustments of the C-arm during the surgery. The
new method would deal with these shortcomings with a
computer-based system that adds to the existing C-arm system.
It would provide the surgeon with a real-time view of the
insertion process, and could improve the accuracy and speed of
certain surgical procedures.
References:
Judith Tan. (June 06,2010). The Straits Times. Retrieved from
http://www.healthxchange.com.sg/News/Pages/C-Arm-X-raymachine-helps-hospital-staff-save-lives.aspx
Fig 9: The BV Pulsera 3D-RX (available
from Fall 2006).
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)( received: August 14,
2001)( updated: April 7, 2009)( verified: April 2009) Retrieved from
http://clinicaltrials.gov/ct2/show/NCT00022802
JULY 2013 | The Technigram | 31
Forensic Radiography |
R.Aarnink, V. Schwier V. (2005). Technology News: Surgery. Medicamundi 2002; 46,3: 58.
Retrieved from Image Intensifier and Television in Casualty Surgery. Medicamundi
1961; 7: 133-136. Wright JDW, Todd D, Waktare JEP, Hughes S, Abell C. Biventricular Pacemaker
Implantation with the BV Pulsera. Medicamundi 49,3: 12-20.Retrived from
http://www.healthcare.philips.com/pwc_hc/main/about/assets/Docs/medicamundi/mm_vol50_no1/
05_Aarnink.pdf
Forensic Radiography
By Joshua Sorenson, City College of San Francisco
With the increased popularity of the modern television crime procedural programs such as CSI, there
has been an increased public interest in the use of forensic science (Romans) for the purpose of solving
crime. “Forensic science is a unique scientific discipline requiring its practitioners to have, in addition
to technical skills, communication skills and awareness of the role of the scientist in our criminal
justice system.” (Romans) Evidence of forensic science can be found in the records of ancient people
from thousands of years ago. These early cultures recognized the importance of the knowledge and
opinion of the forensic medical professional in the realm of legal opinion on the matters of such crimes
as the use of drugs for poisoning and the examination of wounds in different body locations (Thali,
Brogdon & Viner, 2002). In the early sixteenth century forensic medicine began to emerge as its own
separate discipline and in 1871, the first medical examiner system was established in Massachusetts
(Thali, Brogdon & Viner, 2002). This modern medical examiner system established numerous
disciplines and subspecialties. Among those is Forensic Radiology, which is the “performance,
interpretation and reportage of those radiological examinations that have to do with the courts and/or
law” (Thali, Brogdon & Viner, 2002). The applications of forensic radiology are broad and can range
from determination of identity, evaluation of injury and death, to use in criminal and civil litigation
(Thali, Brogdon & Viner, 2002) and the forensic radiologist is considered an essential member of the
forensic team.
When Roentgen discovered his “new kind of ray” in 1895, “its potential application in the field of
medicine and forensic investigations was immediately recognized”(Adams). The first known forensic
radiograph taken was thought to be by a Professor A.W. Wright of Yale University in February 1896.
The victim was a rabbit purchased from a local market. The radiograph required over 1 hour of
exposure but the cause of death was determined in the image as buckshot (Adams). The first court
case in North America that used an x-ray took place in Montreal, Quebec in late 1895. The defendant
was accused of the attempted murder of another man. The victim was quite alive but had been shot in
the leg and there the bullet remained (Romans). A physical examination had failed to retrieve the
bullet and without physical evidence, the defendant’s conviction was unlikely. But thanks to the newly
invented technique of x-ray, the bullet was located after a 45 minute exposure, lodged in the victims
JULY 2013 | The Technigram | 32
Forensic Radiography |
Tibia and Fibula. The bullet was removed and the x-ray image was submitted to the court as evidence.
The defendant was found guilty of attempted murder and sentenced to 14 years (Romans). The first
civil case in the United States that used x-rays as a form of evidence was in a malpractice suit in
December 1896 (Adams). In addition, x-rays were quickly used in customs to investigate suspicious
packages and examine luggage. Radiography was also used in one of the earliest forms of
fingerprinting suspects. In this process, the fingertips were coated with a lead tetroxide dust and were
then exposed to soft x-rays that then produced fine fingerprints (Thali, Brogdon & Viner, 2002). Today
radiography is one of the most commonly used methodologies in the collection of forensic evidence
has been shown to be useful in the detection of non-violent crime, injury that resulted in death, and
violent crime alike (Adams).
Non-violent crimes do not use physical force and cause physical or emotional pain. These include
crimes such as smuggling, larceny, and forgery (wiki). As early as 1897, French customs utilized
fluoroscopic x-ray equipment to apprehend smugglers and contraband (Romans). In the realm of a
non-violent crime such as smuggling, the use of improved drug wrapping techniques have been seen to
undermine the techniques used to thwart the smuggler through the use of blood and urine testing and
clinical observation. Radiologic examination has become increasingly important in exposing criminals
who smuggle drugs through the use of body cavities or the digestive system (Algra, Brogdon, and
Marugg). These smugglers that use the alimentary canal to transport illegal drugs such as cocaine,
heroin, amphetamines, hashish and marijuana are known as “body packers”(Romans). By wrapping
the narcotics in a small form of latex packaging such as condoms, the fingers of surgical gloves, or even
small balloons, the smuggler can stow as many as 214 packages inside his or her body (Romans). This
is where forensic radiography of the smuggling suspect comes into play. The radiographic appearance
of the smuggled packages “is of regularly shaped round or oval foreign bodies outlined by thin, bowshaped air shadows, sometimes in multiple layers” (Gherardi, Baud, Leporc, Marc, Dupeyron &
Diamant-Berger, 1988). CT is also useful with the administration of water-soluble iodinated contrast to
confirm and exclude body packages (Romans).
In cases of larceny, radiography has not been an effective tool in revealing swallowed precious stones
as diamonds and other precious stones are not radiopaque enough to be visualized inside the human
body (Romans). However, fake gems are radiopaque and therefore radiography can be used to
determine fraud in the sale of fake gems (Romans). In another area of larceny, The Israeli National
Police have implemented a radiographic technique to uncover auto theft (Thali, Brogdon & Viner,
2002). “Using an industrial x-ray machine, they have found that properly positioned radiographs
readily display the telltale welding scams of the forged vehicle identification on a stolen automobile.”
(Romans)
Radiography has also been extremely useful in the detection of art fraud. For centuries, the canvas and
wood panels that artists used were very expensive. Artists could not afford to throw out their canvas
or wood panels if mistakes were made in the painting process. Because of the expense many artists
painted over their creations repeatedly. Some oil paintings may actually contain as many as seven
layers of paintings (Romans). These are called underpaintings and occur in both legitimate and forged
paintings. Radiographing has been proven effective in authenticating genuine art from forgeries by
being able to visualize the various layers of underpaintings (Romans).
JULY 2013 | The Technigram | 33
Forensic Radiography |
In the realm of violent crime, forensic radiology has been proven useful in the evaluation of injuries
sustained by the deceased (Romans). There are a variety of indicators that the forensic team may look
for in the evaluation of postmortem injury. For example, in the radiologic evaluation of gunshot
wounds radiography is used in many ways including: Bullet localization; Bullet caliber; Number of
bullets present; Information concerning the angle and direction of fire; and the type of weapon used
(Romans). In cases of suicide by firearm, careful forensic examination can distinguish suicide from
accidental injury or homicide (Romans). In the evaluation of osseous injuries and determining whether
or not the death was intentional, the forensic team may see a variety of indicators revealed by
radiograph. Body parts are manipulated to replicate standard radiographic positions and are imaged
in AP, lateral and oblique projections, similar to clinical radiography (Romans). Certain common types
of fractures are known to be the result of accidents while other types of injuries are considered nearly
impossible to normally sustain. The arrangement and direction of a skull fracture can show the point
and direction of impact on the skull (Adams). In addition, certain types of fractures are known to be
defensive in nature and radiographic evidence of multiple injuries in various stages of healing may be
an indicator of chronic physical abuse.
In mass fatality events such as the Oklahoma City bombings, the terrorist attacks at the World Trade
Center on September 11, and recent tsunamis and hurricanes the radiographer will be part of the
formal forensics team not for the purpose of evaluating trauma to the deceased, but for the purpose of
identifying the deceased (Adams). In these situations it is preferred, when possible, that all remains be
identified scientifically with methods such as radiographs rather than visual identification (Romans).
Following the attacks of September 11, 2001, forensic radiology was a key component in the system of
casualty identification that required the joint effort of both military and civilian forensic experts
(Romans).
Because imaging plays a vital role in determining both the cause of death and the identification of the
victim, the radiographer should make every effort to produce images as close to the true AP/PA and
lateral projections as possible (Adams). The radiographer must remember that the remains of the
deceased individual may be found in every conceivable condition, from early soft tissue stages to
advanced skeletonization. As a result, technical factors may have to vary from subject to subject. It is
imperative that the radiographer has a thorough understanding of the factors governing image
formation (Adams). The radiographer must also remember that for an image to be used in a court of
law, it must be judged to be admissible as evidence. To be admissible the radiographer must be able to
testify in a court of law that any specific image was produced by him or her and at the date and time
recorded on the image. The radiographer must ensure that all data and identifiers are recorded on the
images including date, time and correct anatomical markers. If any data or markers are not correct
then the image should be repeated (Adams).
From its earliest beginnings in ancient civilizations to the modern forensics of today, forensic
radiography has played a tremendously important part in the prosecution of criminal activity and
identification of the victims of criminal activity and disasters. When the x-ray was discovered over 100
years ago, it was immediately seen as having the potential to be an important part of the scientific
forensics team and continues to be an absolutely invaluable forensics tool today. But that tool is only
as valuable as the skills of the radiographer that is a part of the modern forensics team.
JULY 2013 | The Technigram | 34
Forensic Radiography |
References
http://www.cewebsource.com/coursePDFs/forensicRadiology.pdf
Romans, L. (n.d.). Retrieved from http://www.cewebsource.com/coursePDFs/forensicRadiology.pdf
(Romans)
http://www.eradimaging.com/site/article.cfm?ID=657
Adams, N. (n.d.). Retrieved from http://www.eradimaging.com/site/article.cfm?ID=657
Algra, Paul, Byron Brogdon, and Roque Marugg. "Role of Radiology in a National Initiative to Interdict
Drug Smuggling: The Dutch Experience." http://www.ajronline.org. N.p., n.d. Web. 4 May 2013.
(Algra, Brogdon, and Marugg)
(n.d.). Retrieved from http://wiki.answers.com/Q/What_is_considered_a_non_violent_crime
(wiki)
Thali, M., Brogdon, B. G., & Viner, M. (2002). Forensic radiology. CRC Press.
Gherardi, R., Baud, F., Leporc, P., Marc, B., Dupeyron, J., & Diamant-Berger, O. (1988). Detection of drugs
in the urine of body-packers.
JULY 2013 | The Technigram | 35
Osteoarthritis
Osteoarthritis |
By Vinny Sharma, SRT - Cañada College
For the past two years, I have had clinical assignments within the Cañada College
Radiologic Technology Program. Recently, I noticed more pathological incidences than most acute
healthcare settings due to lifestyle, experiences, and age. A pathology that is easily distinguishable on x-rays
is osteoarthritis. To assist in the diagnosis osteoarthritis, special consideration is necessary in patient
positioning and x-ray tube angle. As a student, I have noticed that technologists are performing knee
protocol x-rays in a variety of ways; however, do all the different positions show the same pathology or are
they providing false positive diagnosis? The findings below are an excerpt of the research I conducted to
answer this question for my pathology course. I will reference mostly knee joint osteoarthritis and
considerations a technologist must be aware of in positioning the patient. I will discuss my research findings
on the best radiographic positions for knee x-rays to show knee joint space narrowing and knee osteoarthritis
(OA).
The most common method to diagnose patients for OA is diagnostic x-rays.
Indicators of osteoarthritis includes narrowed joint space, sclerosis, osteophytes, and subchondral cysts.3
Recognizing the radiographic appearance of osteoarthritis is very important in diagnosing and treating a
patient. Since I am a student, I began to establish a relationship with the radiologists to obtain a greater
understanding of what they are looking for to make an accurate diagnosis. I discussed with the radiologists
positioning and technique as part of my image quality analysis. Dr. was kind enough to share some of his
insights and experiences in helping me understand how to highlight knee joint space narrowing without
compromising the study. Dr. told me he looks for four things to identify osteoarthritis, which include joint
space narrowing, osteophytes, subchondral cysts, and sclerosis. Below are findings for the proper
positioning of knee protocol x-rays at my presently assigned hospital in California.
When taking diagnostic
x-rays the radiographer must be aware of patient
positioning, patient capabilities, technical factors,
tube/part/IR relationship, and pathology. Osteoarthritis is a
pathological loss of joint cartilage and reactive new bone
formation.2
Thus patient positioning is vital to the
accuracy and detail of the anatomy for patients suffering
from this condition. For my research, I have mostly
discussed the knee, but the same principles apply to the
shoulder, hip, and ankles. For knees, doctor said he looks
first at the knee tunnel projection because it is an excellent
Fig 51
indicator for joint space narrowing (Fig D in all images).
The second projection he looks at is the skyline or patella view because he wants to see evidence of bone
spurs and joint space narrowing.
JULY 2013 | The Technigram | 36
Fig 61
A regular AP weight-bearing knee projection is not a
good indicator of joint space narrowing because the tibial
plateau is slanted from anterior to posterior in a
downward manner bringing the tibia and femoral
condyles closer together (fig 5A, 6A, 7A). The preferred
projections are B, C, and D because the anterior and
posterior margins of the tibial plateau are superimposed.
Fig D, the tunnel view, is excellent because it matches
the central ray to the joint while still maintaining the
weight-bearing load to the center of the femur and tibia
(blue arrowheads fig 5). If you can contain the load
transmission to the center of the bone, it makes it a lot
easier for the patient to maintain position and obtain an
accurate picture of the joint space narrowing.
After reviewing the above pictures, it is obvious that there are
many radiographic considerations to osteoarthritis. I have tried
using pictures to illustrate the importance of positioning and
technique with reference to this pathology. It is also important
to remember that positioning a particular patient in a consistent
manner allows the radiologist to make an accurate diagnosis.
Therefore, radiologic technologists must try to use the PA
Tunnel View throughout the patients imaging procedures, rather
than alternating from PA to AP Tunnel Views. Using this
methodology, consistent positioning will allow the radiologist
to compare past images to the current x-ray images with greater
accuracy, allowing different radiologists to conduct the
readings.
Fig 71
Works Cited
2. Buckland-Wright, C. (2005) [Graphic Illustration of 4 Knee Projections and Descriptions]. Best Practice
& Research Clinical Rheumatology, 20(1), 39-55. Retrieved from
http://www.sciencedirect.com/science/article/pii/S1521694205001002
3. Eisenberg, R. L., Johnson, N. M. (2012). Comprehensive Radiographic Pathology (5th ed.). St
Louis, Missouri.
15. Harvey, S. (2009, Jun 23). Osteoarthritis. Retrieved from
http://adam.about.net/reports/000035_4.htm
JULY 2013 | The Technigram | 37
Treatment of Intracranial Aneurysms… |
Treatment of Intracranial Aneurysms through Endovascular Stents and
Detachable Embolization Coils
By Joseph Choo, SRT - City College of San Francisco
Aneurysms account for 85% of subarachnoid hemorrhages 1.
Treatment of intracranial aneurysms
has improved significantly in recent decades 2. Occlusion of the aneurysm can be achieved through the
placement of stents within the lumen of the parent artery, the deployment of platinum coils within the
aneurysm, or surgical clipping across the aneurysm neck. Interventional procedures performed in the
I.R. suite include endovascular stent-grafting within the parent artery adjacent to the aneurysm, and
the embolization of the aneurysm by the placement of platinum coils. Both of these procedures are
performed under fluoroscopic guidance and involve the use of contrast media to highlight the vessels
under examination during the angiographic procedure. The focus of this essay will be on
interventional radiographic procedures used to occlude aneurysms, with an emphasis on the two most
prominent interventional procedures in use today: coil embolization and endovascular stent-grafting.
Aneurysms occur when the wall of an artery expands due to increased intra-arterial pressure within
the lumen of the vessel. If left untreated, the vessel wall may rupture leading to hemorrhage.
Intracranial aneurysms were once believed to be of congenital origin, but have now been found to
develop later on in life 1. The two principal types of aneurysm are saccular and fusiform. Saccular
aneurysms normally develop at sites of arterial branching 1, for example the bifurcation of the common
carotid artery into the internal and external carotid arteries. The mechanism of formation of a
saccular aneurysm involves a gradual weakening of the arterial wall due to the high pressure of blood
flowing across the bifurcation. Fusiform aneurysms generally form in the arteries of older patients 3
and are secondary to plaque buildup around the lumen of the artery. Aneurysmal dissections occur
when a tear in the inner lining of the arterial wall introduces blood into the inner and middle layers of
the artery. This is referred to as an intimal tear and results in the build-up of blood between the tunica
intima (inner arterial layer) and the tunica media (middle arterial layer). A fourth type of aneurysm is
referred to as a pseudoaneurysm, or false aneurysm, and occurs when blood leaks from an artery into
the surrounding tissue 4. Pseudoaneurysms may result from puncturing the vessel wall during cardiac
catheterization, or during a non-selective or selective arteriogram. In addition to iatrogenic causes,
pseudoaneurysms may also result from trauma 5 (e.g., stab wounds, gunshot wounds, or car accidents).
Aneurysms tend to occur more frequently in women and in conjunction with the following diseases:
polycystic kidney disease, various connective tissue disorders (e.g., Marfan’s syndrome), and
fibromuscular dysplasia 5. Based on autopsies and angiograms, aneurysms affect 2%-6% of the
population 5. A family history of an aneurysm will also increase the incidence if two or more firstdegree relatives have had an aneurysm in the past 1. Risk of aneurysmal subarachnoid hemorrhage is
dependent on the size of the aneurysm, its location, and any prior history of subarachnoid hemorrhage
5. A bleed into the subarachnoid space may result in further leakage of blood into the surrounding
parenchymal structures and the ventricular system of the brain. In order to prevent this from
occurring the use of either endovascular stent-grafts or coils placed within the aneurysm sac may be
necessary to preclude the possibility of subarachnoid hemorrhage.
JULY 2013 | The Technigram | 38
Treatment of Intracranial Aneurysms… |
The gold standard for diagnosing aneurysms is catheter angiography. During catheter angiography the
superficial femoral artery is punctured using the Seldinger technique, and a guidewire is inserted into
the lumen of the artery being examined. If the superficial femoral artery cannot be used to access the
vessel with the questionable abnormality, the right axillary artery will be punctured. The right axillary
artery is preferred to the left axillary artery because it allows access to all intracranial and extracranial
vessels without the need to make any sharp turns with the guidewire and catheter. A catheter is then
threaded over the guidewire and the guidewire is removed under fluoroscopic guidance. Contrast
media is then injected into the lumen of the artery and pictures are taken during the run to note any
abnormalities in the vessel wall, and to determine the size and type of the aneurysm if one is detected.
CT angiography has been steadily replacing catheter angiography in the evaluation of aneurysms and
of patients with intracranial hemorrhage 5. CTA exams are performed using multidetector CT scanners
during the administration of contrast media. The superior contrast resolution delivered by CT
angiography illustrates clearly why it is supplanting catheter angiography as the modality of choice
when it comes to detecting and diagnosing aneurysms and intracranial hemorrhages. According to
studies conducted comparing the efficacy of CT angiography with digital subtraction angiography, CTA
and MRA have reported sensitivities of up to and exceeding 95% in the detection of aneurysms greater
than 3 mm in size 6. However CT angiography is limited in evaluating aneurysms that are less than 3
mm in size.
The treatment of aneurysms has progressed significantly since the introduction of detachable
embolization coils in the 1990s. First introduced by the Italian neurosurgeon Guido Guglielmi,
detachable embolization coils (or GDC: Guglielmi detachable coil) use a soft detachable platinum coil
delivered through a microcatheter positioned within the aneurysm. Occlusion of the aneurysm is
achieved by applying a low positive direct electric current to the delivery guidewire which attracts
white blood cells, red blood cells, platelets, and fibrinogen to the positively charged coils within the
aneurysm 7. The use of detachable coils is limited when dealing with wide-necked aneurysm because
of the risk of coil migration or protrusion of the coils into the parent artery 8.
Endovascular stent-grafts can also be used in tandem with detachable embolization coils to occlude the
aneurysm and prevent leakage into the aneurysmal sac. Once the embolization coils have been
deposited within the aneurysm, an endovascular stent is placed within the lumen of the parent artery
and over the neck of the occluded aneurysm.
The combined treatment of aneurysms with endovascular stents and detachable embolization coils is a
minimally invasive procedure whose true value may be greatest in those patients to whom surgical
repair (via clipping of the aneurysmal neck) may be contraindicated or has failed.
1
Jan van Gijn, Richard S Kerr, Gabriel JE Rinkel. (2007). Subarachnoid hemorrhage. Lancet, 369, 306-18.
Civan Islak, et al. (2002). Bare Stent-Graft Technique: A New Method of Endoluminal Vascular
Reconstruction for the Treatment of Giant and Fusiform Aneurysms. American Journal of Neuroradiology,
23, 1589-1595.
2
JULY 2013 | The Technigram | 39
3
Linda J. Bagley. (Jan-Feb 2009). Aneurysms—All you need to know. Applied Radiology, pp. 6-18.
UC Davis Vascular Center. (2013). Pseudoaneurysm evaluation and treatment. Retrieved from
http://usdmc.ucdavis.edu/vascular/lab/exams/pseudoaneurysms.html.
5
Stephen M. Kubaska III, et al. (2003). Internal Carotid Artery Pseudoaneurysms: Treatment With the
Wallgraft Endoprosthesis. Journal of Endovascular Therapy, 10, 182-189.
6
Chappell ET, Moure FC, Good MC. (2003). Comparison of Computed Tomographic Angiography and
Digital Subtraction Angiography in the Diagnosis of Cerebral Aneurysms. Neurosurgery, 52, 624-631.
7
Guido Guglielmi, et al. (1991). Electrothrombosis of saccular aneurysms via endovascular approach.
Journal of Neurosurgery, 75, 8-14.
8
Gunther E. Klein, et al. (1997). Posttraumatic Extracranial Aneurysms of the Internal Carotid Artery:
Combined Endovascular Treatment with Coils and Stents. American Journal of Neuroradiology, 18, 12611264.
4
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