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For Alexander and Olivia For Elsevier Content Strategist: Jeremy Bowes Content Development Specialist: Helen Leng Project Manager: Julie Taylor Designer/Design Direction: Miles Hitchen Illustration Manager: Jennifer Rose Illustrator: David Gardner and Antbits Ltd CHAPMAN AND NAKIELNY’S GUIDE TO RADIOLOGICAL PROCEDURES Edited by Nick Watson MBChB MRCP FRCR Consultant Radiologist, University Hospital of North Staffordshire, Stoke-on-Trent; Senior Lecturer, Keele University Medical School, Keele, UK SIXTH EDITION Edinburgh • London • New York • Oxford • Philadelphia • St Louis • Sydney • Toronto 2014 © 2014 Elsevier Ltd. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the publisher (other than as may be noted herein). First edition 1981 Second edition 1986 Third edition 1993 Fourth edition 2001 Fifth edition 2009 Sixth edition 2014 ISBN 9780702051814 Ebook ISBN: 9780702054792 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. The publisher’s policy is to use paper manufactured from sustainable forests Printed in China Preface Radiological techniques continue to evolve as the result of a combination of many factors; particularly the on-going advances in imaging hardware and software technology, and the continued refinement of the physicochemical properties of intravenous contrast media. Successive editions of this Guide have reflected this constant progress and the consequent continual evolution of our diagnostic and therapeutic armamentarium which is a central feature of our specialty. Even in the five years since the previous edition of this Guide, many routine day-to-day examinations have changed led, in particular, by advances in CT scanner technology. The barium enema, the IVP, V/Q isotope scanning and many invasive catheter angiographic examinations have now largely been replaced by their CT-based equivalents. Similar changes are seen reflecting advances in MR and ultrasound technology and radiologists continue to take on an ever-increasing role in therapeutic interventions previously the domain of the surgeon. We set out to reflect these changes but retain the compact nature and accessible format and, therefore, the usefulness, of the Guide. All chapters have been thoroughly reviewed and, where appropriate, revised and rewritten to reflect current radiological practice, and a new chapter on patient consent has been added. As always, it is a difficult balance to ensure that current radiological practice is faithfully reflected but not to dismiss older techniques which may still be used in some centres or may continue to be required where there are contraindications to current preferred techniques such as MR imaging. It has been a great privilege to be involved with this Guide; the 2nd edition of which rarely left my side as a junior radiologist. I hope the book continues to be a valued resource for the current generation of radiology trainees. Nick Watson 2013 v Acknowledgements A number of new contributors have been involved in this latest edition to whom I am very grateful, but I would particularly like to acknowledge the work of previous contributors; J F C Oliff, F M Bryden, M S Moss and P C Thomas, whose chapters have been revised and updated. I am also very grateful for the help given by colleagues, particularly; Dr John Oxtoby for reviewing the Nuclear Medicine elements of chapters 1, 7, 8 and 16; and senior radiographer colleagues Phil Andrews and Peter Sutton for their input into chapter 8. I would like to acknowledge the great support I have had from Jeremy Bowes, Content Strategist, and Helen Leng, Content Development Specialist, at Elsevier. vi List of contributors Frances Aitchison MBChB FRCP FRCR Consultant Radiologist, City Hospital, Birmingham; Senior Clinical Lecturer, University of Birmingham, Birmingham, UK Chapters 1 and 2 Victor Cassar-Pullicino FRCR Consultant Radiologist, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry; Senior Clinical Lecturer, University of Birmingham, Birmingham, UK Chapters 12 and 14 Floriana Coccia MB ChB MRCPsych Consultant Psychiatrist, Heartlands Hospital, Birmingham, UK Chapter 20 Mark Cowling MRCP FRCR Consultant Radiologist, University Hospital of North Staffordshire, Stoke-on-Trent, UK Chapters 9 and 10 Hilary Dobson FRCP FRCP Consultant Radiologist, Clinical Director, West of Scotland Breast Screening Service; Honorary Clinical Senior Lecturer, University of Glasgow, Glasgow, UK Chapter 17 Colm Forde MBBCh FRCR Consultant Radiologist, Queen Elizabeth Hospital, Birmingham, UK Chapters 3 and 4 Jonathan Freedman MBChB MRCS FRCR Consultant Radiologist, Heartlands Hospital, Birmingham, UK Chapter 20 Peter Guest FRCP FRCR Consultant Radiologist, Queen Elizabeth Hospital, Birmingham; Senior Clinical Lecturer, University of Birmingham, Birmingham, UK Chapters 5 and 11 xii List of contributors Amit Herwadkar MBBS FRCR Consultant Neuroradiologist, Salford Royal Hospital, Salford, UK Chapter 13 Arun Jacob FRCR Consultant Radiologist, University Hospital of North Staffordshire, Stoke-on-Trent, UK Chapter 15 Zahid Khan MBBS DA FRCA FCCM FFICM Consultant Anaesthesia and Critical Care, Queen Elizabeth Hospital, Birmingham; Honorary Senior Clinical Lecturer, University of Birmingham, Birmingham, UK Chapters 18 and 19 Balashanmugam Rajashanker MRCP FRCR Consultant Radiologist, Manchester Royal Infirmary and St Mary’s Hospital, Manchester, UK Chapter 6 Polly Richards BA MBBS MRCP FRCR Consultant Radiologist, St Bartholomew’s Hospital, London, UK Chapter 16 Nick Watson MRCP FRCR University Hospital of North Staffordshire, Stoke-on-Trent; Senior Lecturer, Keele University Medical School, Keele, UK Chapters 7 and 8 xiii 1 General notes RADIOLOGY The procedures are laid out under a number of sub-headings, which follow a standard sequence. The general order is outlined below, together with certain points that have been omitted from the discussion of each procedure in order to avoid repetition. Minor deviations from this sequence will be found in the text where this is felt to be more appropriate. Methods A description of the technique for each procedure. Indications Appropriate clinical reasons for using each procedure. Contraindications All radiological procedures carry a risk. The risk incurred by undertaking the procedure must be balanced against the benefit to the patient as deduced from the information obtained. Contraindications may be relative (the majority) or absolute. Factors that increase the risk to the patient can be categorized under three headings: due to radiation; due to the contrast medium; due to the technique. Risk due to radiation Radiation effects on humans may be: • hereditary, i.e. revealed in the offspring of the exposed individual, or • somatic injuries, which fall into two groups: deterministic and stochastic. 1. Deterministic effects result in loss of tissue function, e.g. skin erythema and cataracts. If the radiation dose is distributed over a period of time, cellular mechanisms allow tissue repair. There is then greater tolerance than if the dose had been administered 1 Guide to radiological procedures all at once. This implies a threshold dose above which the tissue will exhibit damage because the radiation dose exceeds the capabilities of cellular repair mechanisms. 2. Stochastic effects refer to random