gia tri xq qui uoc

Gi tr cGi tr cc c k k thuthut t X quang qui X quang qui c c

Trong Trong hhnh nh nh nh hhc Y khoa c Y khoa ngngy nayy nay

Bc s Nguyn Vn Cng

TTYK Medic. 254 Ha Ho. TPHCM.

LLch sch s h hnh nh nh nh hhc c Y khoaY khoa

1895 1895 Roentgen Roentgen ttm ra tia m ra tia X X c c gigii Nobel i Nobel 19011901: : l l phng phng phphp p duy nhduy nht t tto o hhnh nh nh nh chchn n oon y khoa t n y khoa t cho n thp nin cho n thp nin 7070

ThThp nin p nin 1960 1960 nguyn nguyn l l hhi m i m ((tt m my Radar trong y Radar trong II thII th chichinn) ) c nghin cc nghin cu trn u trn ngngi vi vi i ssng siu m ng siu m (Richardson (Richardson 19121912))

John Wild c coi l cha ca SAYK (1949)

LLch sch s h hnh nh nh nh hhc Y khoac Y khoa

ThThp nin p nin 19701970 ra ra i i mmy cy ct lt lp ip in n toton CT scan vn CT scan vi i gigii Nobel i Nobel 19791979 cca a

Cormack Cormack v v Hounsfield.Hounsfield.

LLch sch s h hnh nh nh nh hhc Y khoac Y khoa

Paul C. LauterburPaul C. Lauterbur phpht minh ra ct minh ra cng ng hhng tng t 19711971, , n n 20032003 c c gigii Nobel i Nobel

Raymond Damadian with a Patient in early MRI scanner, 1978

HINH Y HO C HAT NHN (Nuclear medicical imaging)

John Lawrence

Nguyn tNguyn tcc

"As Low As Reasonably Achievable""As Low As Reasonably Achievable"(ALARA)(ALARA) : : LiLiu thu thp nhp nht t t t c c 11 ccch hch hp p ll..

As Low As Reasonably PracticableAs Low As Reasonably Practicable(ALARP):(ALARP): LiLiu thu thp nhp nht t kh kh thi thi 11 ccch hch hp p ll

V V Primum non nocere Primum non nocere ((u tin u tin l l khng khng

c c llm m hhi)i)

Vi nh nghaVi nh ngha

X X quangquang qui qui cc (Conventional X ray):(Conventional X ray):hnhhnh 1 1 bb phnphn cc thth cc tiatia X X xuynxuyn qua qua nn bb phnphn toto nhnh:: BaBa tngtng quangquang + + phimphim (SFR: screen film (SFR: screen film

radiography)radiography) TmTm toto nhnh (Imaging plate) (Imaging plate) vv mymy qutqut (CR: (CR:

Computed radiography).Computed radiography). BngBng toto nhnh trctrc tiptip (DR: Direct radiography).(DR: Direct radiography).CcCc hnhhnh uu gingging nhaunhau trntrn nguynnguyn tctc chocho hhnhnh

22D D theotheo thangthang xxmm..

Cc hu du ca X quang qui cCc hu du ca X quang qui c

CT scanCT scan vi cc lt ct theo trc ngang.vi cc lt ct theo trc ngang. DBTDBT: Digital breast tomosynthesis chp hnh v : Digital breast tomosynthesis chp hnh v

k thut s tng hp hnh theo ct lp c ink thut s tng hp hnh theo ct lp c in Cone beam CTCone beam CT ((CC--arm CTarm CT) ) tia X hnh chp vi tia X hnh chp vi

DR to nh v s l in tonDR to nh v s l in ton: : ch yu cho nha ch yu cho nha khoakhoa, , vvng ng u mu mt ct c..

EOSEOS h thng X quang qut khe h thng X quang qut khe trtrc dc c th c dc c th (Georges Charpak Nobel (Georges Charpak Nobel 19921992).).

Digital Breast Tomosynthesis

Cone beam CT

Chp XChp X--quang qut quang qut khe (Slot scan) dc khe (Slot scan) dc ton b c th ng ton b c th ng thi thi 2 2 chiu thng chiu thng v nghing vi liu v nghing vi liu tia X cc thp t tia X cc thp t

th ng.th ng.

SterSterEOSEOS: : Phn mm Phn mm ti to hnh nh ti to hnh nh 33DD

EOS chu p toa n thn vi ca c s o t ng do ma y tinh cung c p.

1414

PHN TCH HNH PHN TCH HNH NHNHM M X QUANG QUI X QUANG QUI CC


C gi tr vng c th c tng phn t C gi tr vng c th c tng phn t nhinnhin Phi (kh, dch (tim, mch mu, trung tht), Phi (kh, dch (tim, mch mu, trung tht),

xng)xng) Bng (xng, kh trong rut, dch ca tng Bng (xng, kh trong rut, dch ca tng

c)c) Xoang mtXoang mt H xngH xng


Li dng nguyn tc ny nhiu k thut Li dng nguyn tc ny nhiu k thut bm thuc tng phn nhn to vo cc bm thuc tng phn nhn to vo cc b phn ca c th kho st:b phn ca c th kho st:

ng tiu ha c bariumng tiu ha c barium H niu, h mt, huyt qun, tuyn mang H niu, h mt, huyt qun, tuyn mang

tai, l d c cht Iodetai, l d c cht Iode Vi b phn dng kh tri, carbonicVi b phn dng kh tri, carbonic

XQ tuyn mang tai bm cht tng phan (Sialography)

Pneumoenchephalography

Retroperitoneal Pneumography

Cn quang ph qun (Bronchography) c thay th b ng CT scan

Cn quang rut non (Enteroclysis) c thay th

b ng ni soi vin nang

nh gi X quang qui cnh gi X quang qui c

CcCc kk thutthut cc gigi trtr kmkm

CcCc kk thutthut cc gigi trtr trungtrung bnhbnh..

CcCc kk thutthut cc gigi trtr tttt..

X quang qui c c Gi tr kmX quang qui c c Gi tr km

S no tm tn thng do chn thngS no tm tn thng do chn thng, , bbnh nh l l u bu bu u vvng ng u mu mt ct c..

Bng khng sa son tm tn thng cc tng Bng khng sa son tm tn thng cc tng c: gan, lch, thn, tyc: gan, lch, thn, ty

ng tiu ng tiu ho ho c cht tng phn barium.c cht tng phn barium. HH mmt bm thut bm thuc tng c tng phphn qua da hon qua da hoc c

uungng H niu c tim cht tng phn trong bnh l u H niu c tim cht tng phn trong bnh l u

bu.bu.

X Quang s noX Quang s no

Nn thay bNn thay bng CT, MRI s nong CT, MRI s noc gi tr rt tt trong bnh l chn thngc gi tr rt tt trong bnh l chn thng

Hnh CT kho st xoang cnh mi tt hn X quang qui c v cho thy r OMU (Ostial meatal unit) cn cho iu tr.

So snh Blondeau, Tomosynthesis v CT scan xoang

Gy xng mt phn loi Lefort 1,2,3 hnh CT v Xq qui c

Hnh tn thng no trn MRI

BBnh nh l l u bu bu u vvng ng u mu mt ct c

XQ XQ vvng ng s s mmt t gi tr kgi tr km.m. KhKho o sst t hhchch: : siu m tsiu m tt nht nht.t. U bU bu u vvng ng gigipp, , tuytuyn nn nc c bbtt, , taitai, ,

mmii, , hhngng, , hhu MRI u MRI l l PP PP c c chchn n llaa, , c c thth kkt ht hp vp vi siu mi siu m, , v v CT CT scan.scan.

Bng khng sa sonBng khng sa son

tm tn thng tng c nh gan, thn, lch, ty, sinh dc n

Carcinom t bo gan (HCC)Carcinom t bo gan (HCC)

Hnh XQ ng tiu ha c bariumHnh XQ ng tiu ha c barium

L k thut t c gi tr.L k thut t c gi tr. Chu x nhiu (chp ng phi lm Chu x nhiu (chp ng phi lm

fluoroscopy) chp nhiu giai on)fluoroscopy) chp nhiu giai on) Vi tng phn kp, gi tr cng hn ch.Vi tng phn kp, gi tr cng hn ch. Hin nay tt nht l ni soi (d dy, i Hin nay tt nht l ni soi (d dy, i

trng) v c th sinh thit nu cn.trng) v c th sinh thit nu cn. CT h tiu ha l CT h tiu ha l 1 1 k thut quan trng k thut quan trng

khng th thiu.khng th thiu.

D dy cn quangD dy cn quang

Ni soi d dyNi soi d dy

i trng cn quangi trng cn quang

M rng lng i trngM rng lng i trng V vch V vch i i trtrng bt ng bt

thucthuc

Dy vch ai trang

vchvch

CT CT i i trtrng bm ncng bm nc

CT CT i i trtrng bm kh hay ng bm kh hay ni soi ni soi i i trtrng ong o

HH mmtt

ChChch thuch thuc tng c tng phphn qua da n qua da (PTC: percutaneous transhepatic cholangiography)(PTC: percutaneous transhepatic cholangiography)

UUng thung thuc tng c tng phphn n ch chp p tti mi mt t (Oral cholecystogram)(Oral cholecystogram)

HiHin nay n nay c c ERCP ERCP (endoscopic retrograde (endoscopic retrograde cholangiopancreaticography)cholangiopancreaticography) ch ch yyu u c gi tr c gi tr vva cha chn n oon n v v iiu u trtr..

Chup tui mt do ung tng phan

Chup ng mt chi ch qua da PTC

U thn?

U thn 2 bn

Xquang trong bnh l khpXquang trong bnh l khp

Hnh X quang khng c gi tr kho st Hnh X quang khng c gi tr kho st khpkhp--khng thy c bao khp, sn khpkhng thy c bao khp, sn khp-- dy chng, dy gn vng anh khp.dy chng, dy gn vng anh khp.-- huyt qun vng khp.huyt qun vng khp.

Ch c nh khe khp bit gin tip cc Ch c nh khe khp bit gin tip cc cu trc trong khp.cu trc trong khp.

MRI l k thut tt nht kho st khp.MRI l k thut tt nht kho st khp.

MRI khp gi

Cc k thut c gi tr trung bnh.Cc k thut c gi tr trung bnh.

BBng khng sng khng sa a sosonn

Nh Nh nhnh

XQ ngXQ ngcc

X X quangquang bngbng khngkhng sasa sonson

ASP / au bng cp

ASP (+)

ASP (-)

Hi t doTc rutSi .

Siu mCT scan ()

X X quangquang bngbng khngkhng sasa sonson

ASP / au bng ko di

ASP (+)

ASP (-)

Cn quang bt thngHiu ng chon ch

Siu mCT scan

THNG TNG RNG

Tc rut

Nguyn do tc rut?

Lch v huyt qun vi ha

Sn ti mt

nh vi ha trong vim ty mn

Teratoma vng chu

Sn niu qun

Sn san h Vi ha ch m thn (Nephrocalcinosis)

Bnh l g?

HH niuniu KUB:KUB:

SiSi khngkhng cncn quangquang: (: (--)) SiSi cncn quangquang: : tyty kchkch thcthc, , vv trtr CT, SACT, SA

UIV:UIV: HnhHnh thithi: SA, CT: SA, CT ChcChc nngnng bibi tittit: : XX hnhhnh thnthn, CT, MRI, CT, MRI ChCh mm thnthn: (: (--)) NiuNiu qunqun, , thnhthnh bngbng quangquang, , tintin litlit tuyntuyn ((--))

Th n n c

Nh Nh nhnh

V l V l phphn mn mmm, , khkho o sst nht nh ss tng tng phphn tn t nhin m nhin m v v ggm m sm m si tuyi tuyn n v v m mm m, , khi khi c c vi vi ho l ho l bbnh nh ll..

MMy X quang y X quang chchp p nh nh c bic bitt c c Kvp thKvp thp p ((2828 Kv Kv l l max)max) mAs cao.mAs cao. t to tng o tng phphn ngn ngn.n.

L PP ch yu c chp nhn tm L PP ch yu c chp nhn tm sot K v.sot K v.

Mammo: Khi chon ch mt caoSiu m: Khi echo km, b a cung

CRM +

US +

FNAC +

42F.CRM: vi vi ha t m.SA: nang 2 vFNAC:carcinome tuyn

R MLO

CRM +

US

FNAC +

CRM: Khng xc nh r rngUS: Khi echo km, trn, tng m

CRM+/-US +/-FNAC +

Bn 55tUS: U v T, echo km, b u, d= 7 x 7mm +

Hch nch tri.CRM: khng pht hin bt thngFNAC: Carcinome tuyn Chn on nh Siu m + FNAC.

CRM US +FNAC +

Khuynh hng mi

Chp ct lp tng hp nh nh: digital breast tomosynthesis (DBT):

Gii quyt c im yu ca nh nh do s chng lp cc cu trc

Khuynh hng mi:Dng my siu m v t ng ABUS tm sot ung th v. (gii quyt s ty thuc vo ngi lm siu m)

AOCR 11th Hong Kong 2006

Gi tr cGi tr ca a nh nh nhnh

Theo Theo nhinhiuu nghinnghin ccuu nhunhu nhnh cc 1010--3030% % mm tnhtnh gigi..

CnCn cc ii cpcp vivi SA SA vv +++ +++ vava tt bboohhcc

MRI MRI chch ll PP PP hh trtr, , nnnn nhnh MRI MRI chochonhiunhiu dngdng tnhtnh gigi vava lunlun phphii chchchchgadolinium .gadolinium .

CT scan CT scan vv chuynchuyn bitbit hnghng KoningKoning cc FDA FDA chpchp thunthun ((20152015))

XQ phi: XQ phi:

TngTng phnphn tt nhinnhin tttt / x / x quangquang..

VngVng mm / X / X quangquang phiphi..

NnNn chpchp X X quangquang phiphi thngthng & & nghingnghing T T

7474March March 3030, , 20152015

PHN TPHN TCH HNH ACH HNH ANHNHCACAC VUC VUNG HAY BONG HAY BO SOSOT KHI T KHI OOC PHIMC PHIM

Tn thng u?

U phi T vng sau tim

U phi P?

U phi P!!

Bnh g?

U thc qun

Phnh MC ngc?

Thuyn tc phi: gi tr x quang phi=0

HHnh X quang nh X quang gi tr gi tr tttt

X X quangquang bbnhnh lyly xngxng..

XXcc nhnh tutuii xngxng

oo mmtt khokhongng xngxng (Bone Mineral (Bone Mineral Density)Density)

Xquang qui c trong bnh l xngXquang qui c trong bnh l xng

Hnh cn bn gip nhn ton th tn thng Hnh cn bn gip nhn ton th tn thng xng.xng.

Hot ng sinh hc & M hc ca tn Hot ng sinh hc & M hc ca tn thng.thng.

Vai tr cc k thut khc: Vai tr cc k thut khc: X Hnh xng: tm tn thng a X Hnh xng: tm tn thng a CT scan: lm tng k ton thnCT scan: lm tng k ton thn MRIMRI: : tng k ti tng k ti vvng: di cn nhy cc, mch mung: di cn nhy cc, mch mu Siu m: kho st phn mm, huyt qunSiu m: kho st phn mm, huyt qun

Enchondroma Enchondromatosis: Olliers disease

Sarcom xng huy vo xng xam lan phan mem.

Chondroblsatoma:khng tn cng.BN 16 tui ,v tr u xng, co vin x xng, vng giao tip hp,khng xm ln phn mm

Sarcom sinh xng: BN nam 15 tuoi. Huy xng dang moi an, vung chuyen tiep rong, huy vo xng xam lan phan mem, v tr au than xng.

Non ossifying fibroma

Osteosarcoma

Enchondroma Fibrous dysplasia

Gy trt chm xng i (Slipped capital epiphysis)

Trt xng nguyt (Lunar dislocation)

Gy xng cnh tay trn chy vi du di lch ng m cnh khp.

Vim dnh ct sng (Ankylosing spondylitis)

nh tunh tui xngi xng

SS sinhsinh: : chupchup tonton bb 1 1 taytay vv 1 1 chnchn

TT 3 3 ththngng nn trtrngng ththnhnh: : cc vava bbnn taytay

ththngng ((GreulichGreulich & Pyle)& Pyle)

TT 8 8 nn 13 13 tutuii: : thmthm khukhuuu taytay T/N T/N

((SauvegrainSauvegrain))

Test Test RisserRisser

PP Greulich & PylePP Greulich & Pyle

Cho bit din tin ca bnh vo ct sng

Girls BoysRisser Age Risser Age1 13.8 1 15.22 14.3 2 15.23 14.7 3 16.34 16.0 4 16.35 16.1 5 18.0

PP Sauvegrain: XQ khuu tay

Cho la tui 1-9

PP o mPP o mt t kho khong xng ng xng ((BMDBMD) ) hihin nayn nay

o hp thu nng lng kp X quang (o hp thu nng lng kp X quang (Dual Energy Dual Energy XR Absorptiometry)XR Absorptiometry) DEXADEXA

o hp thu Xquang bng hnh X quang o hp thu Xquang bng hnh X quang (Radiographic Absorptiometry)(Radiographic Absorptiometry) RARA

nh lng CLT (Quantitative CT)nh lng CLT (Quantitative CT) Siu m xng gt.Siu m xng gt. Nhn xt:Nhn xt:

QCT chnh xc nht, siu m gt khng n nh.QCT chnh xc nht, siu m gt khng n nh. DEXA & RA thng dng nht.DEXA & RA thng dng nht.

XQ manh nhom & cac xng ot gia ban tay c may ien toan x ly t ong.

OSTEOGRAM o loa ng xng RA (Radiographic Absorptiometry)

Ket qua Osteogram Da vao tuoi, gii tnh, chieu cao, can nang cua benh nhan, OsteoGram tnh ra :

- ty trong khoang xng BMD.

-ty so T (Ty so o lech chuan BMD cua BN so vi ngi tuoi 30)

-ty so Z (Ty so o lech chuan cua BN so vi ngi bnh thng cung la tuoi)

BN nam 54t, au nhc toan thn, v s nt vi ging hat gao lan toatrong c

n tng!!!

Cysticercosis

BN nam 54t au lng v au bng

n tng!!!

Kt LunKt Lun X X quangquang qui qui cc cc 120 120 tuitui HnhHnh nhnh hchc y y khoakhoa cc thmthm cccc kk thutthut mimi::

SiuSiu mm: : KhngKhng gygy nhimnhim xx, , realtimerealtime KhoKho stst tttt phnphn mmmm, , mchmch mumu (+++)(+++) cngcng, , hnghng dndn chcchc dd GiGi thnhthnh

CCtt llpp iinn totonn (CT san)(CT san) PhnPhn bitbit cc nhiunhiu mm HnhHnh ctct ngangngang TiTi toto aa dindin, , 33DD MchMch mumu (+++)(+++)

Kt LunKt Lun CngCng hnghng tt::

tngtng phnphn mm NhiuNhiu chuichui xungxung HH thnthn kinhkinh (++++) (++++) MM mmmm NhiuNhiu ngng dngdng mimi vv ss phtpht trintrin

Y Y hchc htht nhnnhn: : HnhHnh nhnh chcchc nngnng ChuynChuyn bitbit / / khngkhng chuynchuyn PhiPhi hphp CT, MRICT, MRI

Kt LunKt Lun X X quangquang qui qui cc vnvn ll chch nhnh hnghng uu trongtrong mtmt ss

bnhbnh ll:: TnTn thngthng xngxng HH hphp KhoKho stst ban ban uu trongtrong bngbng cpcp cucu

NhngNhng mtmt ss kk thutthut x x quangquang khngkhng ccnn giagia tr tr nhnh X X quangquang trongtrong chnchn thngthng ss -- mtmt CcCc kk thutthut cc barium barium caca ngng tiutiu haha.. HH niuniu cncn quangquang X X quangquang cccc khkhpp xngxng ttmm bbnhnh lyly khkhpp.. X X quangquang qui qui cc c c tngtng phphnn ccaa hh mmtt.. ....

NnNn cc thaythay thth bngbng cccc kk thutthut hinhin ii phuphu hhpp gigipp chch chocho bnhbnh nhnnhn hnhn

Xin cm n

X QUANGSIU M

MRI

CT SCAN

X HNH

BNH L

gia tri xq qui uoc

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