dasar - dasar radiologi metabolik

7/25/2019 Dasar - Dasar Radiologi Metabolik

1/92

Dr. Donny Susilawardhono SpRad

Bagian Radiologi RSAL Ramelan


2/92

Secara tidak langsung, sebagian masih bisamemakai plain foto musculoskeletal

Secara langsung untuk melihat morfologi darikelenjar dengan USG

CT Scan

MRI

Scintigraphy


3/92

Secara langsung, dengan melihat kelenjaratau struktur anatomis primer tertentu tgtpatofisiologinya,

Secara tidak langsung dengan melihat efekyang ditimbulkan


4/92

Tulang mengandung : Ekstraseluler material :

Matriks organik atau jaringan osteoid (collagenfibril yang mangandung mucopolysaccharide

ground subastance) Inorganic crystalline component (hydroxyapatite

atau calcium phosphat)

Celluler material : Osteoblast (induced bone formation) Osteoclast (induced bone resorption)

Osteocyte (inactive cell)


5/92


6/92

Increased Radiodensity Increased Radiolucency

Secondaryhyperparathyroidism

Osteoporosis

Renal osteodystrophy

Osteomalacia

Hyperphosphatasia Rickets

Idiopathic hypercalcemia Scurvy

Paget disease

Primaryhyperparathyroidism

Osteopetrosis* Hypophosphatasia

Pycnodysostosis* Hypophosphatemia

Melorheostosis*

Acromegaly

Hypothyroidism Gaucher disease

Mastocytosis Homocystinuria

Myelofibrosis

Osteogenesis imperfecta*


7/92

Increased Radiodensity Increased Radiolucency

Myelofibrosis Osteogenesis imperfecta*

Gaucher disease(reparative stage)

Fibrogenesis imperfecta

Fluorine poisoning Cushing syndrome

Intoxication with lead,bismuth, or phosphorus

Ochronosis (alkaptonuria)

Osteonecrosis Wilson disease(hepatolenticulardegeneration)

Hypogonadism


8/92


9/92

Osteopenia

Osteoporosis

Deficient matrix

Normal

mineralization

Osteomalacia

Normal matrix

Deficient

mineralization

Hyperparathyroidism

Normal matrix and

mineralization

Increased resorption


10/92

Kualitatif Imaging Techniques forMeasurement Bone Mineral Density

Foto polos CT Scan

Scintigraphy

MRI

Radionuclide and X-RayTechniques Single Photon

Absorptiometry

Dual PhotonAbsorptiometry

Computed TomographyTechnique Quantitative Computed

Tomography Quantitative Ultrasoud

Techniques


11/92

Radioluscent defect pada cortical bone yang

mencerminkan akumulasi nonmineralizedosteoid tissue

Characteristic finding dari osteomalacia


12/92


13/92


14/92

Generalized metabolic bone disease,characterized by insufficient formation orincreased resorption of bone matrix thatdecreased of bone mass


15/92

Genetic Congenital) Endocrine

Osteogenesis imperfecta, Gonadal dysgenesis,

Turner syndrome (XO),

Klinefelter syndrome (XXY),

Hypophosphatasia,

Homocystinuria,

Mucopolysaccharidosis

Gaucher disease

Anemias:

Sickle-cell syndromes

Thalassemia

Hemophilia Christmas disease

Hyperthyroidism Hyperparathyroidism Cushing syndrome Acromegaly

Estrogen deficiency Hypogonadism Diabetes mellitus Pregnancy


16/92

Deficiency States Neoplastic

Scurvy Malnutrition

Anorexia nervosa

Protein deficiency Alcoholism

Liver disease

Myeloma Leukemia Lymphoma

Metastaticdisease


17/92

Iatrogenic Miscellaneous

Heparin-induced Dilantin-induced

Steroid-induced

Involutional(senescent/postmenopausal)

Amyloidosis Ochronosis Paraplegia Weightlessness

Idiopathic


18/92

Immobilization (cast) Disuse

Pain

Infection

Reflex sympathetic dystrophy syndrome (Sudeckatrophy)

Transient regional osteoporosis: Transient osteoporosis of the hip

Regional migratory osteoporosis Idiopathic juvenile osteoporosis

Paget disease (hot phase)


19/92

Target sitesof

Osteoporosis


20/92

Periarthricular Porosis


21/92

Osteoporosis

with

fracture


22/92


23/92

Principal Compressive Group Extend from medial cortex of femoral neck to superior part of femoral head Major weight-bearing trabeculae In normal femur are the thickest and most densely packed Appear accentuated in osteoporosis Last to be obliterated

Secondary Compressive Group Originate at the cortex, near the lesser trochanter

Curve upward and laterally toward the greater trochanter and upper femoralneck Characteristically thin and widely separated

Principal Tensile Group Originate from the lateral cortex, inferior to the greater trochanter Extend in an arch-like configuration medially, terminating in the inferior

portion of the femoral head

Secondary Tensile Group Arise from the lateral cortex below the principal tensile group Extend superiorly and medially to terminate after crossing the middle of the

femoral neck

Greater Trochanter Group Composed of slender and poorly defined tensile trabeculae Arise laterally below the greater trochanter

Extend upward to terminate near the greater trochanter's superior surface


24/92


25/92


26/92


27/92


28/92

Ricket (anak-anak) dan osteomalacia(dewasa)

Faulty mineralization (calcification) of bonematrix


29/92

Nutritional Deficiency

Vitamin D Dietary

Insufficient sunlight Impaired synthesis

Calcium Phosphorus

bsorption bnormalities

Gastric surgery

Intestinal surgery (bypass) Gastric disorders (obstruction)

Intestinal disorders (sprue)


30/92

Renal Disorders

Renal tubular disorders Proximal tubular lesions (failure of absorption of inorganic phosphate,

glucose, amino acids) Distal tubular lesions (renal tubular acidosis)

Combined proximal and distal tubular lesions

Renal osteodystrophy

Miscellaneous

Associated with Wilson disease

Fibrogenesis imperfecta

Fibrous dysplasia Neurofibromatosis Hypophosphatasia

Neoplasm


31/92

Target site

OfRickets


32/92

Infantile Rickets Vitamin D resistant Rickets


33/92

6 -18 months Generalized demineralisation of skeleton

Tend to bowing deformities (in weight bearingbones, when begin to stand and walk)

Restless & sleep poorly Closing of fontanella is delayed

Softening of cranial vault (craniotabes)

Enlargement of cartilage at costochondral

junction (rachitic rosary) Serum calcium dan phosphorous low

ALP increased


34/92

Radiologic landmark : Observed in metaphyse and epiphyse

Widening of the growth plate

Cupping and flaring metaphysis, which appear

disorganized and frayed Similar changes seen in secondary ossification

centers of ephypise

Bones become radiolucent

Loss of sharpness at the periphery

Bowing deformities


35/92

8-year-old boy with untreated dietary rickets shows osteopenia of thebones, widening of the growth plates of the distal radius and ulna, and

flaring of the metaphyses, all typical features of this condition


36/92

4-year-old boy shows wideningof the growth plates of thedistal femur and proximal tibiasecondary to lack of

mineralization in the provisionalzone of calcification.

Note also cupping and flaringof the metaphyses.


37/92

3-year-old girl with vitamin D-deficiency rickets showsincreased bone radiolucency,widening of the growth plates,

cupping and flaring of themetaphyses, and blurring of theoutline of the secondaryossification centers, allradiographic hallmarks of thiscondition.

Note also bowing of the tibia andfibula, a frequent feature ofrickets


38/92

Pathofisiologi sama dgn Ricket Proses terjadi setelah pertumbuhan tulang

terjadi

Seringkali terjadi ok faulty absorption arivitamin D larut lemak di GIT yang sekunderok malabsorption syndrome


39/92

Histologically, osteomalacia is characterized by excessive quantities ofinadequately mineralized bone matrix (osteoid) coating the surfaces oftrabeculae in spongy bone and lining the haversian canals in the cortex.

Radiographically, osteomalacia presents with generalized osteopenia,and multiple, bilateral, and often symmetric radiolucent lines are seen inthe cortex perpendicular to the long axis of the bone; they are referredto as pseudofractures or Looser zones.

These defects, which represent cortical stress fractures filled with poorlymineralized callus, osteoid, and fibrous tissue, are common along theaxillary margins of the scapulae, the inner margin of the femoral neck,the proximal dorsal aspect of the ulnae, the ribs, and the pubic andischial rami

The condition, described by Milkman and known as Milkmansyndrome, is a mild form of osteomalacia in which the pseudofracturesare particularly numerous.


40/92


41/92

Generalized osteitis fibrosa cystica or Recklinghausendisease of bone Overactivity of the parathormone-producing parathyroid

glands. Increased production of this hormone is secondary to

either gland hyperplasia (9% of cases) or adenoma (90%);

only in very rare instances (1%) does hyperparathyroidismoccur secondary to parathyroid carcinoma. Excessive secretion of parathormone, which acts on the

kidneys and on bone, leads to disturbances in calcium andphosphorus metabolism, resulting in hypercalcemia,hyperphosphaturia, and hypophosphatemia.

Renal excretion of calcium and phosphate is increased,and serum levels of calcium are elevated, while those ofphosphorus are reduced. Serum levels of alkalinephosphatase are also elevated.


42/92

Hyperparathyroidism can be divided into primary,secondary, and tertiary forms. The classic form ofthe disorder,

Primary hyperparathyroidism, is marked byincreased secretion of parathormone resulting

from hyperplasia, adenoma, or carcinoma of theparathyroid glands. S Secondary hyperparathyroidism is caused by

increased secretion of parathyroid hormone inresponse to a sustained hypocalcemic state.

Tertiary hyperparathyroidism represents atransformation from a hypocalcemic to ahypercalcemic state.


43/92

Primary hyperparathyroidism is usuallyassociated with hypercalcemia.

Women are affected about three times asoften as men, and the condition is most often

seen in the patient's third to fifth decade


44/92


45/92

The parathyroid glands escape from theregulatory effect of serum calcium levels.

Patients in whom this escape occurs areusually receiving kidney hemodialysis; they

are considered to have autonomoushyperparathyroidism


46/92

Target Site

Of

Hyperparathyroidism


47/92

Generalized osteopenia; subperiosteal,subchondral, and cortical bone resorption;brown tumors; and soft-tissue and cartilagecalcifications.

Intracortical resorption is manifested bylongitudinal striations, a finding known astunneling, which can be most clearlyappreciated on magnification studies

In the skull, there is a characteristic mottlingof the vault, which yields a salt-and-pepperappearance


48/92

loss of the lamina dura around the toothsocket, which normally is seen as a thin sharpwhite line surrounding the peridentalmembrane that attaches the tooth to bone


49/92

Generalized increase in bone density occurs,particularly in younger patients. In the spine, this change is reflected in dense

sclerotic bands seen adjacent to the vertebral endplates, giving the vertebrae a sandwich-likeappearance (rugger-jersey spine)

However, it must be kept in mind in the evaluation ofhyperparathyroidism that osteosclerotic changes mayalso occur as a manifestation of healing,eitherspontaneously or as a result of treatment.

Deposition of calcium in fibrocartilage, articular

cartilage, and soft tissue is common, and vascularcalcifications are much more frequent in patients withsecondary hyperparathyroidism


50/92

Primary

hyperparathyroidism


51/92

Primary

Hyperparathyroidism

Subchondral bone resorption ispresent at the head of the secondmetacarpal (arrow).

Note also subperiosteal resorptionat the proximal and distal phalanges(open arrows).


52/92

Primary

Hyperparathyroidism

resorption of theacromial end of the rightclavicle


53/92

Primary Hyperparathyroidism

decrease in the overall density of the bone and a granular appearance ofthe vaultthe so-called salt-and-pepper skull


54/92

Primary

Hyperparathyroidism

Brown tumor


55/92

Secondary

Hyperparathyroidism

17-year-old boy with chronic

renal failure developedsecondaryhyperparathyroidism

Rugger-Jersey spine


56/92

Secondary Hyperparathyroidism

48-year-old woman shows evidence of soft-tissue and vascularcalcifications, characteristic findings in secondary hyperparathyroidism.

Note also diffuse osteopenia.


57/92


58/92

Evaluasi terbaik dengan modalitas MRI Kedua dengan CT Scan

Foto polos : Ballooning sella

Double floor


59/92

Sella Measurement

Children


60/92

Sella Measurement - Adult


61/92

Double floor Baloning sella tursica


62/92


63/92


64/92

Sisi kiri Sella Sisi kanan Sella


65/92

MRI MRI


66/92

CT Scan CT Scan


67/92

Tidak tampak jelas pada foto polos biasa Dengan foto polos, tampak sebagai soft

tissue area, lihat airway

USG Grayscale dan Powerdoppler - sensitif

MRI Sensitif

CT Scan spesifik

Scintigraphy


68/92

USG dengan doppler Mudah, murah, praktis

Mengevaluasi kista dan nodule dengan baik

CT Scan Evaluasi morfologis dengan baik

MRI Evaluasi morfologis terbaik

Scintigraphy


69/92


70/92


71/92


72/92


73/92


74/92

ThoracicGoiter


75/92

Sulit ditemukan Modalitas yang paling sensitif adalah MRI

Tampak jelas bila membesar


76/92


77/92


78/92


79/92

Modalitas yang dapat dipakai adalah USG, CTScan, MRI

Perlu diperhatikan ukuran, homogenitasparenchyme dan ductus pancreaticus


80/92


81/92


82/92


83/92

Diterbitkan sebagai buku yang bernama : ARadiographic Standard of Reference for theGrowing Hand and Wrist

Disiapkan untuk : The United States National,

Health Examination Survey Diterbitkan oleh : The Press of Case Western

Reseve University, Chicagi, 1950 Dibuat oleh :

S.Idle Pyle PhD Alice M. Waterhouse MD William Walter Greulich PhD


84/92

Vicente Gilsanz, M.D., Ph.D. Department ofRadiology, Childrens Hospital Los Angeles,, 4650Sunset Blvd., MS#81, Los Angeles, CA 90027

Osman Ratib, M.D., Ph.D., Department of

Radiology, David Geffen School of Medicine atUCLA, 100 Medical Plaza, Los Angeles, CA 90095

ISBN 3-540-20951-4 Springer-Verlag BerlinHeidelberg New York, Library of Congress

Control Number: 2004114078 Springer-Verlag Berlin Heidelberg New York

Terbaru th 2005


85/92

Bone age assessment is frequently performedin pediatric patients to evaluate growth andto diagnose and manage amultitude ofendocrine disorders and pediatric syndromes

Bones in the hand and wrist are the mostsuitable indicators of skeletal maturity duringthe different phases of postnataldevelopment.

Vicente Gilsanz Osman RatibHand Bone Age


86/92

Six major categories and highlighted inparentheses the specific ossification centers thatare the best predictors of skeletal maturity foreach group: 1) Infancy (the carpal bones and radial epiphyses);

2) Toddlers (the number of epiphyses visible in the longbones of the hand);

3) Pre-puberty (the size of the phalangeal epiphyses); 4) Early and Mid-puberty (the size of the phalangeal

epiphyses);

5) Late Puberty (the degree of epiphyseal fusion); and, 6) Post-puberty (the degree of epiphyseal fusion of the

radius and ulna).



87/92

Late Puberty

Females: 13 years to 15 years of age Males: 14 years to 16 years of age

Assessments of skeletal maturity in this stage are primarilybased on the degree of epiphyseal fusion of the distal phalanges.Fusion of the epiphyses to the metaphyses in the long bones ofthe hand tends to occur in an orderly characteristic pattern, asfollows: 1) Fusion of the distal phalanges; 2) Fusion of the metacarpals; 3) Fusion of the proximal phalanges; and, 4) Fusion of the middle phalanges.

Because of their morphologies, the epiphyseal fusion of themetacarpals is poorly depicted by radiographs and greaterattention is, therefore, placed on the degree of fusion at thephalanges. Since all carpal bones have now attained their earlyadult shape, they are of less value for determination of bone age.



88/92

Depiction, from left to right, of the rogressivedegrees of fusion of the epiphyses to themetaphyses,which usually begins at the centerof the physis


89/92

Assessments in latestages of pubertyand sexualmaturityare based on the

degree ofepiphyseal fusion ofthe distal phalanges(first) and on thedegree of fusion ofthe middlephalanges (second)


90/92

8-month-old boy 10-month-old boy


91/92

10-year-old boy 14-year-old boy


92/92

dasar - dasar radiologi metabolik

Documents