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Chest radiology part 3


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  • 1. Gamal Rabie Agmy, MD, FCCPProfessor of Chest Diseases, Assiut UniversityERS National Delegate of Egypt
  • 2. Bulla<1mmwall>1cmsizePneumatocele<1mmwallstaph.infectionHoneycombing<1cmsizemultipleequalCyst1-3mmwall1-10cmsizeCavity>3mmwallAnysizeCavitarylesionsoflung
  • 3. BullaDefinition•Thin-walled–less than 1 mm•Air-filled space•In the lung> 1 cm in size and up to 75% of lung•Walls may be formed by pleura, septa,or compressed lung tissue.•Results from destruction, dilatation andconfluence of airspaces distal to terminalbronchioles.
  • 4. •Bullous disease may be primary or associatedwith emphysema or interstitial lung disease.• Primary bullous lung disease may be familialand has been associated with Marfans, EhlersDanlos, IV drug users, HIV infection, andvanishing lung syndrome.•Bullae may occasionally become very largeand compromise respiratory function. Thushas been referred as vanishing lung syndrome,and may be seen in young men.
  • 5. Upper lobe Bulla
  • 6. Lower lobe Bulla
  • 7. A: Xray shows bilateral bulla.B: CT shows bilateral bulla.C: CT after bullectomy.
  • 8. Pneumatocele is a benign air containing cyst of lung, withthin wall < 1mm as bulla but with different mechanism Infection with staph aureus is the commonest cause ( lesscommon causes are, trauma, barotrauma) lead to necrosisand liquefaction followed by air leak and subpleuraldissection forming a thin walled cyst.
  • 9. •Honeycombing is defined as multiple cysts < 1cm in diameter,withwell defined walls, in a background of fibrosis, tend to formclusters and is considered as end stage lung .•It is formed by extensive interstitial fibrosis of lung with residualcystic areas.
  • 10. A cyst is a ringshadow > 1 cm indiameter and up to10 cm with wallthickness from 1-3mm.
  • 11. Thin walled cysts of LAM
  • 12. A cavity is > 1cmin diameter, and itswall thickness ismore than 3 mm.
  • 13. •A central portion  necrosis and communicate to bronchus.•The draining bronchus is visible (arrow). CT (2 mm slice thickness)shows discrete air bronchograms in the consolidated area.Mechanism
  • 14. 1. Site
  • 15. A cavity in apicoposterior segment of left upper lobe
  • 16. 2.NumberMultiple cavities:1. Aspiration.2. TB3. Fungal.4. Metastatic.5. Septic emboli.6.Wegners granulomatosis
  • 17. Multiple cysts of metastasisfrom squamous cellcarcinoma.Multiple thick wall cavities fromadenocarcinoma of right lung
  • 18. Irregular , nodular inner lining of thick wall abscessMalignant cavity.3. Thickness andirregularity
  • 19. 4. eccentricMalignant
  • 20. 5. Relation to lymphnode enlargement
  • 21. 6. Contents
  • 22. •Arrow head  Crescent sign.•Black arrows  Fibrotic bands surrounding cavity(Fibrocavitary TB).
  • 23. Primary Lung Cancer• Thick wall• Shaggy lumen• Eccentric cavitation
  • 24. |Squamous Cell Carcinoma LungLUL massThick walled cavityEccentric location of cavity
  • 25. Fungous BallLong standing cavityContaining round density (A)Mobile densityAdjacent pleural reaction (B) - characteristic of aspergilloma
  • 26. Cavitating MetastasisMultipleThin Walled CavitiesCancer Cervix
  • 27. Lung Cancer / Squamous CellMass densityAnterior segment of LULThick wall cavitation
  • 28. SquamousCell CarcinomaAnterior segment of LULThick wallFluid levelFull hilum
  • 29. SquamousCell Carcinoma LungThick wallIrregular lumenleft hilar LN
  • 30. Etiology:Cavity can be encountered in practically most lungdiseases.Common diseases and their characteristics include:Primary Lung CancerThick wallShaggy lumenEccentric cavitationNecrotizing PneumoniaLung abscessGravity dependant segmentsThick wallAir-fluid levelsTuberculosisSuperior segmentsInfiltrate aroundBilateralFungal infectionsAspergillusFungous ballSub acute invasive aspergillosisMetastatic diseaseThin walled (Squamous cell)Thick wall (Adenoma)
  • 31. Diffuse Alveolar PneumoniaThe most common causes for diffuse alveolar pneumonia are:PneumocystisCytomegalovirus
  • 32. Consolidation RightUpper Lobe /Density in right upper lungfieldLobar densityLoss of ascending aortasilhouetteNo shift of mediastinumTransverse fissure notsignificantly shiftedAir bronchogram
  • 33. Necrotizing Pneumonia / Lung Abscess / AspirationSuperior segment RLL dense pneumoniaProgression / Cavity
  • 34. Radiation PneumoniaPost Mediastinal RadiationAir space disease (air bronchogram)Over radiation port (vertical and paramediastinal)BilateralProgression to fibrosis
  • 35. Round PneumoniaRound densityShorter doubling timeAir bronchogramThe most common causes for round pneumonia are:FungalTuberculosis
  • 36. Consolidation / LingulaDensity in left lower lung fieldLoss of left heart silhouetteDiaphragmatic silhouette intactNo shift of mediastinumBlunting of costophrenic angleLateralLobar densityOblique fissure notsignificantly shiftedAir bronchogram
  • 37. Consolidation Left Lower LobeDensity in left lower lung fieldLeft heart silhouette intactLoss of diaphragmatic silhouetteNo shift of mediastinumPneumatoceleOne diaphragm only visibleLobar densityOblique fissure not significantlyshifted
  • 38. Left Upper Lobe ConsolidationDensity in the left upper lung fieldLoss of silhouette of left heart marginDensity in the projection of LUL in lateral viewAir bronchogram in PA viewNo significant loss of lung volume
  • 39. Vague density right lower lung fieldIndistinct right cardiac silhouetteIntact diaphragmatic silhouetteDensity corresponding to RMLNo loss of lung volumeRML pneumonia
  • 40. Consolidation Right Upper Lobe /Air BronchogramDensity in right upper lung fieldLobar densityLoss of ascending aorta silhouetteNo shift of mediastinumTransverse fissure not significantly shiftedAir bronchogram
  • 41. PneumoperitoneumAir under diaphragm
  • 42. Elevated Diaphragm"Note pneumoperitoneumSupradiaphragmatic massCan be mistaken for elevated diaphragmPellets
  • 43. Alveolar Cell Carcinoma - ProgressionOld film on leftSolitary pulmonary nodule resectedOnset of diaphragmatic paralysisProgression to multicentric acinar nodules
  • 44. Hyperlucent LungFactorsVasculature: DecreaseAir: ExcessTissue : DecreaseBilateral diffuseEmphysemaAsthmaUnilateralSwyer James syndromeAgenesis of pulmonary arteryAbsent breast or pectoral musclePartial airway obstructionCompensatory hyperinflationLocalizedBullaeWestermarks sign : Pulmonary embolus
  • 45. Agenesis of Left Pulmonary ArteryMissing vascular markings in left lungLeft hilum not seenEntire cardiac output to right lung
  • 46. Missing Right Breast"Hyperlucent" right base secondary to missing breast.
  • 47. Unilateral Hyperlucent LungLeft Upper Lobe ResectionLeft lung hyper lucentLeft hilum pulled upNo abnormal density
  • 48. Pneumomediastinum
  • 49. Alveolar ProteinosisBilateral diffuse alveolar diseaseButterfly patternMedullary distributionAir bronchograms
  • 50. Adult Respiratory Distress SyndromeNon-cardiogenic pulmonary edemaDistinguishing characteristics:Normal size heartNo pleural effusion
  • 51. Foreign Body Aspiration
  • 52. Chest Tubes
  • 53. Achalasia ofesophagus• Inhomogeneouscardiac density:Right half moredense than left• Density crossingmidline (right blackarrow)• Right sided inlet tooutlet shadow• Right para spinal line(left black arrow)• Barium swallowbelow: Dilatedesophagus
  • 54. Aortic Aneurysms• Location– Ascending / Anterior mediastinum– Arch / Middle mediastinum– Descending / Posterior mediastinum• Characteristics– Mediastinal "mass" density– Extrapleural– Calcification of wall• Dissecting– Inward displacement of calcified intima– Wavy margin– Inlet to outlet shadow– Left pleural effusion
  • 55. Dissecting AneurysmMediastinal wideningInlet to outlet shadowon left sideRetrocardiac: Intactsilhouette of left heartmarginPulmonary arteryoverlay sign: Densitybehind left lower lobeWavy margin
  • 56. Pulmonary Metastsis
  • 57. Colon in front of liver
  • 58. Lymph Nodes
  • 59. Thrombotic Pulmonary Embolism
  • 60. Thrombotic Pulmonary Embolism
  • 61. Thrombotic Pulmonary Embolism
  • 62. Embolism Nonthrombotic Pulmonary
  • 63. Embolism Nonthrombotic Pulmonary
  • 64. Embolism Nonthrombotic Pulmonary
  • 65. Embolism Nonthrombotic Pulmonary
  • 66. Embolism Nonthrombotic Pulmonary
  • 67. of PE Diagnostic Algorithm1. Patients with normal chest radiographic findingsare evaluated with a perfusion scan and, ifnecessary, an aerosol ventilation scan. Patientswith normal or very low probability scintigraphicfindings are presumed not to have pulmonaryemboli .2-Patients with a high-probability scan usuallyundergo anticoagulation therapy. All other patientsshould be evaluated with helical CT pulmonaryangiography, conventional pulmonaryangiography, or lower-extremity US, depending onthe clinical situation
  • 68. of PE Diagnostic Algorithm3-Patients with abnormal chest radiographic findings, areunlikely to have definitive scintigraphic findings. Thesepatients undergo helical CT pulmonary angiography as wellas axial CT of the inferior vena cava and the iliac, femoral,and popliteal veins. If the findings at helical CT pulmonaryangiography are equivocal or technically inadequate (5%–10% of cases) or clinical suspicion remains high despitenegative findings, additional imaging is required.4-Patients who have symptoms of deep venous thrombosisbut not of pulmonary embolism initially undergo US, whichis a less expensive alternative. If the findings are negative,imaging is usually discontinued; if they are positive, thepatient is evaluated for pulmonary embolism at thediscretion of the referring physician.
  • 69. Developmental Anomalies
  • 70. Developmental Anomalies
  • 71. Developmental Anomalies
  • 72. Developmental Anomalies
  • 73. Developmental Anomalies
  • 74. Pulmonary A-V Malformations
  • 75. Pulmonary Edema
  • 76. Pulmonary Artery Aneurysms
  • 77. Pulmonary Artery Aneurysms
  • 78. Pulmonary –Systemic Communications
  • 79. Pulmonary –Systemic Communications
  • 80. Pulmonary –Systemic ommunications
  • 81. Abnormal Systemic Arteries
  • 82. Pulmonary Hypertension
  • 83. Pulmonary Hemorrhage
  • 84. Pneumomediastinum
  • 85. Potential Sources of Mediastinal AirIntrathoracicTrachea and major bronchiEsophagusLungPleural spaceExtrathoracicHead and neckIntraperitoneum and retroperitoneum
  • 86. Radiographic Signs of PneumomediastinumSubcutaneous emphysemaThymic sail signPneumoprecardiumRing around the artery signTubular artery signDouble bronchial wall signContinuous diaphragm signExtrapleural signAir in the pulmonary ligament
  • 87. Mediastinal Cysts
  • 88. The CT features of benignmediastinal cyst are(a) a smooth, oval or tubular mass with a well-defined thin wall that usually enhances afterintravascular administration of contrastmaterial,(b) homogeneous attenuation, usually in therange of water attenuation (0–20 HU),(c) no enhancement of cyst contents, and(d) no infiltration of adjacent mediastinalstructures.
  • 89. Cysts that contain serous fluid typically havelong T1 and T2 relaxation values, whichproduce low signal intensity on T1-weightedMR images and high signal intensity on T2-weighted images.
  • 90. Because cysts containing nonserousfluid can have high attenuation at CT,they may be mistaken for solidlesions. MR imaging can be useful inshowing the cystic nature of thesemasses because these cysts continueto have characteristically high signalintensity when imaged with T2-weighted sequences regardless of thenature of the cyst contents
  • 91. Radionuclide imaging can be helpful indetecting functioning thyroid tissue(iodine-123 or I-131) or parathyroidtissue (technetium-99m sestamibi) inthe mediastinal cystic mass . gallium-67 scintigraphy may show increasedradiotracer uptake in the cysticmalignancy owing to necrosis such aslymphoma or metastatic carcinoma.
  • 92. Ultrasonography (US) can be useful inevaluating a mass adjacent to thepleural surface or cardiophrenic angle.At US, the benign cysts typicallyappear as anechoic thin-walledmasses with increased throughtransmission
  • 93. Bronchogenic Cysts
  • 94. Duplication Cyst
  • 95. Pericardial Cyst
  • 96. Meningocele
  • 97. Thymic Cysts
  • 98. Cystic Teratoma
  • 99. Lymphangioma
  • 100. Cystlike Lesions
  • 101. •Mediastinal Pancreatic Pseudocyst
  • 102. Mediastinal Abscess