Chest radiology part 1

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Chest radiology part 1

  1. 1. Gamal Rabie Agmy, MD, FCCPProfessor of Chest Diseases, Assiut UniversityERS National Delegate of Egypt
  2. 2. L:LungR:RibT:TracheaAK:Aortic knobA:Ascending aortaH:HeartV: VertebraP: PulmonaryarteryS:Spleen
  3. 3. Missing Right Breast"Hyperlucent" right base secondaryto missing breast.Silicone Breast Implantation
  4. 4. Cancer BreastLarger right breastInverted nippleRadiation Fibrosis ofLungRight lung smallerRight hemithorax smallerParamediastinal fibrosis
  5. 5. Cervical Rib
  6. 6. Pleural Effusion / Lytic Lesions in Clavicle and Scapula
  7. 7. Cervical rib
  8. 8. Kyphoscoliosis
  9. 9. Rib Fracture / Hematoma
  10. 10. Extra Pleural SignCancer LungDensity in peripherySharp inner marginIndistinct outer marginAngle of contact with chest wallExpanding destructive rib lesionParatracheal wideningThis is an example of an RUL lesion
  11. 11. Neurofibromatosis
  12. 12. Sprengels DeformityHigh set scapulaVertebral anomalyRib anomaly
  13. 13. Subcutaneous EmphysemaAir outlining pectoral musclesAir along chest wallPneumomediastinum
  14. 14. Lateral ChestThere is valuable information that can be obtained by a chestlateral view. A few of them are listed below:SternumVertebral columnRetrosternal spaceLocalization of lung lesionsLobes of lungsOblique fissuresPulmonary arteryHeartAortaMediastinal massesDiaphragmVolume measurementsSPNRadiologic TLCTracheoesophageal stripe
  15. 15. Tuberculosis of SpineLoss of intervertebral spaceVertebral collapseCold abscess is not present in this case. PA view is not diagnostic.
  16. 16. Mediastinal Lymph NodesExtrapleuralPolycyclic marginAnterior mediastinum
  17. 17. RML AtelectasisVague density in right lower lung field, almost normalRML atelectasis in lateral view, not evident in PA view
  18. 18. Atelectasis Left UpperLobeHazy density over leftupper lung fieldLoss of left heartsilhouetteTracheal shift to leftA: Forward movement of obliquefissureC: Atelectatic LULB: Herniated right lung
  19. 19. LocalizationWhen a lesion is not contiguous to asilhouette, it is not possible to localize itwithout a lateral view. This is a case of asolitary pulmonary nodule with popcorncalcification: Hamartoma.
  20. 20. Air Bronchogram• In a normal chest x-ray, the tracheobronchial tree is notvisible beyond the 4th order. As the bronchial treebranches, the cartilaginous rings become thinner, andeventually disappear in respiratory bronchioles. Thelumen of the bronchus contains air and the surroundingalveoli contain air. Thus, there is no contrast to visualizethe bronchi.• The air column in the bronchi beyond the 4th orderbecomes recognizable if the surrounding alveoli is filled,providing a contrast or if the bronchi get thickened• The term air bronchogram is used for the former stateand signifies alveolar disease.
  21. 21. Silhouette SignAdjacent Lobe/SegmentSilhouetteRLL/Basal segmentsRight diaphragmRML/Medial segmentRight heart marginRUL/Anterior segmentAscending aortaLUL/Posterior segmentAortic knobLingula/Inferior segmentLeft heart marginLLL/Superior and basal segmentsDescending aortaLLL/Basal segmentsLeft diaphragmCardiac margins are clearly seen because there is contrast between the fluiddensity of the heart and the adjacent air filled alveoli. Both being of fluid density,you cannot visualize the partition of the right and left ventricle because there is nocontrast between them. If the adjacent lung is devoid of air, the clarity of thesilhouette will be lost. The silhouette sign is extremely useful in localizing lunglesions.
  22. 22. Atelectasis Right LungHomogenous density right hemithoraxMediastinal shift to rightRight hemithorax smallerRight heart and diaphragmatic silhouette are not identifiable
  23. 23. Atelectasis Left LungHomogenous density left hemithoraxMediastinal shift to leftLeft hemithorax smallerDiaphragm and heart silhouette are not identifiable
  24. 24. LateralMovement of oblique and transversefissuresAtelectasis Right Upper LobeHomogenous density right upper lungfieldMediastinal shift to rightLoss of silhouette of ascending aorta
  25. 25. Atelectasis Left UpperLobeHazy density over leftupper lung fieldLoss of left heartsilhouetteTracheal shift to leftLateralA: Forward movement ofoblique fissureB: Herniated right lungC: Atelectatic LUL
  26. 26. Consolidation RightUpper Lobe /Density in right upper lungfieldLobar densityLoss of ascending aortasilhouetteNo shift of mediastinumTransverse fissure notsignificantly shiftedAir bronchogram
  27. 27. 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
  28. 28. 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
  29. 29. Vague density right lower lung fieldIndistinct right cardiac silhouetteIntact diaphragmatic silhouetteDensity corresponding to RMLNo loss of lung volumeRML pneumonia
  30. 30. S Curve of GoldenWhen there is a massadjacent to a fissure, thefissure takes the shapeof an "S". The proximalconvexity is due to a mass,and the distal concavity isdue to atelectasis. Note theshape of the transversefissure.This example represents aRUL mass with atelectasis
  31. 31. Tracheal ShiftTrachea is index of upper mediastinal position. The pleural pressures on eitherside determine the position of the mediastinum. The mediastinum will shifttowards the side with relatively higher negative pressure compared to theopposite side. Tracheal deviation can occur under the following conditions:• Deviated towards diseased side– Atelectasis– Agenesis of lung– Pneumonectomy– Pleural fibrosis• Deviated away from diseased side– Pneumothorax– Pleural effusion– Large mass• Mediastinal masses• Tracheal masses• Kyphoscoliosis
  32. 32. Atelectasis Right Lung• Homogenous densityright hemithorax• Mediastinal shift to right• Right hemithorax smaller• Right heart anddiaphragmatic silhouetteare not identifiable•
  33. 33. Pleural Effusion Massive• Unilateral homogenousdensity• Mediastinal shift to right• Left diaphragmatic andleft heart silhouettes lost• Left hemithorax larger
  34. 34. Pneumonectomy• Opacity lefthemithorax• Tracheal shift to left• Cardiac and leftdiaphragmaticsilhouettes missing• Crowding of ribs
  35. 35. Air Bronchogram• In a normal chest x-ray, the tracheobronchial tree is notvisible beyond the 4th order. As the bronchial treebranches, the cartilaginous rings become thinner, andeventually disappear in respiratory bronchioles. Thelumen of the bronchus contains air and the surroundingalveoli contain air. Thus, there is no contrast to visualizethe bronchi.• The air column in the bronchi beyond the 4th orderbecomes recognizable if the surrounding alveoli is filled,providing a contrast or if the bronchi get thickened• The term air bronchogram is used for the former stateand signifies alveolar disease.
  36. 36. Bowing Sign• In LUL atelectasis orfollowing resection, as inthis case, the obliquefissure bows forwards(lateral view). Bowingsign refers to this feature.The arrow points to theforward movement of theleft oblique fissure.
  37. 37. Doubling Time• Time to double in volume (not diameter)• Useful in determining the etiology of solitarypulmonary nodule• Utility– Less than 30 days: Inflammatory process– Greater than 450 days: Benign tumor– Malignancy falls in between
  38. 38. Eccentric Location of Cavity in aMass• Thick wall and irregular lumen can beseen in both malignancy andinflammatory lesions.• However eccentric location of cavity isdiagnostic of malignancy.
  39. 39. • This is an example ofsquamous cellcarcinoma lung.• LUL mass• Thick walled cavity• Eccentric location ofcavity• Fluid level• This is diagnostic ofmalignancy.
  40. 40. Cortical Distribution• Mirror image of pulmonary edema• Alveolar disease of outer portion of lung• Encountered in:– Eosinophilic pneumonia– Bronchiolitis obliterans with pneumonia
  41. 41. Medullary Distribution• It is also called "butterfly pattern"• Note the sparing of lung periphery both inthe CT, PA and lateral views• This is one of the radiologic signsindicative of diffuse alveolar disease• This is an example of alveolar proteinosis.
  42. 42. Note the sparing of lung periphery both in the CT, and PA viewThis is one of the radiologic signs indicative of diffuse alveolar diseaseThis is an example of alveolar proteinosis.
  43. 43. Diffuse Alveolar DiseaseRadiological Signs• Butterfly distribution / Medullary distribution• Lobar or segmental distribution• Air bronchogram• Alveologram• Confluent shadows• Soft fluffy edges• Acinar nodules• Rapid changes• No significant loss of lung volume• Ground glass appearance on HRCT
  44. 44. Distribution• Cortical– Eosinophilic pneumonia– BOOP• Lower lobes / Mineral oil aspiration• Medullary
  45. 45. Acute Diffuse Alveolar Disease• Water– Pulmonary edema, Cardiogenic, Neurogenic pulmonary edema• Blood– SLE– Goodpastures syndrome– Idiopathic pulmonary hemosiderosis– Wegeners granulomatosis• Inflammatory– Cytomegalovirus pneumonia– Pneumocystis carinii pneumonia– Influenza– Chicken pox pneumonia• Fat embolism• Amniotic fluid embolism• Adult respiratory distress syndrome
  46. 46. Acinar NodulesInterstitialAcinarSame sizeSharp edgessmallerVarying in sizeIndistinct edgesLarger than interstitial nodulesAcinar nodules are difficult to distinguish from interstitialnodules. Some distinguishing characteristics are as follows:
  47. 47. Cut Off Sign• When you see an abrupt ending of visualizedbronchus, it is called a "cut off sign". It indicatesan intrabronchial lesion. This is useful to identifythe etiology of atelectasis . Be careful as thetracheobronchial tree is three dimensional andthe finding need to be confirmed with tomogram.In the modern era, a CT scan will take care ofthis.
  48. 48. Air Fluid LevelCauses• Cavities• Pleural space: Hydropneumothorax• Bowel: Hiatal hernia• Esophagus: Obstruction• Mediastinum: Abscess• Chest wall• Normal stomach• Dilated biliary tract• Sub diaphragmatic abscess
  49. 49. Wedge Shaped DensityThe wedges base is pleuraland the apex is towards thehilum, giving a triangularshape. You can encountereither of the following:Vascular wedges :InfarctInvasive aspergillosisBronchial wedges :ConsolidationAtelectasis
  50. 50. Polycyclic MarginThe wavy shape ofthe mediastinal massmargin indicates thatit is made up ofmultiple masses,usually lymph nodes.This is a case oflymphoma.
  51. 51. Open Bronchus Sign / Alveolar AtelectasisThe right lung is atelectatic. You can see air bronchogram, which indicatesthat the airways are patent .This case is an example of adhesive alveolaratelectasis.
  52. 52. Pulmonary Artery OverlaySignThis is the same concept asa silhouette sign. If you canrecognize the interlobarpulmonary artery, it meansthat the mass seen is eitherin front of or behind it.This is an example of adissecting aneurysm.
  53. 53. S Curve of GoldenWhen there is a massadjacent to a fissure, thefissure takes the shapeof an "S". The proximalconvexity is due to a mass,and the distal concavity isdue to atelectasis. Note theshape of the transversefissure.This example represents aRUL mass with atelectasis
  54. 54. Tracheoesophageal StripeThe posterior wall of the trachea (T)and the anterior wall of the esophagus(E) are in close contact and form thetracheoesophageal stripe in the lateralview (arrow).It is considered abnormal when it iswider than __ mm.Common causes for thickening oftracheoesophageal stripe are:Esophageal diseaseNodal enlargement
  55. 55. AV FistulaOsler-Weber-RenduSyndrome"Pulmonary nodule"Multiple lesionsFeeding vesselCardiomegalyPatient presented withsevere congestive heartfailure and severe irondeficiency anemia. Hadmultiple telangiectasia oftongue, lips andconjunctivae.
  56. 56. PneumonectomyDiffuse hazinessSmaller right hemithoraxMediastinal shift to rightSurgical clips

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