Chest radiology part 3


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Chest radiology part 3

  1. 1. Gamal Rabie Agmy, MD, FCCPProfessor of Chest Diseases, Assiut UniversityERS National Delegate of Egypt
  2. 2. Bulla<1mmwall>1cmsizePneumatocele<1mmwallstaph.infectionHoneycombing<1cmsizemultipleequalCyst1-3mmwall1-10cmsizeCavity>3mmwallAnysizeCavitarylesionsoflung
  3. 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. 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. 5. Upper lobe Bulla
  6. 6. Lower lobe Bulla
  7. 7. A: Xray shows bilateral bulla.B: CT shows bilateral bulla.C: CT after bullectomy.
  8. 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. 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. 10. A cyst is a ringshadow > 1 cm indiameter and up to10 cm with wallthickness from 1-3mm.
  11. 11. Thin walled cysts of LAM
  12. 12. A cavity is > 1cmin diameter, and itswall thickness ismore than 3 mm.
  13. 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. 14. 1. Site
  15. 15. A cavity in apicoposterior segment of left upper lobe
  16. 16. 2.NumberMultiple cavities:1. Aspiration.2. TB3. Fungal.4. Metastatic.5. Septic emboli.6.Wegners granulomatosis
  17. 17. Multiple cysts of metastasisfrom squamous cellcarcinoma.Multiple thick wall cavities fromadenocarcinoma of right lung
  18. 18. Irregular , nodular inner lining of thick wall abscessMalignant cavity.3. Thickness andirregularity
  19. 19. 4. eccentricMalignant
  20. 20. 5. Relation to lymphnode enlargement
  21. 21. 6. Contents
  22. 22. •Arrow head  Crescent sign.•Black arrows  Fibrotic bands surrounding cavity(Fibrocavitary TB).
  23. 23. Primary Lung Cancer• Thick wall• Shaggy lumen• Eccentric cavitation
  24. 24. |Squamous Cell Carcinoma LungLUL massThick walled cavityEccentric location of cavity
  25. 25. Fungous BallLong standing cavityContaining round density (A)Mobile densityAdjacent pleural reaction (B) - characteristic of aspergilloma
  26. 26. Cavitating MetastasisMultipleThin Walled CavitiesCancer Cervix
  27. 27. Lung Cancer / Squamous CellMass densityAnterior segment of LULThick wall cavitation
  28. 28. SquamousCell CarcinomaAnterior segment of LULThick wallFluid levelFull hilum
  29. 29. SquamousCell Carcinoma LungThick wallIrregular lumenleft hilar LN
  30. 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. 31. Diffuse Alveolar PneumoniaThe most common causes for diffuse alveolar pneumonia are:PneumocystisCytomegalovirus
  32. 32. Consolidation RightUpper Lobe /Density in right upper lungfieldLobar densityLoss of ascending aortasilhouetteNo shift of mediastinumTransverse fissure notsignificantly shiftedAir bronchogram
  33. 33. Necrotizing Pneumonia / Lung Abscess / AspirationSuperior segment RLL dense pneumoniaProgression / Cavity
  34. 34. Radiation PneumoniaPost Mediastinal RadiationAir space disease (air bronchogram)Over radiation port (vertical and paramediastinal)BilateralProgression to fibrosis
  35. 35. Round PneumoniaRound densityShorter doubling timeAir bronchogramThe most common causes for round pneumonia are:FungalTuberculosis
  36. 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. 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. 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. 39. Vague density right lower lung fieldIndistinct right cardiac silhouetteIntact diaphragmatic silhouetteDensity corresponding to RMLNo loss of lung volumeRML pneumonia
  40. 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. 41. PneumoperitoneumAir under diaphragm
  42. 42. Elevated Diaphragm"Note pneumoperitoneumSupradiaphragmatic massCan be mistaken for elevated diaphragmPellets
  43. 43. Alveolar Cell Carcinoma - ProgressionOld film on leftSolitary pulmonary nodule resectedOnset of diaphragmatic paralysisProgression to multicentric acinar nodules
  44. 44. Hyperlucent LungFactorsVasculature: DecreaseAir: ExcessTissue : DecreaseBilateral diffuseEmphysemaAsthmaUnilateralSwyer James syndromeAgenesis of pulmonary arteryAbsent breast or pectoral musclePartial airway obstructionCompensatory hyperinflationLocalizedBullaeWestermarks sign : Pulmonary embolus
  45. 45. Agenesis of Left Pulmonary ArteryMissing vascular markings in left lungLeft hilum not seenEntire cardiac output to right lung
  46. 46. Missing Right Breast"Hyperlucent" right base secondary to missing breast.
  47. 47. Unilateral Hyperlucent LungLeft Upper Lobe ResectionLeft lung hyper lucentLeft hilum pulled upNo abnormal density
  48. 48. Pneumomediastinum
  49. 49. Alveolar ProteinosisBilateral diffuse alveolar diseaseButterfly patternMedullary distributionAir bronchograms
  50. 50. Adult Respiratory Distress SyndromeNon-cardiogenic pulmonary edemaDistinguishing characteristics:Normal size heartNo pleural effusion
  51. 51. Foreign Body Aspiration
  52. 52. Chest Tubes
  53. 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. 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. 55. Dissecting AneurysmMediastinal wideningInlet to outlet shadowon left sideRetrocardiac: Intactsilhouette of left heartmarginPulmonary arteryoverlay sign: Densitybehind left lower lobeWavy margin
  56. 56. Pulmonary Metastsis
  57. 57. Colon in front of liver
  58. 58. Lymph Nodes
  59. 59. Thrombotic Pulmonary Embolism
  60. 60. Thrombotic Pulmonary Embolism
  61. 61. Thrombotic Pulmonary Embolism
  62. 62. Embolism Nonthrombotic Pulmonary
  63. 63. Embolism Nonthrombotic Pulmonary
  64. 64. Embolism Nonthrombotic Pulmonary
  65. 65. Embolism Nonthrombotic Pulmonary
  66. 66. Embolism Nonthrombotic Pulmonary
  67. 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. 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. 69. Developmental Anomalies
  70. 70. Developmental Anomalies
  71. 71. Developmental Anomalies
  72. 72. Developmental Anomalies
  73. 73. Developmental Anomalies
  74. 74. Pulmonary A-V Malformations
  75. 75. Pulmonary Edema
  76. 76. Pulmonary Artery Aneurysms
  77. 77. Pulmonary Artery Aneurysms
  78. 78. Pulmonary –Systemic Communications
  79. 79. Pulmonary –Systemic Communications
  80. 80. Pulmonary –Systemic ommunications
  81. 81. Abnormal Systemic Arteries
  82. 82. Pulmonary Hypertension
  83. 83. Pulmonary Hemorrhage
  84. 84. Pneumomediastinum
  85. 85. Potential Sources of Mediastinal AirIntrathoracicTrachea and major bronchiEsophagusLungPleural spaceExtrathoracicHead and neckIntraperitoneum and retroperitoneum
  86. 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. 87. Mediastinal Cysts
  88. 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. 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. 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. 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. 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. 93. Bronchogenic Cysts
  94. 94. Duplication Cyst
  95. 95. Pericardial Cyst
  96. 96. Meningocele
  97. 97. Thymic Cysts
  98. 98. Cystic Teratoma
  99. 99. Lymphangioma
  100. 100. Cystlike Lesions
  101. 101. •Mediastinal Pancreatic Pseudocyst
  102. 102. Mediastinal Abscess