Radiological Presentation of Chest Diseases

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Radiological Presentation of Chest Diseases

  1. 1. Gamal Rabie Agmy, MD, FCCP Professor of Chest Diseases, Assiut University ERS National Delegate of Egypt
  2. 2. L:Lung R:Rib T:Trachea AK:Aortic knob A:Ascending aorta H:Heart V: Vertebra P: Pulmonary artery S:Spleen
  3. 3. Missing Right Breast "Hyperlucent" right base secondary to missing breast. Silicone Breast Implantation
  4. 4. Cancer Breast Larger right breast Inverted nipple Radiation Fibrosis of Lung Right lung smaller Right hemithorax smaller Paramediastinal 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 Sign Cancer Lung Density in periphery Sharp inner margin Indistinct outer margin Angle of contact with chest wall Expanding destructive rib lesion Paratracheal widening This is an example of an RUL lesion
  11. 11. Neurofibromatosis
  12. 12. Sprengel's Deformity High set scapula Vertebral anomaly Rib anomaly
  13. 13. Subcutaneous Emphysema Air outlining pectoral muscles Air along chest wall Pneumomediastinum
  14. 14. Lateral Chest There is valuable information that can be obtained by a chest lateral view. A few of them are listed below: Sternum Vertebral column Retrosternal space Localization of lung lesions Lobes of lungs Oblique fissures Pulmonary artery Heart Aorta Mediastinal masses Diaphragm Volume measurements SPN Radiologic TLC Tracheoesophageal stripe
  15. 15. Tuberculosis of Spine Loss of intervertebral space Vertebral collapse Cold abscess is not present in this case. PA view is not diagnostic.
  16. 16. Mediastinal Lymph Nodes Extrapleural Polycyclic margin Anterior mediastinum
  17. 17. RML Atelectasis Vague density in right lower lung field, almost normal RML atelectasis in lateral view, not evident in PA view
  18. 18. Atelectasis Left Upper Lobe Hazy density over left upper lung field Loss of left heart silhouette Tracheal shift to left A: Forward movement of oblique fissure C: Atelectatic LUL B: Herniated right lung
  19. 19. Localization When a lesion is not contiguous to a silhouette, it is not possible to localize it without a lateral view. This is a case of a solitary pulmonary nodule with popcorn calcification: Hamartoma.
  20. 20. Air Bronchogram • In a normal chest x-ray, the tracheobronchial tree is not visible beyond the 4th order. As the bronchial tree branches, the cartilaginous rings become thinner, and eventually disappear in respiratory bronchioles. The lumen of the bronchus contains air and the surrounding alveoli contain air. Thus, there is no contrast to visualize the bronchi. • The air column in the bronchi beyond the 4th order becomes 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 state and signifies alveolar disease.
  21. 21. Silhouette Sign Adjacent Lobe/SegmentSilhouette RLL/Basal segmentsRight diaphragm RML/Medial segmentRight heart margin RUL/Anterior segmentAscending aorta LUL/Posterior segmentAortic knob Lingula/Inferior segmentLeft heart margin LLL/Superior and basal segmentsDescending aorta LLL/Basal segmentsLeft diaphragm Cardiac margins are clearly seen because there is contrast between the fluid density 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 no contrast between them. If the adjacent lung is devoid of air, the clarity of the silhouette will be lost. The silhouette sign is extremely useful in localizing lung lesions.
  22. 22. Atelectasis Right Lung Homogenous density right hemithorax Mediastinal shift to right Right hemithorax smaller Right heart and diaphragmatic silhouette are not identifiable
  23. 23. Atelectasis Left Lung Homogenous density left hemithorax Mediastinal shift to left Left hemithorax smaller Diaphragm and heart silhouette are not identifiable
  24. 24. Lateral Movement of oblique and transverse fissures Atelectasis Right Upper Lobe Homogenous density right upper lung field Mediastinal shift to right Loss of silhouette of ascending aorta
  25. 25. Atelectasis Left Upper Lobe Hazy density over left upper lung field Loss of left heart silhouette Tracheal shift to left Lateral A: Forward movement of oblique fissure B: Herniated right lung C: Atelectatic LUL
  26. 26. Consolidation Right Upper Lobe / Density in right upper lung field Lobar density Loss of ascending aorta silhouette No shift of mediastinum Transverse fissure not significantly shifted Air bronchogram
  27. 27. Consolidation Left Lower Lobe Density in left lower lung field Left heart silhouette intact Loss of diaphragmatic silhouette No shift of mediastinum Pneumatocele One diaphragm only visible Lobar density Oblique fissure not significantly shifted
  28. 28. Left Upper Lobe Consolidation Density in the left upper lung field Loss of silhouette of left heart margin Density in the projection of LUL in lateral view Air bronchogram in PA view No significant loss of lung volume
  29. 29. Vague density right lower lung field Indistinct right cardiac silhouette Intact diaphragmatic silhouette Density corresponding to RML No loss of lung volume RML pneumonia
  30. 30. S Curve of Golden When there is a mass adjacent to a fissure, the fissure takes the shape of an "S". The proximal convexity is due to a mass, and the distal concavity is due to atelectasis. Note the shape of the transverse fissure. This example represents a RUL mass with atelectasis
  31. 31. Tracheal Shift Trachea is index of upper mediastinal position. The pleural pressures on either side determine the position of the mediastinum. The mediastinum will shift towards the side with relatively higher negative pressure compared to the opposite 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 density right hemithorax • Mediastinal shift to right • Right hemithorax smaller • Right heart and diaphragmatic silhouette are not identifiable •
  33. 33. Pleural Effusion Massive • Unilateral homogenous density • Mediastinal shift to right • Left diaphragmatic and left heart silhouettes lost • Left hemithorax larger
  34. 34. Pneumonectomy • Opacity left hemithorax • Tracheal shift to left • Cardiac and left diaphragmatic silhouettes missing • Crowding of ribs
  35. 35. Air Bronchogram • In a normal chest x-ray, the tracheobronchial tree is not visible beyond the 4th order. As the bronchial tree branches, the cartilaginous rings become thinner, and eventually disappear in respiratory bronchioles. The lumen of the bronchus contains air and the surrounding alveoli contain air. Thus, there is no contrast to visualize the bronchi. • The air column in the bronchi beyond the 4th order becomes 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 state and signifies alveolar disease.
  36. 36. Bowing Sign • In LUL atelectasis or following resection, as in this case, the oblique fissure bows forwards (lateral view). Bowing sign refers to this feature. The arrow points to the forward movement of the left oblique fissure.
  37. 37. Doubling Time • Time to double in volume (not diameter) • Useful in determining the etiology of solitary pulmonary 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 a Mass • Thick wall and irregular lumen can be seen in both malignancy and inflammatory lesions. • However eccentric location of cavity is diagnostic of malignancy.
  39. 39. • This is an example of squamous cell carcinoma lung. • LUL mass • Thick walled cavity • Eccentric location of cavity • Fluid level • This is diagnostic of malignancy.
  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 in the CT, PA and lateral views • This is one of the radiologic signs indicative 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 view This is one of the radiologic signs indicative of diffuse alveolar disease This is an example of alveolar proteinosis.
  43. 43. Diffuse Alveolar Disease Radiological 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 – Goodpasture's syndrome – Idiopathic pulmonary hemosiderosis – Wegener's granulomatosis • Inflammatory – Cytomegalovirus pneumonia – Pneumocystis carinii pneumonia – Influenza – Chicken pox pneumonia • Fat embolism • Amniotic fluid embolism • Adult respiratory distress syndrome
  46. 46. Acinar Nodules InterstitialAcinar Same size Sharp edges smaller Varying in size Indistinct edges Larger than interstitial nodules Acinar nodules are difficult to distinguish from interstitial nodules. Some distinguishing characteristics are as follows:
  47. 47. Cut Off Sign • When you see an abrupt ending of visualized bronchus, it is called a "cut off sign". It indicates an intrabronchial lesion. This is useful to identify the etiology of atelectasis . Be careful as the tracheobronchial tree is three dimensional and the finding need to be confirmed with tomogram. In the modern era, a CT scan will take care of this.
  48. 48. Air Fluid Level Causes • 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 Density The wedge's base is pleural and the apex is towards the hilum, giving a triangular shape. You can encounter either of the following: Vascular wedges : Infarct Invasive aspergillosis Bronchial wedges : Consolidation Atelectasis
  50. 50. Polycyclic Margin The wavy shape of the mediastinal mass margin indicates that it is made up of multiple masses, usually lymph nodes. This is a case of lymphoma.
  51. 51. Open Bronchus Sign / Alveolar Atelectasis The right lung is atelectatic. You can see air bronchogram, which indicates that the airways are patent .This case is an example of adhesive alveolar atelectasis.
  52. 52. Pulmonary Artery Overlay Sign This is the same concept as a silhouette sign. If you can recognize the interlobar pulmonary artery, it means that the mass seen is either in front of or behind it. This is an example of a dissecting aneurysm.
  53. 53. S Curve of Golden When there is a mass adjacent to a fissure, the fissure takes the shape of an "S". The proximal convexity is due to a mass, and the distal concavity is due to atelectasis. Note the shape of the transverse fissure. This example represents a RUL mass with atelectasis
  54. 54. Tracheoesophageal Stripe The posterior wall of the trachea (T) and the anterior wall of the esophagus (E) are in close contact and form the tracheoesophageal stripe in the lateral view (arrow). It is considered abnormal when it is wider than __ mm. Common causes for thickening of tracheoesophageal stripe are: Esophageal disease Nodal enlargement
  55. 55. AV Fistula Osler-Weber-Rendu Syndrome "Pulmonary nodule" Multiple lesions Feeding vessel Cardiomegaly Patient presented with severe congestive heart failure and severe iron deficiency anemia. Had multiple telangiectasia of tongue, lips and conjunctivae.
  56. 56. Pneumonectomy Diffuse haziness Smaller right hemithorax Mediastinal shift to right Surgical clips
  57. 57. The definition of atelectasis is loss of air in the alveoli; alveoli devoid of air (not replaced). A diagnosis of atelectasis requires the following: 1-A density, representing lung devoid of air 2-Signs indicating loss of lung volume Atelectasis
  58. 58. 1-Absorption Atelectasis When airways are obstructed there is no further ventilation to the lungs and beyond. In the early stages, blood flow continues and gradually the oxygen and nitrogen get absorbed, resulting in atelectasis. Types of Atelectasis:
  59. 59. 2-Relaxation Atelectasis The lung is held close to the chest wall because of the negative pressure in the pleural space. Once the negative pressure is lost the lung tends to recoil due to elastic properties and becomes atelectatic. This occurs in patients with pneumothorax and pleural effusion. In this instance, the loss of negative pressure in the pleura permits the lung to relax, due to elastic recoil. There is common misconception that atelectasis is due to compression. Types of Atelectasis:
  60. 60. 3-Adhesive Atelectasis : Surfactant reduces surface tension and keeps the alveoli open. In conditions where there is loss of surfactant, the alveoli collapse and become atelectatic. In ARDS this occurs diffusely to both lungs. In pulmonary embolism due to loss of blood flow and lack of CO2, the integrity of surfactant gets impaired. Types of Atelectasis:
  61. 61. Types of Atelectasis: 4-Cicatricial Atelectasis –Alveoli gets trapped in scar and becomes atelectatic in fibrotic disorders
  62. 62. . 5-Round Atelectasis An instance where the lung gets trapped by pleural disease and is devoid of air. Classically encountered in asbestosis. Types of Atelectasis:
  63. 63. Generalized 1-Shift of mediastinum: The trachea and heart gets shifted towards the atelectatic lung. 2-Elevation of diaphragm: The diaphragm moves up and the normal relationship between left and right side gets altered. 3-Drooping of shoulder. 4-Crowding of ribs: The interspace between the ribs is narrower compared to the opposite side. Signs of Loss of Lung Volume:
  64. 64. Movement of Fissures You need a lateral view to appreciate the movement of oblique fissures. Forward movement of oblique fissure in LUL atelectasis. Backward movement in lower lobe atelectasis. Movement of transverse fissure can be recognized in the PA film. Signs of Loss of Lung Volume:
  65. 65. Movement of Hilum The right hilum is normally slightly lower than the left. This relationship will change with lobar atelectasis. Signs of Loss of Lung Volume:
  66. 66. Compensatory Hyperinflation Compensatory hyperinflation as evidenced by increased radiolucency and splaying of vessels can be seen with the normal lobe or opposite lung. Signs of Loss of Lung Volume:
  67. 67. Alterations in Proportion of Left and Right Lung The right lung is approximately 55% and left lung 45%. In atelectasis this apportionment will change and can be a clue to recognition of atelectasis. . Signs of Loss of Lung Volume:
  68. 68. Hemithorax Asymmetry In normals, the right and left hemithorax are equal in size. The size of the hemithorax will be asymmetrical and smaller on the side of atelectasis Signs of Loss of Lung Volume:
  69. 69. Signs of Loss of Lung Volume: Generalized Shift of mediastinum: The trachea and heart gets shifted towards the atelectatic lung. Elevation of diaphragm: The diaphragm moves up and the normal relationship between left and right side gets altered. Drooping of shoulder. Crowding of ribs: The interspace between the ribs is narrower compared to the opposite side. Movement of Fissures You need a lateral view to appreciate the movement of oblique fissures. Forward movement of oblique fissure in LUL atelectasis. Backward movement in lower lobe atelectasis. Movement of transverse fissure can be recognized in the PA film. Movement of Hilum The right hilum is normally slightly lower than the left. This relationship will change with lobar atelectasis. Compensatory Hyperinflation Compensatory hyperinflation as evidenced by increased radiolucency and splaying of vessels can be seen with the normal lobe or opposite lung. Alterations in Proportion of Left and Right Lung The right lung is approximately 55% and left lung 45%. In atelectasis this apportionment will change and can be a clue to recognition of atelectasis. Hemithorax Asymmetry In normals, the right and left hemithorax are equal in size. The size of the hemithorax will be asymmetrical and smaller on the side of atelectasis
  70. 70. Atelectasis Right Lung Homogenous density right hemithorax Mediastinal shift to right Right hemithorax smaller Right heart and diaphragmatic silhouette are not identifiable
  71. 71. Atelectasis Left Lung Homogenous density left hemithorax Mediastinal shift to left Left hemithorax smaller Diaphragm and heart silhouette are not identifiable
  72. 72. Left Lower Lobe Atelectasis • Inhomogeneous cardiac density • Left hilum pulled down • Non-visualization of left diaphragm • Triangular retrocardiac atelectatic LLL
  73. 73. Atelectasis Left Lower Lobe Double density over heart Inhomogenous cardiac density  Triangular retrocardiac density Left hilum pulled down Other findings include: Pneumomediastinum
  74. 74. Atelectasis Left Upper Lobe Mediastinal shift to left Density left upper lung field Loss of aortic knob and left hilar silhouettes Herniation of right lung Atelectatic left upper lobe Forward movement of left oblique fissure "Bowing sign"
  75. 75. Atelectasis Left Upper Lobe Hazy density over left upper lung field Loss of left heart silhouette Tracheal shift to left Lateral A: Forward movement of oblique fissure B: Herniated right lung C: Atelectatic LUL
  76. 76. Lateral Movement of oblique and transverse fissures Atelectasis Right Upper Lobe Homogenous density right upper lung field Mediastinal shift to right Loss of silhouette of ascending aorta
  77. 77. Lateral Movement of oblique and transverse fissures Atelectasis Right Upper Lobe Homogenous density right upper lung field Mediastinal shift to right Loss of silhouette of ascending aorta
  78. 78. RML Atelectasis Vague density in right lower lung field, almost normal RML atelectasis in lateral view, not evident in PA view
  79. 79. Vague density in right lower lung field (almost a normal film). Dramatic RML atelectasis in lateral view, not evident in PA view. Movement of transverse fissure. Other findings include: Azygous lobe
  80. 80. Atelectasis Right Lower Lobe Density in right lower lung field Indistinct right diaphragm Right heart silhouette retained Transverse fissure moved down Right hilum moved down
  81. 81. Adhesive Atelectasis Alveoli are kept open by the integrity of surfactant. When there is loss of surfactant, alveoli collapse. ARDS is an example of diffuse alveolar atelectasis. Plate-like atelectasis is an example of focal loss of surfactant.
  82. 82. Relaxation Atelectasis The lung is held in apposition to the chest wall because of negative pressure in the pleura. When the negative pressure is lost, as in pneumothorax or pleural effusion, the lung relaxes to its atelectatic position. The atelectasis is a secondary event. The pleural problem is primary and dictates other radiological findings.
  83. 83. Round Atelectasis Mass like density Pleural based Base of lungs Blunting of costophrenic angle Pleural thickening Pulmonary vasculature curving into the density Esophageal surgical clips
  84. 84. Round Atelectasis Mass like density Pleural based Base of lungs Blunting of costophrenic angle, pleural thickening Pulmonary vasculature curving into the density
  85. 85. RML Lateral Segment Atelectasis
  86. 86. Sub-segmental Atelectasis
  87. 87. Atelectasis Segmental Anterior sub-segment of RUL "Bronchial wedge"
  88. 88. Hilar Displacement
  89. 89. Bronchiectasis Left lung atelectasis due to mucus plugging Mucus plugs suctioned with bronchoscopy Bronchogram done after bronchoscopy Saccular bronchiectasis in bronchogram below
  90. 90. Bronchogram Bronchograms are rarely done nowadays. The need for it disappeared with the invention of the fiberoptic bronchoscopy and high resolution CT scan. View these images to get a greater understanding of a three dimensional view of a bronchial tree..
  91. 91. Bronchogram Bronchograms are rarely done nowadays. The need for it disappeared with the invention of the fiberoptic bronchoscopy and high resolution CT scan.
  92. 92. Calcification Focal lung lesion: Ghon's complex Miliary lung calcification: Histoplasmosis Tuberculosis Alveolar microlithiasis Chicken pox pneumonia Solitary pulmonary nodule : Central / Granuloma Lamellar / Histoplasmosis Pop corn / Hamartoma Eccentric / Scar Cancer
  93. 93. Calcification Nodes: Homogenous / TB Clumpy / Histoplasmosis Egg shell / Silicosis, Sarcoidosis Tracheal cartilage : Aging Tumor: Mediastinal mass / Teratoma Healed lymphoma / Metstasis
  94. 94. Calcification Vascular: Aortic calcification Pulmonary artery calcification Pulmonary hypertension Pleural: Visceral / Hemothorax, TB, Empyema Parietal / Asbestosis Subcutaneous calcification: Cysticercus
  95. 95. Broncholith Subsegmental atelectasis Calcified node Broncholith obstructing bronchus
  96. 96. Silicosis Egg shell calcification of lymph nodes Other findings include: Diaphragmatic pleural calcification Multiple cavities with fluid levels
  97. 97. Histoplasmosis Calcified nodes Clumpy calcification Calcified nodules in lungs
  98. 98. Hamartoma Popcorn calcification
  99. 99. Pleural Calcification Visceral pleural calcification Parietal pleura appears black because it is sandwiched between bony densities
  100. 100. Pleural Calcification Visceral pleura Old TB
  101. 101. Visceral pleural calcification Open drainage with air fluid levels in pleural space
  102. 102. Subcutaneous calcification
  103. 103. Cavitary Lung Lesions
  104. 104. Number: Multiple bilateral cavities would raise suspicion for either bronchiogenous or hematogenous process. You should consider: Aspiration lung abscess Septic emboli Metastatic lesions Vasculitis (Wegener's) Coccidioidomycosis, tuberculosis
  105. 105. Location: • Classical locations for aspiration lung abscess are superior segment of the lower lobes posterior segments of upper lobes. • Tuberculous cavities are common in superior segments of upper and lower lobes or posterior segments of upper lobes. • When a cavity in anterior segment is encountered, a strong suspicion for lung cancer should be raised. TB and aspiration lung abscess are rare in anterior segments. Cancer lung can occur in any segment.
  106. 106. Wall Thickness: • Thick walls are seen in: – Lung abscess – Necrotizing squamous cell lung cancer – Wegener's granulomatosis – Blastomycosis
  107. 107. Wall Thickness: • Thin walled cavities are seen in: • Coccidioidomycosis • Metastatic cavitating squamous cell carcinoma from the cervix • M. Kansasii infection • Congenital or acquired bullae • Post-traumatic cysts • Open negative TB
  108. 108. Contents: • The most common cause for air fluid level is lung abscess. Air fluid levels can rarely be seen in malignancy and in tuberculous cavities from rupture of Rasmussen's aneurysm. • A fungous ball should make you consider aspergillosis. A blood clot and fibrin ball will have the same appearance. • Floating Water Lily: The collapsed membrane of a ruptured echinococcal cyst, floats giving this appearance.
  109. 109. Lining of Wall: The wall lining is irregular and nodular in lung cancer or shaggy in lung abscess
  110. 110. Evolution of Lesion: Many times review of old films to assess the evolution of the radiological appearance of the lesion extremely helpful. Examples • Infected bullae • Aspergilloma • Sub acute necrotizing aspergillosis • Bleeding from Rasmussen's aneurysm in a tuberculous cavity
  111. 111. Associated Features: Ipsilateral lymph nodes or lytic lesions of the bone is seen with malignancy
  112. 112. Bulla <1mmwall >1cmsize Pneumatocele <1mmwall staph.infection Honeycombing <1cmsize multipleequal Cyst 1-3mmwall 1-10cmsize Cavity >3mmwall Anysize Cavitarylesionsoflung
  113. 113. Bulla Definition •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 and confluence of airspaces distal to terminal bronchioles.
  114. 114. •Bullous disease may be primary or associated with emphysema or interstitial lung disease. • Primary bullous lung disease may be familial and has been associated with Marfan's, Ehler's Danlos, IV drug users, HIV infection, and vanishing lung syndrome. •Bullae may occasionally become very large and compromise respiratory function. Thus has been referred as vanishing lung syndrome, and may be seen in young men.
  115. 115. Upper lobe Bulla
  116. 116. Lower lobe Bulla
  117. 117. A: Xray shows bilateral bulla. B: CT shows bilateral bulla. C: CT after bullectomy.
  118. 118. Pneumatocele is a benign air containing cyst of lung, with thin wall < 1mm as bulla but with different mechanism  Infection with staph aureus is the commonest cause ( less common causes are, trauma, barotrauma) lead to necrosis and liquefaction followed by air leak and subpleural dissection forming a thin walled cyst.
  119. 119. •Honeycombing is defined as multiple cysts < 1cm in diameter,with well defined walls, in a background of fibrosis, tend to form clusters and is considered as end stage lung . •It is formed by extensive interstitial fibrosis of lung with residual cystic areas.
  120. 120. A cyst is a ring shadow > 1 cm in diameter and up to 10 cm with wall thickness from 1-3 mm.
  121. 121. Thin walled cysts of LAM
  122. 122. A cavity is > 1cm in diameter, and its wall thickness is more than 3 mm.
  123. 123. •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
  124. 124. 1. Site
  125. 125. A cavity in apicoposterior segment of left upper lobe
  126. 126. 2.Number Multiple cavities: 1. Aspiration. 2. TB 3. Fungal. 4. Metastatic. 5. Septic emboli. 6.Wegners granulomatosis
  127. 127. Multiple cysts of metastasis from squamous cell carcinoma. Multiple thick wall cavities from adenocarcinoma of right lung
  128. 128. Irregular , nodular inner lining of thick wall abscess Malignant cavity. 3. Thickness and irregularity
  129. 129. 4. eccentric Malignant
  130. 130. 5. Relation to lymph node enlargement
  131. 131. 6. Contents
  132. 132. •Arrow head  Crescent sign. •Black arrows  Fibrotic bands surrounding cavity (Fibrocavitary TB).
  133. 133. Primary Lung Cancer • Thick wall • Shaggy lumen • Eccentric cavitation
  134. 134. | Squamous Cell Carcinoma Lung LUL mass Thick walled cavity Eccentric location of cavity
  135. 135. Fungous Ball Long standing cavity Containing round density (A) Mobile density Adjacent pleural reaction (B) - characteristic of aspergilloma
  136. 136. Cavitating Metastasis MultipleThin Walled Cavities Cancer Cervix
  137. 137. Lung Cancer / Squamous Cell Mass density Anterior segment of LUL Thick wall cavitation
  138. 138. SquamousCell Carcinoma Anterior segment of LUL Thick wall Fluid level Full hilum
  139. 139. SquamousCell Carcinoma Lung Thick wall Irregular lumen left hilar LN
  140. 140. Etiology: Cavity can be encountered in practically most lung diseases. Common diseases and their characteristics include: Primary Lung Cancer Thick wall Shaggy lumen Eccentric cavitation Necrotizing Pneumonia Lung abscess Gravity dependant segments Thick wall Air-fluid levels Tuberculosis Superior segments Infiltrate around Bilateral Fungal infections Aspergillus Fungous ball Sub acute invasive aspergillosis Metastatic disease Thin walled (Squamous cell) Thick wall (Adenoma)
  141. 141. Diffuse Alveolar Pneumonia The most common causes for diffuse alveolar pneumonia are: Pneumocystis Cytomegalovirus
  142. 142. Consolidation Right Upper Lobe / Density in right upper lung field Lobar density Loss of ascending aorta silhouette No shift of mediastinum Transverse fissure not significantly shifted Air bronchogram
  143. 143. Necrotizing Pneumonia / Lung Abscess / Aspiration Superior segment RLL dense pneumonia Progression / Cavity
  144. 144. Radiation Pneumonia Post Mediastinal Radiation Air space disease (air bronchogram) Over radiation port (vertical and paramediastinal) Bilateral Progression to fibrosis
  145. 145. Round Pneumonia Round density Shorter doubling time Air bronchogram The most common causes for round pneumonia are: Fungal Tuberculosis
  146. 146. Consolidation / Lingula Density in left lower lung field Loss of left heart silhouette Diaphragmatic silhouette intact No shift of mediastinum Blunting of costophrenic angle Lateral Lobar density Oblique fissure not significantly shifted Air bronchogram
  147. 147. Consolidation Left Lower Lobe Density in left lower lung field Left heart silhouette intact Loss of diaphragmatic silhouette No shift of mediastinum Pneumatocele One diaphragm only visible Lobar density Oblique fissure not significantly shifted
  148. 148. Left Upper Lobe Consolidation Density in the left upper lung field Loss of silhouette of left heart margin Density in the projection of LUL in lateral view Air bronchogram in PA view No significant loss of lung volume
  149. 149. Vague density right lower lung field Indistinct right cardiac silhouette Intact diaphragmatic silhouette Density corresponding to RML No loss of lung volume RML pneumonia
  150. 150. Consolidation Right Upper Lobe / Air Bronchogram Density in right upper lung field Lobar density Loss of ascending aorta silhouette No shift of mediastinum Transverse fissure not significantly shifted Air bronchogram
  151. 151. Pneumoperitoneum Air under diaphragm
  152. 152. Elevated Diaphragm" Note pneumoperitoneum Supradiaphragmatic mass Can be mistaken for elevated diaphragm Pellets
  153. 153. Alveolar Cell Carcinoma - Progression Old film on left Solitary pulmonary nodule resected Onset of diaphragmatic paralysis Progression to multicentric acinar nodules
  154. 154. Hyperlucent Lung Factors Vasculature: Decrease Air: Excess Tissue : Decrease Bilateral diffuse Emphysema Asthma Unilateral Swyer James syndrome Agenesis of pulmonary artery Absent breast or pectoral muscle Partial airway obstruction Compensatory hyperinflation Localized Bullae Westermark's sign : Pulmonary embolus
  155. 155. Agenesis of Left Pulmonary Artery Missing vascular markings in left lung Left hilum not seen Entire cardiac output to right lung
  156. 156. Missing Right Breast "Hyperlucent" right base secondary to missing breast.
  157. 157. Unilateral Hyperlucent Lung Left Upper Lobe Resection Left lung hyper lucent Left hilum pulled up No abnormal density
  158. 158. Pneumomediastinum
  159. 159. Alveolar Proteinosis Bilateral diffuse alveolar disease Butterfly pattern Medullary distribution Air bronchograms
  160. 160. Adult Respiratory Distress Syndrome Non-cardiogenic pulmonary edema Distinguishing characteristics: Normal size heart No pleural effusion
  161. 161. Foreign Body Aspiration
  162. 162. Chest Tubes
  163. 163. Achalasia of esophagus • Inhomogeneous cardiac density: Right half more dense than left • Density crossing midline (right black arrow) • Right sided inlet to outlet shadow • Right para spinal line (left black arrow) • Barium swallow below: Dilated esophagus
  164. 164. 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
  165. 165. Dissecting Aneurysm Mediastinal widening Inlet to outlet shadow on left side Retrocardiac: Intact silhouette of left heart margin Pulmonary artery overlay sign: Density behind left lower lobe Wavy margin
  166. 166. Pulmonary Metastsis
  167. 167. Colon in front of liver
  168. 168. Lymph Nodes
  169. 169. Thrombotic Pulmonary Embolism
  170. 170. Thrombotic Pulmonary Embolism
  171. 171. Thrombotic Pulmonary Embolism
  172. 172. Embolism Nonthrombotic Pulmonary
  173. 173. Embolism Nonthrombotic Pulmonary
  174. 174. Embolism Nonthrombotic Pulmonary
  175. 175. Embolism Nonthrombotic Pulmonary
  176. 176. Embolism Nonthrombotic Pulmonary
  177. 177. of PE Diagnostic Algorithm 1. Patients with normal chest radiographic findings are evaluated with a perfusion scan and, if necessary, an aerosol ventilation scan. Patients with normal or very low probability scintigraphic findings are presumed not to have pulmonary emboli . 2-Patients with a high-probability scan usually undergo anticoagulation therapy. All other patients should be evaluated with helical CT pulmonary angiography, conventional pulmonary angiography, or lower-extremity US, depending on the clinical situation
  178. 178. of PE Diagnostic Algorithm 3-Patients with abnormal chest radiographic findings, are unlikely to have definitive scintigraphic findings. These patients undergo helical CT pulmonary angiography as well as axial CT of the inferior vena cava and the iliac, femoral, and popliteal veins. If the findings at helical CT pulmonary angiography are equivocal or technically inadequate (5%– 10% of cases) or clinical suspicion remains high despite negative findings, additional imaging is required. 4-Patients who have symptoms of deep venous thrombosis but not of pulmonary embolism initially undergo US, which is a less expensive alternative. If the findings are negative, imaging is usually discontinued; if they are positive, the patient is evaluated for pulmonary embolism at the discretion of the referring physician.
  179. 179. Developmental Anomalies
  180. 180. Developmental Anomalies
  181. 181. Developmental Anomalies
  182. 182. Developmental Anomalies
  183. 183. Developmental Anomalies
  184. 184. Pulmonary A-V Malformations
  185. 185. Pulmonary Edema
  186. 186. Pulmonary Artery Aneurysms
  187. 187. Pulmonary Artery Aneurysms
  188. 188. Pulmonary –Systemic Communications
  189. 189. Pulmonary –Systemic Communications
  190. 190. Pulmonary –Systemic ommunications
  191. 191. Abnormal Systemic Arteries
  192. 192. Pulmonary Hypertension
  193. 193. Pulmonary Hemorrhage
  194. 194. Pneumomediastinum
  195. 195. Potential Sources of Mediastinal Air Intrathoracic Trachea and major bronchi Esophagus Lung Pleural space Extrathoracic Head and neck Intraperitoneum and retroperitoneum
  196. 196. Radiographic Signs of Pneumomediastinum Subcutaneous emphysema Thymic sail sign Pneumoprecardium Ring around the artery sign Tubular artery sign Double bronchial wall sign Continuous diaphragm sign Extrapleural sign Air in the pulmonary ligament
  197. 197. Mediastinal Cysts
  198. 198. The CT features of benign mediastinal cyst are (a) a smooth, oval or tubular mass with a well- defined thin wall that usually enhances after intravascular administration of contrast material, (b) homogeneous attenuation, usually in the range of water attenuation (0–20 HU), (c) no enhancement of cyst contents, and (d) no infiltration of adjacent mediastinal structures.
  199. 199. Cysts that contain serous fluid typically have long T1 and T2 relaxation values, which produce low signal intensity on T1-weighted MR images and high signal intensity on T2- weighted images.
  200. 200. Because cysts containing nonserous fluid can have high attenuation at CT, they may be mistaken for solid lesions. MR imaging can be useful in showing the cystic nature of these masses because these cysts continue to have characteristically high signal intensity when imaged with T2- weighted sequences regardless of the nature of the cyst contents
  201. 201. Radionuclide imaging can be helpful in detecting functioning thyroid tissue (iodine-123 or I-131) or parathyroid tissue (technetium-99m sestamibi) in the mediastinal cystic mass . gallium- 67 scintigraphy may show increased radiotracer uptake in the cystic malignancy owing to necrosis such as lymphoma or metastatic carcinoma.
  202. 202. Ultrasonography (US) can be useful in evaluating a mass adjacent to the pleural surface or cardiophrenic angle. At US, the benign cysts typically appear as anechoic thin-walled masses with increased through transmission
  203. 203. Bronchogenic Cysts
  204. 204. Duplication Cyst
  205. 205. Pericardial Cyst
  206. 206. Meningocele
  207. 207. Thymic Cysts
  208. 208. Cystic Teratoma
  209. 209. Lymphangioma
  210. 210. Cystlike Lesions
  211. 211. •Mediastinal Pancreatic Pseudocyst
  212. 212. Mediastinal Abscess

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