Radiological presentation of chest diseases gamal agmy

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Radiological presentation of chest diseases gamal agmy

  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
  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 air2-Signs indicating loss of lung volumeAtelectasis
  58. 58. 1-Absorption AtelectasisWhen airways are obstructed there is no furtherventilation to the lungs and beyond. In the earlystages, blood flow continues and gradually theoxygen and nitrogen get absorbed, resulting inatelectasis.Types of Atelectasis:
  59. 59. 2-Relaxation AtelectasisThe lung is held close to the chest wall because of thenegative pressure in the pleural space. Once thenegative pressure is lost the lung tends to recoil dueto elastic properties and becomes atelectatic. Thisoccurs in patients with pneumothorax and pleuraleffusion. In this instance, the loss of negativepressure in the pleura permits the lung to relax, dueto elastic recoil. There is common misconception thatatelectasis is due to compression.Types of Atelectasis:
  60. 60. 3-Adhesive Atelectasis :Surfactant reduces surface tension and keeps thealveoli open. In conditions where there is loss ofsurfactant, the alveoli collapse and becomeatelectatic. In ARDS this occurs diffusely to bothlungs. In pulmonary embolism due to loss of bloodflow and lack of CO2, the integrity of surfactantgets impaired.Types of Atelectasis:
  61. 61. Types of Atelectasis:4-Cicatricial Atelectasis–Alveoli gets trapped in scar andbecomes atelectatic in fibroticdisorders
  62. 62. .5-Round AtelectasisAn instance where the lung gets trapped bypleural disease and is devoid of air.Classically encountered in asbestosis.Types of Atelectasis:
  63. 63. Generalized1-Shift of mediastinum: The trachea and heart gets shiftedtowards the atelectatic lung.2-Elevation of diaphragm: The diaphragm moves up andthe normal relationship between left and right side getsaltered.3-Drooping of shoulder.4-Crowding of ribs: The interspace between the ribs isnarrower compared to the opposite side.Signs of Loss of Lung Volume:
  64. 64. Movement of FissuresYou need a lateral view to appreciate the movement ofoblique fissures. Forward movement of oblique fissure inLUL atelectasis. Backward movement in lower lobeatelectasis.Movement of transverse fissure can be recognized in thePA film.Signs of Loss of Lung Volume:
  65. 65. Movement of HilumThe 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 HyperinflationCompensatory hyperinflation as evidenced by increasedradiolucency and splaying of vessels can be seen with thenormal lobe or opposite lung.Signs of Loss of Lung Volume:
  67. 67. Alterations in Proportion of Left andRight LungThe right lung is approximately 55% and left lung 45%. Inatelectasis this apportionment will change and can be aclue to recognition of atelectasis. .Signs of Loss of Lung Volume:
  68. 68. Hemithorax AsymmetryIn normals, the right and left hemithorax are equal in size.The size of the hemithorax will be asymmetrical andsmaller on the side of atelectasisSigns of Loss of Lung Volume:
  69. 69. Signs of Loss of Lung Volume:GeneralizedShift of mediastinum: The trachea and heart gets shifted towards the atelectatic lung.Elevation of diaphragm: The diaphragm moves up and the normal relationship between leftand right side gets altered.Drooping of shoulder.Crowding of ribs: The interspace between the ribs is narrower compared to the opposite side.Movement of FissuresYou need a lateral view to appreciate the movement of oblique fissures. Forward movement ofoblique fissure in LUL atelectasis. Backward movement in lower lobe atelectasis.Movement of transverse fissure can be recognized in the PA film.Movement of HilumThe right hilum is normally slightly lower than the left. This relationship will change with lobaratelectasis.Compensatory HyperinflationCompensatory hyperinflation as evidenced by increased radiolucency and splaying of vesselscan be seen with the normal lobe or opposite lung.Alterations in Proportion of Left and Right LungThe right lung is approximately 55% and left lung 45%. In atelectasis this apportionment willchange and can be a clue to recognition of atelectasis.Hemithorax AsymmetryIn normals, the right and left hemithorax are equal in size. The size of the hemithorax will beasymmetrical and smaller on the side of atelectasis
  70. 70. Atelectasis Right LungHomogenous density right hemithoraxMediastinal shift to rightRight hemithorax smallerRight heart and diaphragmatic silhouette are not identifiable
  71. 71. Atelectasis Left LungHomogenous density left hemithoraxMediastinal shift to leftLeft hemithorax smallerDiaphragm 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 LeftUpper LobeMediastinal shift to leftDensity left upper lung fieldLoss of aortic knob and left hilarsilhouettesHerniation of right lungAtelectatic left upper lobeForward movement of leftoblique fissure "Bowing sign"
  75. 75. Atelectasis Left UpperLobeHazy density over leftupper lung fieldLoss of left heartsilhouetteTracheal shift to leftLateralA: Forward movement ofoblique fissureB: Herniated right lungC: Atelectatic LUL
  76. 76. LateralMovement of oblique and transversefissuresAtelectasis Right Upper LobeHomogenous density right upper lungfieldMediastinal shift to rightLoss of silhouette of ascending aorta
  77. 77. LateralMovement of oblique and transversefissuresAtelectasis Right Upper LobeHomogenous density right upper lung fieldMediastinal shift to rightLoss of silhouette of ascending aorta
  78. 78. RML AtelectasisVague density in right lower lung field, almost normalRML 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 oftransverse fissure.Other findings include: Azygous lobe
  80. 80. Atelectasis Right Lower LobeDensity in right lower lung fieldIndistinct right diaphragmRight heart silhouette retainedTransverse fissure moved downRight hilum moved down
  81. 81. Adhesive AtelectasisAlveoli are kept open by the integrity of surfactant. When there is lossof surfactant, alveoli collapse. ARDS is an example of diffuse alveolaratelectasis.Plate-like atelectasis is an example of focal loss of surfactant.
  82. 82. Relaxation AtelectasisThe lung is held in apposition to the chest wall because of negative pressurein the pleura. When the negative pressure is lost, as in pneumothorax orpleural effusion, the lung relaxes to its atelectatic position. The atelectasis isa secondary event. The pleural problem is primary and dictates otherradiological findings.
  83. 83. Round AtelectasisMass like densityPleural basedBase of lungsBlunting of costophrenic anglePleural thickeningPulmonary vasculature curvinginto the densityEsophageal surgical clips
  84. 84. Round AtelectasisMass like densityPleural basedBase of lungsBlunting of costophrenic angle, pleural thickeningPulmonary vasculature curving into the density
  85. 85. RML Lateral Segment Atelectasis
  86. 86. Sub-segmental Atelectasis
  87. 87. AtelectasisSegmentalAnterior 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. BronchogramBronchograms are rarely done nowadays. The need for itdisappeared with the invention of the fiberopticbronchoscopy and high resolution CT scan. View theseimages to get a greater understanding of a threedimensional view of a bronchial tree..
  91. 91. BronchogramBronchograms are rarely done nowadays. The need for it disappeared with theinvention of the fiberoptic bronchoscopy and high resolution CT scan.
  92. 92. CalcificationFocal lung lesion: Ghons complexMiliary lung calcification:HistoplasmosisTuberculosisAlveolar microlithiasisChicken pox pneumoniaSolitary pulmonary nodule :Central / GranulomaLamellar / HistoplasmosisPop corn / HamartomaEccentric / Scar Cancer
  93. 93. CalcificationNodes:Homogenous / TBClumpy / HistoplasmosisEgg shell / Silicosis, SarcoidosisTracheal cartilage : AgingTumor:Mediastinal mass / TeratomaHealed lymphoma / Metstasis
  94. 94. CalcificationVascular:Aortic calcificationPulmonary artery calcificationPulmonary hypertensionPleural:Visceral / Hemothorax, TB, EmpyemaParietal / AsbestosisSubcutaneous calcification:Cysticercus
  95. 95. BroncholithSubsegmental atelectasisCalcified nodeBroncholith obstructing bronchus
  96. 96. SilicosisEgg shell calcification of lymph nodesOther findings include:Diaphragmatic pleural calcificationMultiple cavities with fluid levels
  97. 97. HistoplasmosisCalcified nodesClumpy calcification Calcified nodules in lungs
  98. 98. HamartomaPopcorn calcification
  99. 99. Pleural CalcificationVisceral pleuralcalcificationParietal pleura appearsblack because it issandwiched betweenbony densities
  100. 100. Pleural CalcificationVisceral pleuraOld TB
  101. 101. Visceral pleural calcificationOpen drainage with air fluid levels in pleural space
  102. 102. Subcutaneous calcification
  103. 103. Cavitary Lung Lesions
  104. 104. Number:Multiple bilateral cavities would raisesuspicion for either bronchiogenous orhematogenous process. You should consider:Aspiration lung abscessSeptic emboliMetastatic lesionsVasculitis (Wegeners)Coccidioidomycosis, tuberculosis
  105. 105. Location:• Classical locations for aspiration lung abscessare superior segment of the lower lobesposterior segments of upper lobes.• Tuberculous cavities are common in superiorsegments of upper and lower lobes or posteriorsegments of upper lobes.• When a cavity in anterior segment isencountered, a strong suspicion for lung cancershould be raised. TB and aspiration lungabscess are rare in anterior segments. Cancerlung can occur in any segment.
  106. 106. Wall Thickness:• Thick walls are seen in:– Lung abscess– Necrotizing squamous cell lung cancer– Wegeners granulomatosis– Blastomycosis
  107. 107. Wall Thickness:• Thin walled cavities are seen in:• Coccidioidomycosis• Metastatic cavitating squamous cellcarcinoma 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 islung abscess. Air fluid levels can rarely beseen in malignancy and in tuberculouscavities from rupture of Rasmussensaneurysm.• A fungous ball should make you consideraspergillosis. A blood clot and fibrin ball willhave the same appearance.• Floating Water Lily: The collapsed membraneof a ruptured echinococcal cyst, floats givingthis appearance.
  109. 109. Lining of Wall:The wall lining is irregular and nodular inlung cancer or shaggy in lung abscess
  110. 110. Evolution of Lesion:Many times review of old films to assess theevolution of the radiological appearance ofthe lesion extremely helpful. Examples• Infected bullae• Aspergilloma• Sub acute necrotizing aspergillosis• Bleeding from Rasmussens aneurysm in atuberculous cavity
  111. 111. Associated Features:Ipsilateral lymph nodes or lyticlesions of the bone is seenwith malignancy
  112. 112. Bulla<1mmwall>1cmsizePneumatocele<1mmwallstaph.infectionHoneycombing<1cmsizemultipleequalCyst1-3mmwall1-10cmsizeCavity>3mmwallAnysizeCavitarylesionsoflung
  113. 113. 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.
  114. 114. •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.
  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, 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.
  119. 119. •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.
  120. 120. A cyst is a ringshadow > 1 cm indiameter and up to10 cm with wallthickness from 1-3mm.
  121. 121. Thin walled cysts of LAM
  122. 122. A cavity is > 1cmin diameter, and itswall thickness ismore 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.NumberMultiple cavities:1. Aspiration.2. TB3. Fungal.4. Metastatic.5. Septic emboli.6.Wegners granulomatosis
  127. 127. Multiple cysts of metastasisfrom squamous cellcarcinoma.Multiple thick wall cavities fromadenocarcinoma of right lung
  128. 128. Irregular , nodular inner lining of thick wall abscessMalignant cavity.3. Thickness andirregularity
  129. 129. 4. eccentricMalignant
  130. 130. 5. Relation to lymphnode 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 LungLUL massThick walled cavityEccentric location of cavity
  135. 135. Fungous BallLong standing cavityContaining round density (A)Mobile densityAdjacent pleural reaction (B) - characteristic of aspergilloma
  136. 136. Cavitating MetastasisMultipleThin Walled CavitiesCancer Cervix
  137. 137. Lung Cancer / Squamous CellMass densityAnterior segment of LULThick wall cavitation
  138. 138. SquamousCell CarcinomaAnterior segment of LULThick wallFluid levelFull hilum
  139. 139. SquamousCell Carcinoma LungThick wallIrregular lumenleft hilar LN
  140. 140. 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)
  141. 141. Diffuse Alveolar PneumoniaThe most common causes for diffuse alveolar pneumonia are:PneumocystisCytomegalovirus
  142. 142. Consolidation RightUpper Lobe /Density in right upper lungfieldLobar densityLoss of ascending aortasilhouetteNo shift of mediastinumTransverse fissure notsignificantly shiftedAir bronchogram
  143. 143. Necrotizing Pneumonia / Lung Abscess / AspirationSuperior segment RLL dense pneumoniaProgression / Cavity
  144. 144. Radiation PneumoniaPost Mediastinal RadiationAir space disease (air bronchogram)Over radiation port (vertical and paramediastinal)BilateralProgression to fibrosis
  145. 145. Round PneumoniaRound densityShorter doubling timeAir bronchogramThe most common causes for round pneumonia are:FungalTuberculosis
  146. 146. Consolidation / LingulaDensity in left lower lung fieldLoss of left heart silhouetteDiaphragmatic silhouette intactNo shift of mediastinumBlunting of costophrenic angleLateralLobar densityOblique fissure notsignificantly shiftedAir bronchogram
  147. 147. 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
  148. 148. 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
  149. 149. Vague density right lower lung fieldIndistinct right cardiac silhouetteIntact diaphragmatic silhouetteDensity corresponding to RMLNo loss of lung volumeRML pneumonia
  150. 150. Consolidation Right Upper Lobe /Air BronchogramDensity in right upper lung fieldLobar densityLoss of ascending aorta silhouetteNo shift of mediastinumTransverse fissure not significantly shiftedAir bronchogram
  151. 151. PneumoperitoneumAir under diaphragm
  152. 152. Elevated Diaphragm"Note pneumoperitoneumSupradiaphragmatic massCan be mistaken for elevated diaphragmPellets
  153. 153. Alveolar Cell Carcinoma - ProgressionOld film on leftSolitary pulmonary nodule resectedOnset of diaphragmatic paralysisProgression to multicentric acinar nodules
  154. 154. Hyperlucent LungFactorsVasculature: DecreaseAir: ExcessTissue : DecreaseBilateral diffuseEmphysemaAsthmaUnilateralSwyer James syndromeAgenesis of pulmonary arteryAbsent breast or pectoral musclePartial airway obstructionCompensatory hyperinflationLocalizedBullaeWestermarks sign : Pulmonary embolus
  155. 155. Agenesis of Left Pulmonary ArteryMissing vascular markings in left lungLeft hilum not seenEntire cardiac output to right lung
  156. 156. Missing Right Breast"Hyperlucent" right base secondary to missing breast.
  157. 157. Unilateral Hyperlucent LungLeft Upper Lobe ResectionLeft lung hyper lucentLeft hilum pulled upNo abnormal density
  158. 158. Pneumomediastinum
  159. 159. Alveolar ProteinosisBilateral diffuse alveolar diseaseButterfly patternMedullary distributionAir bronchograms
  160. 160. Adult Respiratory Distress SyndromeNon-cardiogenic pulmonary edemaDistinguishing characteristics:Normal size heartNo pleural effusion
  161. 161. Foreign Body Aspiration
  162. 162. Chest Tubes
  163. 163. 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
  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 AneurysmMediastinal wideningInlet to outlet shadowon left sideRetrocardiac: Intactsilhouette of left heartmarginPulmonary arteryoverlay sign: Densitybehind left lower lobeWavy 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 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
  178. 178. 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.
  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 AirIntrathoracicTrachea and major bronchiEsophagusLungPleural spaceExtrathoracicHead and neckIntraperitoneum and retroperitoneum
  196. 196. Radiographic Signs of PneumomediastinumSubcutaneous emphysemaThymic sail signPneumoprecardiumRing around the artery signTubular artery signDouble bronchial wall signContinuous diaphragm signExtrapleural signAir in the pulmonary ligament
  197. 197. Mediastinal Cysts
  198. 198. 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.
  199. 199. 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.
  200. 200. 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
  201. 201. 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.
  202. 202. 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
  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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