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CT CHEST      Giselle Revah        University of Toronto        Class of 0T7      Dr. N. Jaffer        Staff Radiologist M...
THE BASICS INTRO     1. The different options for CT              imaging of the lungCT TYPE           2. An approach to l...
CT TYPES           1.   Standard INTRO           2.   High Resolution           3.   Low DoseCT TYPE           4.   CT Ang...
1. STANDARD CT           •   Slice thickness: 3-10 mm INTRO     •   scans a large volume, very quickly           •   Cover...
2. HIGH RESOLUTION (HRCT)              • narrow x-ray beam collimation: 1-1.3mm INTRO          vs. conventional 3-10mm    ...
2. HIGH RESOLUTION (HRCT)           Indications INTRO           • Hemoptysis           • Diffusely abnormal CXR           ...
3. LOW DOSE           • Premise: lower dose radiation will not INTRO       reduce the diagnostic functionality of         ...
4. ANGIOGRAPHY (CTA)           •   contrast injected into peripheral vein INTRO     •   injection timing/rate controlled a...
APPROACHING THE ANATOMY INTRO           Three Windows           1. Soft TissueCT TYPE                  2. BoneANATOMY 3. L...
1. SOFT TISSUE WINDOW           Look at these structures           • Thyroid INTRO     • Chest wall           • Pleura    ...
Ascending aorta                                           Main pulmonary artery                 SVC INTRO                 ...
2. BONE WINDOW                               Manubrium/ INTRO                         SternumCT TYPEANATOMY DISEASE   R Ri...
3. LUNG WINDOW            AIRWAYS                        Bronchial Tree INTRO                     CentralCT TYPE          ...
COMMON PATHOLOGIC           FEATURES INTRO     1.   Air Bronchograms           2.   BronchiectasisCT TYPE    3.   Septal T...
1. AIR BRONCHOGRAMS           Description INTRO     •   Bronchi become visible due to increased               attenuation ...
2. BRONCHIECTASIS           Dilatation of medium-sized bronchi (>2 mm)            impaired clearance  recurrent infectio...
3. SPETAL THICKENING           • abnormalities of interlobular septa or INTRO       peripheral alveoli           • thicken...
4. GROUND GLASS OPACITIES           •   common nonspecific finding INTRO     •   decreased air content without            ...
5. EMPHYSEMA           •   permanent enlargement of air               spaces distal to the terminal INTRO         bronchio...
5. EMPHYSEMA           3 Types           1. Centriacinar/lobular INTRO     • respiratory bronchioles  periphery          ...
6. NODULES           CT can detect nodules 3-4 mm INTRO     Benign           • Small, unchanged over 2 years           • L...
6. NODULES           Neoplastic           Infectious   Inflammatory INTRO           Benign (hamartoma)   Granuloma    Rheu...
7. FILLING DEFECTS           •   Pulmonary Embolism is a well defined hypodensity in the               pulmonary artery IN...
REFERENCES           1. Engeler CE, Tashjian JH, Trenkner SW, and Walsh JW.              Ground Glass Opacity of the Lung ...
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Approach to ct chest 578

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Approach to ct chest 578

  1. 1. CT CHEST Giselle Revah University of Toronto Class of 0T7 Dr. N. Jaffer Staff Radiologist MSH and University of Toronto
  2. 2. THE BASICS INTRO 1. The different options for CT imaging of the lungCT TYPE 2. An approach to looking at chest CT’sANATOMY DISEASE 3. A few disease patterns that willPATTERNS help you impress
  3. 3. CT TYPES 1. Standard INTRO 2. High Resolution 3. Low DoseCT TYPE 4. CT AngioANATOMY DISEASEPATTERNS
  4. 4. 1. STANDARD CT • Slice thickness: 3-10 mm INTRO • scans a large volume, very quickly • Covers the full lungCT TYPE • +/- contrast Indications • CXR abnormalityANATOMY • Pleural and mediastinal abnormalities • Lung cancer staging • F/U metastases DISEASE • Empyema vs abscessPATTERNS
  5. 5. 2. HIGH RESOLUTION (HRCT) • narrow x-ray beam collimation: 1-1.3mm INTRO vs. conventional 3-10mm • cross sections are further apart: 10 mm • high definition images of lung parenchyma: vessels, airspaces, airwayCT TYPE and interstitium • No contrast STANDARD CT HRCTANATOMY DISEASEPATTERNS
  6. 6. 2. HIGH RESOLUTION (HRCT) Indications INTRO • Hemoptysis • Diffusely abnormal CXR • Normal CXR with abnormal PFT’sCT TYPE • Baseline for pts with diffuse lung disease • Solitary pulmonary nodules • Reversible (active) vs. non-reversibleANATOMY (fibrotic) lung disease • Lung biopsy guide • F/U known lung disease DISEASE • Assess Rx responsePATTERNS
  7. 7. 3. LOW DOSE • Premise: lower dose radiation will not INTRO reduce the diagnostic functionality of the scan (eg. 250 mAs 50 mAs) • Detail is decreasedCT TYPE Uses • ScreeningANATOMY – ongoing trials • F/U – infections DISEASE – post lung transplantPATTERNS – metastases
  8. 8. 4. ANGIOGRAPHY (CTA) • contrast injected into peripheral vein INTRO • injection timing/rate controlled automatically • dye is where you want it during scan • replaced conventional catheter angiogramCT TYPE Indications • Pulmonary embolism • Aortic aneurysmsANATOMY • Aortic dissection Risks DISEASE • Iodinated contrast: – Allergic/ nephrotoxicPATTERNS
  9. 9. APPROACHING THE ANATOMY INTRO Three Windows 1. Soft TissueCT TYPE 2. BoneANATOMY 3. Lung DISEASEPATTERNS
  10. 10. 1. SOFT TISSUE WINDOW Look at these structures • Thyroid INTRO • Chest wall • Pleura HeartCT TYPE • Chambers • CA calcifications • PericardiumANATOMY Vessels • Aorta • PA • Smaller vasculature DISEASEPATTERNS Nodes • mediastinal •
  11. 11. Ascending aorta Main pulmonary artery SVC INTRO L pulmonary arteryCT TYPE R pulmonary artery Descending aortaANATOMY Esophagus DISEASE Azygous veinPATTERNS What is this duct?
  12. 12. 2. BONE WINDOW Manubrium/ INTRO SternumCT TYPEANATOMY DISEASE R Ribs L RibsPATTERNS Vertebrae
  13. 13. 3. LUNG WINDOW AIRWAYS Bronchial Tree INTRO CentralCT TYPE PARENCHYMA RULANATOMY LUL Fissure DISEASEPATTERNS Fissure RLL LLL
  14. 14. COMMON PATHOLOGIC FEATURES INTRO 1. Air Bronchograms 2. BronchiectasisCT TYPE 3. Septal Thickening 4. Ground Glass OpacityANATOMY 5. Emphysema 6. Nodules 7. Filling Defect DISEASEPATTERNS
  15. 15. 1. AIR BRONCHOGRAMS Description INTRO • Bronchi become visible due to increased attenuation of surrounding lung • Implies proximal bronchi patency • Excludes pleural or mediastinal lesionCT TYPE DDx • Non-obstructive atelectasisANATOMY • Pneumonia • Pulmonary edema • Hemorrhage DISEASE • Bronchioloalveolar carcinomaPATTERNS • Lymphoma
  16. 16. 2. BRONCHIECTASIS Dilatation of medium-sized bronchi (>2 mm)  impaired clearance  recurrent infection bronchial INTRO damage What type Types is this? 1. Cylindrical 2. CysticCT TYPE 3. Varicose HRCT is diagnostic tool of choiceANATOMY DDx • Infection • Immunodeficiency states • Bronchial obstruction • alpha 1-Antitrypsin deficiency • Cystic fibrosis • RA and Sjögren DISEASE • Primary ciliary • Pulmonary fibrosisPATTERNS dyskinesia
  17. 17. 3. SPETAL THICKENING • abnormalities of interlobular septa or INTRO peripheral alveoli • thickening and outlining of the secondaryCT TYPE pulmonary lobules is best seen on HRCT • often well depicted in the apicesANATOMY Most Common Causes • pulmonary edema DISEASE • pulmonary hemorrhagePATTERNS • lymphangitic cancer spread
  18. 18. 4. GROUND GLASS OPACITIES • common nonspecific finding INTRO • decreased air content without totally obliterating the alveoli • increased lung opacity not sufficient toCT TYPE obscure pulmonary vessels Early DDx • Alveolitis or interstitial pneumonitisANATOMY – Hypersensitivity pneumonitis – IPF – Sarcoidosis • Pulmonary edema DISEASE • Resolving pneumonia/ hemorrhagePATTERNS Dense
  19. 19. 5. EMPHYSEMA • permanent enlargement of air spaces distal to the terminal INTRO bronchioles • destruction of the walls without obvious fibrosisCT TYPE DDx • smoking • alpha 1-Antitrypsin deficiency • IV drugsANATOMY • Immundeficiency • Vasculitis • Connective tissue disorders Young pt with bullous emphysema at the lung DISEASE bases.PATTERNS What’s the diagnosis?
  20. 20. 5. EMPHYSEMA 3 Types 1. Centriacinar/lobular INTRO • respiratory bronchioles  periphery • upper half of lungs • smokingCT TYPE 2. Panacinar • destroys entire alveolus uniformly • lower half of lungs • homozygous alpha1-antitrypsinANATOMY deficiency 3. Distal acinar/paraseptal • distal airway, alveolar ducts, and alveolar sacs • What 2 types are found DISEASE around the lung septae or pleura here? • apical bullae may spontaneouslyPATTERNS pneumothorax
  21. 21. 6. NODULES CT can detect nodules 3-4 mm INTRO Benign • Small, unchanged over 2 years • Less than 15-20 HU • fat within (hamartoma)CT TYPE • halo sign: ground-glass surrounding nodule indicates infection Malignant • Enhancement of greater than 20 HUANATOMY • Caution: active granulomas/ infectious lesions • Spiculated • Multiple DISEASE Can you spot thePATTERNS nodule?
  22. 22. 6. NODULES Neoplastic Infectious Inflammatory INTRO Benign (hamartoma) Granuloma Rheumatoid arthritis Bronchogenic Ca Abscess Wegener’s Mets SarcoidosisCT TYPE Lymphoma Circumscribed nodulesANATOMY suspect metastatic disease Septated nodules, suspect primary lung malignancy DISEASEPATTERNS
  23. 23. 7. FILLING DEFECTS • Pulmonary Embolism is a well defined hypodensity in the pulmonary artery INTRO • • CTA sensitive for PE (90%) can’t evaluate arteries below 4th segmental level DDx: • Anatomical landmarks and variants eg intersegmentalCT TYPE nodes • Vascular tumor invasion • Technical psuedo filling defects (eg flow artifact)ANATOMY DISEASEPATTERNS
  24. 24. REFERENCES 1. Engeler CE, Tashjian JH, Trenkner SW, and Walsh JW. Ground Glass Opacity of the Lung Parenchyma: A Guide to INTRO analysis with High Resolution CT. AJR 1993; 160: 249-251. 2. Collins, J. CT signs and patterns of lung disease. Radiol Clin North Am. 2001 Nov;39(6):1115-35.CT TYPE 3. Lee JKT, Sagel SS, Stanley RJ, Heiken JP. Computed Body Tomography with MRI correlation. 3rd ed. Raven Press NYC, 1998.ANATOMY DISEASEPATTERNS

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