Radiology: Chest Imaging

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chest radiology

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Radiology: Chest Imaging

  1. 1. Chest Imaging
  2. 2. Densities • • • • • Four densities on XR Black – air/gas Dark grey – fat Light grey – fluid/solid organ White – bone/calcium Increasing opacification
  3. 3. CXR • Rule No 1! – always check name of patient and date • Check orientation (L & R labeled correctly) • Projection (PA or AP, lateral, decubitus, supine) • Accurate assessment of heart size and mediastinum on PA views • All supine/portable - AP
  4. 4. CXR - systematic • ABCDE for both frontal & lateral projection • A – airways – Trachea/central bronchi midline or just to right, no narrowing, carinal angle <90° • B – breathing/lungs – Parenchyma – too white or too black? • Look at the fissures – Bones – ribs, vertebrae, humeri clavicles, scapulae – for fractures, lytic(black), sclerotic (white) lesions, vertebral body heights • C – cardiac/vessels – Cardiac silhouette & Mediastinum contours & width – Hilum – normal hilar shadow made up of vessels, Lt is higher than right by 0-2.5 cm. Must have concave shape – Pulmonary vessels – upper zone vessels vessels smaller than lower
  5. 5. CXR - systematic • D – look under the diaphragm – free gas – perforated viscus – Costophrenic angle for pleural effusion • E – extremities – The corners of the film • Line position • Hidden areas: lung apices, behind the heart, breast shadows, paravertebral, thyroid
  6. 6. Normal CXR Trachea Aortic Arch Rt Mainstem bronchus Pulm artery RA Pulm artery Atrial appendage LV Diaphragm stomach
  7. 7. Normal CXR Trachea Pulmonary artery Aortic arch LA RV LV Costophrenic angle
  8. 8. Anatomy RUL LUL ML RLL LLL
  9. 9. Heart • Cardiothoracic ratio (CTR) – <50% adults – PA film – AP magnifies heart – Causes of increased CTR • Obesity, pectus, portable film, cardiomegaly, pericardial effusion • Shape • Valve calcification
  10. 10. Lungs • Too black • Too white – Opacity, density, infiltrate, mass/nodule • Alveolar air cells – Normally contain air (black) – Cells eg infection/inflam pus, tumour, eosinophils – Fluid eg aspiration, drowning, oedema, haemorrhage • Interstitial • Collapse V consolidation – Volume loss: mediastinal shift, fissures, diaphragm, hilum, rib crowding – Air bronchograms
  11. 11. Silhouette sign • When air in alveoli replaced with fluid/cells contrast between the lung and the neighbouring structure (heart, diaphragm) is lost and borders become indistinct. • Use the silhouette sign to determine which lobe of the lung consolidation is in.
  12. 12. 14 y M
  13. 13. Hx: 61 y M SOB
  14. 14. 10 y F bilateral crackles. No response to ventolin
  15. 15. Hx 60 y M, chronic cough, haemoptysis
  16. 16. Hx 12 Y F fever & cough
  17. 17. Hx: 5Y M reduced air sounds left chest, decrease O2 sat
  18. 18. Hx 23 F confusion
  19. 19. 66 Y F SOB
  20. 20. FHx: 54 y M SOB
  21. 21. Hx 41 Y F
  22. 22. Hx 16 Y M known malignancy
  23. 23. Hx: 88 Y M fever weight loss
  24. 24. Hx 78 Y F previous rectal cancer
  25. 25. The Black Lung • First consider Rotation: – (look at the clavicles) – The lung closer to the film plate will absorb more of the x-rays and so be whiter, whilst the lung further away allows distance for scattered rays to get through, and so will be blacker
  26. 26. 9 y M Wheeze
  27. 27. 23 y M
  28. 28. 21 y M chest pain
  29. 29. 20 Y M
  30. 30. 87 y M SOB pseudopneumothorax
  31. 31. Pulmonary embolism • Abnormalities seen on CXR in PE – – – – – – – – MORE OFTEN NORMAL – never forget this!! Segments/subsegments of linear atelectasis Raised hemidiaphragm Focal region of hyperlucency (oligaemia) “Westermark’s sign” – black area of lung seen in only 2% Peripheral foci of consolidation (infarction) e.g. Hampton’s Hump. <10% show infarction. Dilated central arteries due to arterial hypertension. Abrupt cut-off of a vessel – only if in the central arteries Pleural effusion
  32. 32. 38 y M
  33. 33. Pleural Plaques • Associated with asbestos exposure • Thickening of the parietal pleura which calcifies, especially seen over the diaphragmatic surface as dense linear bands. • Does NOT equal asbestosis, which is pulmonary parenchymal disease related to asbestos exposure – can occur together.
  34. 34. 77 y M
  35. 35. • Hilar Enlargement – unilateral or bilateral – Look for the convex contour • Neoplasm: – central bronchogenic tumour itself, or lymphadenopathy. e.g. Ca Bronchus, lymphoma, Lymphangitis carcinomatosis • • • • • Infective e.g. TB (usually unilateral), Mycoplasma, Viral in children Sarcoidosis rarely unilateral, very symmetrical Post-stenotic dilatation of pulmonary artery Pulmonary artery aneurysm (very rare) All causes of pulmonary arterial hypertension: primary (idiopathic) or secondary e.g. COAD, long- term PE, chronic left to right cardiac shunt.
  36. 36. Mediastinum • • • • • • • When reviewing CXR, don’t forget this region, which contains the oesophagus, the trachea, the aorta, the thymus Differential Diagnosis of an anterior Mediastinal mass: “The 4 Ts” Thymoma Thyroid goitre Teratoma Terrible Lymphoma Assessing the mediastinal width after severe road trauma is important to assess for – • aortic rupture. However, these films are always supine (so AP) so very variable!! In practice, if the widest part of the upper mediastinum is >30% of the total thorax diameter at that level, suspect aortic injury if clinically possible. However, NEVER ignore high clinical suspicion even if the xray seems normal.
  37. 37. 14 y M

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