Chest imaging


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Chest imaging

  1. 1. Chest Imaging RADIOLOGY DEPARTMENT
  2. 2. IMAGING MODALITIES1. Plain chest Radiograph2. Fluoroscopy3. Computerized tomography4. Radionuclide lung scan5. MRI6. Ultrasound7. Pulmonary angiography
  3. 3. Plain chest radiograph• Diagnostic in 80% cases• Standard views 1. Postero-anterior(P/A) 2. Lateral (right/left)• Additional views 1. Oblique view(ribs) 2. Apical lordotic view 3. Expiration view 4. Decubitus view
  4. 4. Computed Tomography• Numerous protocols/techniques depending on clinical history• Helical/spiral versus high resolution• Contrast – Renal failure – Allergy
  5. 5. Computed Tomography• Role of CT – Main further investigation for most CXR abnormality (eg nodule/mass) or to exclude disease with normal CXR – Main investigation for certain scenarios (PE, dissection, trauma)
  6. 6. MRI• Multiple planes• No radiation• Common Indication – Pancoast tumour – Brachial plexus – Cardiac – Vascular (aorta)• Usually targeted examination (unlike CT) Coronal
  7. 7. Nuclear Medicine• Variety of tests: functional rather than anatomic• V/Q specific to chest imaging• Others: bone scan, gallium, WBC etc.
  8. 8. Ultrasound• Limited use in thorax (non cardiac) due to air in lungs• Assess pleural effusions• Mainly used for procedures
  9. 9. Chest Radiographs• PA (posterior to anterior) and Lateral (left) – Minimizes magnification of heart (heart closest to film)• Portable (nearly always AP) – Supine or Erect• Specialized Views – Lordotic – Lateral decubitus (for effusions, pneumothorax)
  10. 10. Lordotic View Better assess apices without bone overlap
  11. 11. 1 1: Adequate penetration of 4 a the mediastinum-is the a thoracic spine seen? 2: Has the patient taken a good inspiratory effort? About 8-107 posterior thoracic ribs should be seen through the lungs 3: Is there any rotation of the chest? Assessed by checking 10 the upper thoracic spinous process (oval) in relation to the medial ends of the clavicles (lines ‘a’) - this CXR is rotated to left
  12. 12. Retro sternal space Retro cardiac space
  13. 13. Chest Radiograph: Approach and Normal AnatomyTHERE IS NO ONE APPROACH: BE SYSTEMATIC• Bone and Soft Tissue including abdomen• Heart• Mediastinum-aorta, trachea• Hila• Pulmonary Vasculature• Lungs• Pleura
  14. 14. Sequence For X Ray Reading 5 Ds• Detect• Describe• Differential Diagnosis• Discuss• Diagnosis
  15. 15. CXR: Superimposition
  16. 16. CT Coronal ReconstructionRight Brachiocephalic Left Brachiocephalic VeinVein Superior Vena Cava Right Atrium Inferior Vena Cava
  17. 17. Heart Size • Normal is <50% on PA upright radiograph
  18. 18. Increased Cardiac Size Normal for comparisonCardiomegaly (Big heart)
  19. 19. MRI of Aorta Aorta PA view Aortic arch Descending Aorta
  20. 20. Aorta CXR: Lateral ViewAscending DescendingAorta Aorta
  21. 21. Case: Aorta can be enlarged (aneurysm)
  22. 22. Pulmonary Artery Left LungCoronal Image PA Lung “markings” are pulmonary arteries and veins
  23. 23. • Spine Sign: Lungs posteriorly should get Scapula darker as you go down inspexp more inferiorlyRetrosternal Airspace Hilum IVC Pulmonary Vessels
  24. 24. Case: (Look at the trachea)Trachea isDeviated bylarge mass(goiter)
  25. 25. Abnormal Cases• Bone• Cardiovascular• Airspace Disease including Silhouette Sign• Interstitial Disease and Pulmonary Edema• Atelectasis• Pulmonary Nodule• Pleura and Diaphragm• Mediastinal Mass
  26. 26. ACINAR PATTERN (CXR) Radiology: Round or elliptical ill-defined 4-8mm opacities in lungMicroscopic: Portion of lung distal to terminal bronchial (respiratory bronchial, alveolar duct, alveolar sac and alveoli) is the acinus CXR close up of acinar pattern
  27. 27. ACINAR PATTERN (CT SCAN)Round or elliptical ill-defined 4-8mm opacities in lung CT scan of right upper lobe showing typical acinar pattern (arrow)
  28. 28. AIR BRONCHOGRAMAir containing bronchus peripheral to the hilum surrounded by airless lung CXR CT Scan Air Bronchogram
  29. 29. NODULAR PATTERN Collection of innumerable small, linear and nodular opacities together producing a net with small superimposed nodules. CTCXR Close up of nodular pattern
  30. 30. EMPHYSEMA: Abnormally expanded air spaces distal to terminal bronchiole with destruction of walls of involved air spaces..BULLA: Gas containing avascularity of lung measuring 1cm or more in diameter, 1mm thickness Bulla CT of bulla
  31. 31. Pneumonia (consolidation)• Air bronchograms would confirm an alveolar process.• The lung volume should not be lost (may even be increased).• Usually all radiographic abnormalities should disappear after 6 weeks of appropriate antibiotic therapy.
  32. 32. Pneumonia RML
  33. 33. Right Upper Lobe Pneumonia
  34. 34. Left Lingular Pneumonia
  35. 35. Left Lower Lobe Pneumonia
  36. 36. Pneumonia RLL
  37. 37. Consolidation and follow-up X-rays• Recommendations are, repeat film at 1, 3 and 7 days to check for the development of complications.• Resolution of the X-ray signs always lags behind the clinical findings• The X-ray should therefore be repeated 4 weeks later to check for resolution.• If there is persistent consolidation at this stage, further investigation is necessary to exclude an obstructive lesion.
  38. 38. SIGNS OF COLLAPSEDIRECT SIGNS:• Displacement of fissures• Loss of aeration• Vascular & bronchial signsINDIRECT SIGNS:• Mediastinal & Hilar displacement• Elevation of Hemidiphragm• Compensatory hyperinflation
  39. 39. Collapse RUL
  40. 40. Collapse LUL
  41. 41. Indistinct Right Heart Border
  42. 42. Right Middle Lobe Atelectasis
  43. 43. Left lower lobe collapse• Further investigations?
  44. 44. Diagnosis: LLL Collapse• Collapse secondary to central obstructing tumour
  45. 45. Pleural Effusion
  46. 46. Small Pleural Effusion
  47. 47. Small Pleural Effusion Normal: Sharp AnglesBlunted posterior costophrenic sulcus
  48. 48. Pleural Effusion
  49. 49. Tension Pneumothorax
  50. 50. ptxinspexpInspiration Expiration
  51. 51. hugeptx Tracheal Deviation Collapsed Right Lung What would you do with this patient?Tension Pneumothorax: Requires chest tube
  52. 52. Causes of a pneumothorax• Spontaneous• Iatrogenic/trauma,• Obstructive lung disease, e.g. asthma, COPD• Infection, e.g. pneumonia, tuberculosis Cystic fibrosis• Connective Tissue Disorders, e.g. Marfan’s, Ehlers-Danlos
  53. 53. Pneumomed
  54. 54. Diagnosis: Pneumomediastinum
  55. 55. Coin Lesion
  56. 56. Causes of single coin lesions• Benign tumor, e.g. hamartoma• Malignant tumor, e.g. bronchial carcinoma, single secondary• Infection, e.g. pneumonia, abscess, tuberculosis, hydatid cyst• Infarction• Rheumatoid nodule
  57. 57. Solitary Pulmonary Nodule can be:Malignant: Adenocarcinoma Benign: Densely calcified nodule
  58. 58. Cavitating lung lesion
  59. 59. Causes of cavitating lung lesions• Abscess• Neoplasm• Cavitating pneumonia• Cavitations in infarct• Rheumatoid nodules (rare)
  60. 60. Left Ventricular Failure
  61. 61. CASE 1 1:What is your diagnosisHistory: Young patient with cough and night sweats 2: Give differential diagnosis for upper lobe
  62. 62. Normal
  63. 63. Severe heart failure• Severe pulmonary edema gives confluent alveolar shadowing which spreads out from the hilum giving a bats wing appearance.• If this is the cause of generalized shadowing then upper lobe blood diversion and Kerley B lines should be present.• In pulmonary edema hilum may appear distended and the vessels close to the hilum may be blurred.
  64. 64. Severe heart failure vs. non- carcinogenic pulmonary edema• In non-cardiogenic pulmonary edema the heart size is likely to be normal and there will not necessarily be sparing of the peripheries.
  65. 65. COPD
  66. 66. Bronchiectasis
  67. 67. Causes of Bronchiectasis• Structural, e.g. Kartagener syndrome,• obstruction (carcinoma, foreign body)• Infection, e.g. childhood pertussis or measles, tuberculosis, pneumonia• Immune, e.g. hypogammaglobulinaemia, allergic bronchopulmonary aspergillosis• Metabolic, e.g. cystic fibrosis• Idiopathic to stasis
  68. 68. Unilateral Hilar enlargement
  69. 69. Unilateral Hilar Enlargement• Causes of hilar lymphadenopothy – Neoplastic, e.g. spread from bronchial carcinoma, primary lymphoma – Infective, e.g. tuberculosis – Sarcoidosis (rarely unilateral)• Causes of hilar vascular enlargement – Pulmonary artery aneurysm – Poststenotic dilatation of the pulmonary artery
  70. 70. Bilateral Hilar Enlargement
  71. 71. Bilateral Hilar Enlargement• Causes of bilateral hilar lymphadenopathy – Sarcoid – Tumors, e.g. lymphoma, bronchial carcinoma, metastatic tumors – Infection, e.g. tuberculosis, recurrent chest infections, AIDS – Berylliosis• Causes of pulmonary hypertension – Obstructive lung disease, e.g. asthma, COPD – Left heart disease, e.g. mitral stenosis, left ventricular failure – Left to right shunts, e.g. ASD, VSD – Recurrent pulmonary emboli – Primary pulmonary hypertension
  72. 72. Paratracheal and Hilar Lymphadenopathy: ?Diagnosis
  73. 73. NORMAL
  74. 74. Sarcoidosis
  75. 75. benignthymoma
  76. 76. Lateral shows mass is anterior NORMAL
  77. 77. Computed Tomography Thymoma:Do you know of any associated clinical syndrome?
  78. 78. Presenting CXR
  79. 79. MRI Computed Tomography
  80. 80. pulmedemaSOB
  81. 81. Same Patient
  82. 82. baselineSame Patient: Baseline
  83. 83. Rul collapseRUL Collapse
  84. 84. Lul consolidation
  85. 85. Diagnosis: LUL Consolidation
  86. 86. Paratracheal ln
  87. 87. Right Paratracheal Lymphadenopathy
  88. 88. RML Consolidation Rml consolidation
  89. 89. 50 y.o female with progressive SOB. What can you do to improve SOB?
  90. 90. Volume loss with atelectasis Mass effect with large effusion
  91. 91. baselineMastectomy
  92. 92. Hiatus hernia hh
  93. 93. Rt. ParatrachealLymphadenopathy (Lymphoma) After Therapy Where is the Lymphadenopathy?
  94. 94. Nipple Shadow