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Chest imaging
This document provides an overview of various imaging modalities used for chest imaging including plain chest radiographs, computed tomography, MRI, nuclear medicine scans, ultrasound, and pulmonary angiography. It describes the technical aspects and clinical applications of each modality. Key points covered include how plain chest radiographs remain diagnostic in 80% of cases and involve standard views, as well as how computed tomography is the main further investigation for most chest x-ray abnormalities and certain scenarios like pulmonary embolism.
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Chest imaging
- 1. Chest Imaging RADIOLOGYDEPARTMENT
- 2. IMAGING MODALITIES 1. Plain chest Radiograph 2. Fluoroscopy 3. Computerized tomography 4. Radionuclide lung scan 5. MRI 6. Ultrasound 7. Pulmonary angiography
- 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. Computed Tomography • Numerous protocols/techniques depending on clinical history • Helical/spiral versus high resolution • Contrast – Renal failure – Allergy
- 5. Computed Tomography • Roleof 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. MRI • Multiple planes •No radiation • Common Indication – Pancoast tumour – Brachial plexus – Cardiac – Vascular (aorta) • Usually targeted examination (unlike CT) Coronal
- 7. Nuclear Medicine • Varietyof tests: functional rather than anatomic • V/Q specific to chest imaging • Others: bone scan, gallium, WBC etc.
- 8. Ultrasound • Limited usein thorax (non cardiac) due to air in lungs • Assess pleural effusions • Mainly used for procedures
- 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. Lordotic View Better assess apices without bone overlap
- 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 8-10 7 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
- 14. Retro sternal space Retro cardiac space
- 15. Chest Radiograph: Approachand Normal Anatomy THERE IS NO ONE APPROACH: BE SYSTEMATIC • Bone and Soft Tissue including abdomen • Heart • Mediastinum-aorta, trachea • Hila • Pulmonary Vasculature • Lungs • Pleura
- 16. Sequence For XRay Reading 5 Ds • Detect • Describe • Differential Diagnosis • Discuss • Diagnosis
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- 18. CT Coronal Reconstruction RightBrachiocephalic Left Brachiocephalic Vein Vein Superior Vena Cava Right Atrium Inferior Vena Cava
- 19. Heart Size • Normal is <50% on PA upright radiograph
- 20. Increased Cardiac Size Normal for comparison Cardiomegaly (Big heart)
- 21. MRI of Aorta Aorta PA view Aortic arch Descending Aorta
- 22. Aorta CXR: Lateral View Ascending Descending Aorta Aorta
- 23. Case: Aorta canbe enlarged (aneurysm)
- 24. Pulmonary Artery Left Lung Coronal Image PA Lung “markings” are pulmonary arteries and veins
- 25. • Spine Sign:Lungs posteriorly should get Scapula darker as you go down inspexp more inferiorly Retrosternal Airspace Hilum IVC Pulmonary Vessels
- 26. Case: (Look atthe trachea) Trachea is Deviated by large mass (goiter)
- 27. Abnormal Cases • Bone • Cardiovascular • Airspace Disease including Silhouette Sign • Interstitial Disease and Pulmonary Edema • Atelectasis • Pulmonary Nodule • Pleura and Diaphragm • Mediastinal Mass
- 29. ACINAR PATTERN (CXR) Radiology: Round or elliptical ill-defined 4-8mm opacities in lung Microscopic: Portion of lung distal to terminal bronchial (respiratory bronchial, alveolar duct, alveolar sac and alveoli) is the acinus CXR close up of acinar pattern
- 30. ACINAR PATTERN (CTSCAN) Round or elliptical ill-defined 4-8mm opacities in lung CT scan of right upper lobe showing typical acinar pattern (arrow)
- 31. AIR BRONCHOGRAM Air containingbronchus peripheral to the hilum surrounded by airless lung CXR CT Scan Air Bronchogram
- 32. NODULAR PATTERN Collectionof innumerable small, linear and nodular opacities together producing a net with small superimposed nodules. CT CXR Close up of nodular pattern
- 33. 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
- 34. Pneumonia (consolidation) • Airbronchograms 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.
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- 36. Right Upper LobePneumonia
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- 38. Left Lower LobePneumonia
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- 40. Consolidation and follow-upX-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.
- 41. SIGNS OF COLLAPSE DIRECTSIGNS: • Displacement of fissures • Loss of aeration • Vascular & bronchial signs INDIRECT SIGNS: • Mediastinal & Hilar displacement • Elevation of Hemidiphragm • Compensatory hyperinflation
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- 44. Indistinct Right Heart Border
- 45. Right Middle LobeAtelectasis
- 48. Left lower lobecollapse • Further investigations?
- 49. Diagnosis: LLL Collapse •Collapse secondary to central obstructing tumour
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- 52. Small Pleural Effusion Normal: Sharp Angles Blunted posterior costophrenic sulcus
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- 57. ptxinspexp Inspiration Expiration
- 58. hugeptx Tracheal Deviation Collapsed Right Lung What would you do with this patient? Tension Pneumothorax: Requires chest tube
- 59. Causes of apneumothorax • 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
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- 64. Causes of singlecoin 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
- 65. Solitary Pulmonary Nodulecan be: Malignant: Adenocarcinoma Benign: Densely calcified nodule
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- 67. Causes of cavitatinglung lesions • Abscess • Neoplasm • Cavitating pneumonia • Cavitations in infarct • Rheumatoid nodules (rare)
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- 69. CASE 1 1:What is your diagnosis History: Young patient with cough and night sweats 2: Give differential diagnosis for upper lobe
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- 72. Severe heart failure •Severe pulmonary edema gives confluent alveolar shadowing which spreads out from the hilum giving a 'bat's 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.
- 73. Severe heart failurevs. 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.
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- 76. 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
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- 78. 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
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- 80. 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
- 81. Paratracheal and HilarLymphadenopathy: ?Diagnosis
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- 85. Lateral shows massis anterior NORMAL
- 86. Computed Tomography Thymoma: Do you know of any associated clinical syndrome?
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- 89. MRI Computed Tomography
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- 98. RML Consolidation Rmlconsolidation
- 99. 50 y.o femalewith progressive SOB. What can you do to improve SOB?
- 100. Volume loss withatelectasis Mass effect with large effusion
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- 103. Rt. Paratracheal Lymphadenopathy (Lymphoma) After Therapy Where is the Lymphadenopathy?
- 104.