Chest radiology part 3
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Gamal Rabie Agmy, MD provides definitions and descriptions of various cavitary lung lesions and cystic mediastinal structures in 3 sentences or less: Bullae are thin-walled air spaces greater than 1 cm in size that result from destruction and dilatation of distal airspaces. Pneumatoceles are thin-walled lung cysts less than 1 mm thick resulting from staph infection and necrosis. Honeycombing describes multiple cysts less than 1 cm in diameter in a background of fibrosis, representing end-stage lung disease.
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Chest radiology part 3
- 2. Gamal Rabie Agmy, MD, FCCP Professor of Chest Diseases, Assiut University ERS National Delegate of Egypt
- 4. Bulla Definition •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 and confluence of airspaces distal to terminal bronchioles.
- 5. •Bullous disease may be primary or associated with emphysema or interstitial lung disease. • Primary bullous lung disease may be familial and has been associated with Marfan's, Ehler's Danlos, IV drug users, HIV infection, and vanishing lung syndrome. •Bullae may occasionally become very large and compromise respiratory function. Thus has been referred as vanishing lung syndrome, and may be seen in young men.
- 8. A: Xray shows bilateral bulla. B: CT shows bilateral bulla. C: CT after bullectomy.
- 10. Pneumatocele is a benign air containing cyst of lung, with thin wall < 1mm as bulla but with different mechanism Infection with staph aureus is the commonest cause ( less common causes are, trauma, barotrauma) lead to necrosis and liquefaction followed by air leak and subpleural dissection forming a thin walled cyst.
- 11. •Honeycombing is defined as multiple cysts < 1cm in diameter,with well defined walls, in a background of fibrosis, tend to form clusters and is considered as end stage lung . •It is formed by extensive interstitial fibrosis of lung with residual cystic areas.
- 13. A cyst is a ring shadow > 1 cm in diameter and up to 10 cm with wall thickness from 1-3 mm.
- 15. Thin walled cysts of LAM
- 16. A cavity is > 1cm in diameter, and its wall thickness is more than 3 mm.
- 17. •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
- 18. 1. Site
- 19. A cavity in apicoposterior segment of left upper lobe
- 20. 2.Number Multiple cavities: 1. Aspiration. 2. TB 3. Fungal. 4. Metastatic. 5. Septic emboli. 6.Wegners granulomatosis
- 21. Multiple cysts of metastasis from squamous cell carcinoma. Multiple thick wall cavities from adenocarcinoma of right lung
- 24. Irregular , nodular inner lining of thick wall abscess Malignant cavity. 3. Thickness and irregularity
- 26. 5. Relation to lymph node enlargement
- 27. 6. Contents
- 28. •Arrow head Crescent sign. •Black arrows Fibrotic bands surrounding cavity (Fibrocavitary TB).
- 30. Primary Lung Cancer • Thick wall • Shaggy lumen • Eccentric cavitation
- 31. | Squamous Cell Carcinoma Lung LUL mass Thick walled cavity Eccentric location of cavity
- 32. Fungous Ball Long standing cavity Containing round density (A) Mobile density Adjacent pleural reaction (B) - characteristic of aspergilloma
- 33. Cavitating Metastasis MultipleThin Walled Cavities Cancer Cervix
- 34. Lung Cancer / Squamous Cell Mass density Anterior segment of LUL Thick wall cavitation
- 35. SquamousCell Carcinoma Anterior segment of LUL Thick wall Fluid level Full hilum
- 36. SquamousCell Carcinoma Lung Thick wall Irregular lumen left hilar LN
- 38. Etiology: Cavity can be encountered in practically most lung diseases. Common diseases and their characteristics include: Primary Lung Cancer Thick wall Shaggy lumen Eccentric cavitation Necrotizing Pneumonia Lung abscess Gravity dependant segments Thick wall Air-fluid levels Tuberculosis Superior segments Infiltrate around Bilateral Fungal infections Aspergillus Fungous ball Sub acute invasive aspergillosis Metastatic disease Thin walled (Squamous cell) Thick wall (Adenoma)
- 39. Diffuse Alveolar Pneumonia The most common causes for diffuse alveolar pneumonia are: Pneumocystis Cytomegalovirus
- 40. Consolidation Right Upper Lobe / Density in right upper lung field Lobar density Loss of ascending aorta silhouette No shift of mediastinum Transverse fissure not significantly shifted Air bronchogram
- 41. Necrotizing Pneumonia / Lung Abscess / Aspiration Superior segment RLL dense pneumonia Progression / Cavity
- 42. Radiation Pneumonia Post Mediastinal Radiation Air space disease (air bronchogram) Over radiation port (vertical and paramediastinal) Bilateral Progression to fibrosis
- 43. Round Pneumonia Round density Shorter doubling time Air bronchogram The most common causes for round pneumonia are: Fungal Tuberculosis
- 46. Consolidation / Lingula Density in left lower lung field Loss of left heart silhouette Diaphragmatic silhouette intact No shift of mediastinum Blunting of costophrenic angle Lateral Lobar density Oblique fissure not significantly shifted Air bronchogram
- 47. Consolidation Left Lower Lobe Density in left lower lung field Left heart silhouette intact Loss of diaphragmatic silhouette No shift of mediastinum Pneumatocele One diaphragm only visible Lobar density Oblique fissure not significantly shifted
- 48. Left Upper Lobe Consolidation Density in the left upper lung field Loss of silhouette of left heart margin Density in the projection of LUL in lateral view Air bronchogram in PA view No significant loss of lung volume
- 49. Vague density right lower lung field Indistinct right cardiac silhouette Intact diaphragmatic silhouette Density corresponding to RML No loss of lung volume RML pneumonia
- 50. Consolidation Right Upper Lobe / Air Bronchogram Density in right upper lung field Lobar density Loss of ascending aorta silhouette No shift of mediastinum Transverse fissure not significantly shifted Air bronchogram
- 52. Elevated Diaphragm" Note pneumoperitoneum Supradiaphragmatic mass Can be mistaken for elevated diaphragm Pellets
- 53. Alveolar Cell Carcinoma - Progression Old film on left Solitary pulmonary nodule resected Onset of diaphragmatic paralysis Progression to multicentric acinar nodules
- 54. Hyperlucent Lung Factors Vasculature: Decrease Air: Excess Tissue : Decrease Bilateral diffuse Emphysema Asthma Unilateral Swyer James syndrome Agenesis of pulmonary artery Absent breast or pectoral muscle Partial airway obstruction Compensatory hyperinflation Localized Bullae Westermark's sign : Pulmonary embolus
- 55. Agenesis of Left Pulmonary Artery Missing vascular markings in left lung Left hilum not seen Entire cardiac output to right lung
- 56. Missing Right Breast "Hyperlucent" right base secondary to missing breast.
- 57. Unilateral Hyperlucent Lung Left Upper Lobe Resection Left lung hyper lucent Left hilum pulled up No abnormal density
- 59. Alveolar Proteinosis Bilateral diffuse alveolar disease Butterfly pattern Medullary distribution Air bronchograms
- 60. Adult Respiratory Distress Syndrome Non-cardiogenic pulmonary edema Distinguishing characteristics: Normal size heart No pleural effusion
- 65. Chest Tubes
- 68. Achalasia of esophagus • Inhomogeneous cardiac density: Right half more dense than left • Density crossing midline (right black arrow) • Right sided inlet to outlet shadow • Right para spinal line (left black arrow) • Barium swallow below: Dilated esophagus
- 69. 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
- 73. Dissecting Aneurysm Mediastinal widening Inlet to outlet shadow on left side Retrocardiac: Intact silhouette of left heart margin Pulmonary artery overlay sign: Density behind left lower lobe Wavy margin
- 84. Colon in front of liver
- 89. Lymph Nodes
- 101. of PE Diagnostic Algorithm 1. Patients with normal chest radiographic findings are evaluated with a perfusion scan and, if necessary, an aerosol ventilation scan. Patients with normal or very low probability scintigraphic findings are presumed not to have pulmonary emboli . 2-Patients with a high-probability scan usually undergo anticoagulation therapy. All other patients should be evaluated with helical CT pulmonary angiography, conventional pulmonary angiography, or lower-extremity US, depending on the clinical situation
- 102. of PE Diagnostic Algorithm 3-Patients with abnormal chest radiographic findings, are unlikely to have definitive scintigraphic findings. These patients undergo helical CT pulmonary angiography as well as axial CT of the inferior vena cava and the iliac, femoral, and popliteal veins. If the findings at helical CT pulmonary angiography are equivocal or technically inadequate (5%– 10% of cases) or clinical suspicion remains high despite negative findings, additional imaging is required. 4-Patients who have symptoms of deep venous thrombosis but not of pulmonary embolism initially undergo US, which is a less expensive alternative. If the findings are negative, imaging is usually discontinued; if they are positive, the patient is evaluated for pulmonary embolism at the discretion of the referring physician.
- 110. Pulmonary Edema
- 118. Pulmonary Hemorrhage
- 119. Pneumomediastinum
- 122. Potential Sources of Mediastinal Air Intrathoracic Trachea and major bronchi Esophagus Lung Pleural space Extrathoracic Head and neck Intraperitoneum and retroperitoneum
- 126. Radiographic Signs of Pneumomediastinum Subcutaneous emphysema Thymic sail sign Pneumoprecardium Ring around the artery sign Tubular artery sign Double bronchial wall sign Continuous diaphragm sign Extrapleural sign Air in the pulmonary ligament
- 137. Mediastinal Cysts
- 138. The CT features of benign mediastinal cyst are (a) a smooth, oval or tubular mass with a well- defined thin wall that usually enhances after intravascular administration of contrast material, (b) homogeneous attenuation, usually in the range of water attenuation (0–20 HU), (c) no enhancement of cyst contents, and (d) no infiltration of adjacent mediastinal structures.
- 139. Cysts that contain serous fluid typically have long T1 and T2 relaxation values, which produce low signal intensity on T1-weighted MR images and high signal intensity on T2- weighted images.
- 141. Because cysts containing nonserous fluid can have high attenuation at CT, they may be mistaken for solid lesions. MR imaging can be useful in showing the cystic nature of these masses because these cysts continue to have characteristically high signal intensity when imaged with T2- weighted sequences regardless of the nature of the cyst contents
- 142. Radionuclide imaging can be helpful in detecting functioning thyroid tissue (iodine-123 or I-131) or parathyroid tissue (technetium-99m sestamibi) in the mediastinal cystic mass . gallium- 67 scintigraphy may show increased radiotracer uptake in the cystic malignancy owing to necrosis such as lymphoma or metastatic carcinoma.
- 143. Ultrasonography (US) can be useful in evaluating a mass adjacent to the pleural surface or cardiophrenic angle. At US, the benign cysts typically appear as anechoic thin-walled masses with increased through transmission
- 144. Bronchogenic Cysts
- 147. Duplication Cyst
- 149. Pericardial Cyst
- 151. Meningocele
- 153. Thymic Cysts
- 155. Cystic Teratoma
- 157. Lymphangioma
- 159. Cystlike Lesions
- 165. Mediastinal Abscess