Diagnostic radiology of cardiovascular 2009

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Diagnostic radiology of cardiovascular 2009

  1. 1. Diagnostic Radiology of Cardiovascular System Chen, Shaoqiong Acknowledgement : most of the slices are refer to the ppt provided by Dr. Biling Liang is gratefully acknowledged.
  2. 2. Diagnostic Radiology of Cardiovascular System /231 Imaging methods normal appearances abnormities diseases methods normal abnormities diseases
  3. 3. Cadiovascular Anatomy
  4. 4. heart
  5. 5. <ul><li>多层螺旋心脏大血管 CTA </li></ul><ul><li>(三维重建图) </li></ul>
  6. 6. 多层螺旋心脏大血管 CTA (三维重建图)
  7. 7. Methods <ul><li>X-ray </li></ul><ul><ul><li>Fluoroscopy </li></ul></ul><ul><ul><li>Plain radiography ? </li></ul></ul><ul><li>Angiocardiography & DSA </li></ul><ul><li>CT & CTA </li></ul><ul><li>MRI & MRA </li></ul><ul><li>Echocardiography (US) </li></ul><ul><li>Nuclear medicine </li></ul>
  8. 8. X-ray---- PA view ----high KV, 2M /231 X-ray methods normal abnormities diseases
  9. 9. X-ray---- Lat view /231 <ul><li>left lateral </li></ul>X-ray methods normal abnormities diseases
  10. 10. Observing the chest plain film <ul><li>The size, shape, and position of the heart </li></ul><ul><li>The state of the lungs and pulmonary vessels </li></ul><ul><li>Aorta and cardiac calcifications </li></ul>methods normal abnormities diseases
  11. 11. Normal appearance <ul><li>right ventricle, atrium : front </li></ul><ul><li>left ventricle, atrium : behind </li></ul>/231 <ul><li>Location of the heart : </li></ul><ul><ul><li>2 / 3 on the left side of midline , 1/ 3 on the right side </li></ul></ul><ul><ul><li>apex of heart point to left bottom , oblique axis </li></ul></ul>methods normal abnormities diseases
  12. 12. Normal appearance ----PA View <ul><li>Composition : </li></ul><ul><ul><li>Right border of heart : </li></ul></ul><ul><ul><ul><li>aorta ( old )、 superior vena cava ( youth ) </li></ul></ul></ul><ul><ul><ul><li>right atrium </li></ul></ul></ul><ul><ul><li>Left border of heart : </li></ul></ul><ul><ul><ul><li>aortic bulb : aortic arch </li></ul></ul></ul><ul><ul><ul><li>pulmonary artery segment ( cardiac waist ): main pulmonary artery </li></ul></ul></ul><ul><ul><ul><li>left ventricle : </li></ul></ul></ul>/231 Upper 1/2 Lower 1/2 midline methods normal abnormities diseases 70 20
  13. 13. <ul><li>Aorta arch below the clavicle, 2.0±1.0cm </li></ul><ul><li>aorta arch wider and higher –eldly, high BP </li></ul><ul><li>no aorta knob -- right aorta arch – variation </li></ul><ul><li>aorticopulmonary window – small indentation of the lung into the mediastinum, between the arch and left PA </li></ul>
  14. 14. PA view /231 Left atrium PV PA methods normal abnormities diseases
  15. 15. Normal appearance ---- Lat. view <ul><li>Composition: </li></ul><ul><ul><li>Anterior border of heart </li></ul></ul><ul><ul><ul><li>Ascending aorta </li></ul></ul></ul><ul><ul><ul><li>The infundibular of the right ventricle, pulmonary trunk </li></ul></ul></ul><ul><ul><ul><li>Anterior border of right ventricle </li></ul></ul></ul><ul><ul><li>Posterior border of heart </li></ul></ul><ul><ul><ul><li>Left atrium </li></ul></ul></ul><ul><ul><ul><li>Left ventricle </li></ul></ul></ul>/231 The normal R. atrium is not border-forming in this projection methods normal abnormities diseases
  16. 16. Normal appearance ---- Lat. view /231 <ul><ul><li>Retrocardiac </li></ul></ul><ul><ul><li>esophageal space </li></ul></ul>Retrosternal space the anterior heart border touch the1/3 of the distance between the diaphagm and the suprasternal notch RV CT CT X-ray methods normal abnormities diseases
  17. 17. Normal appearance ---- Lat. view /231 <ul><li>normal L. atrium don’t displace the esophagus </li></ul>Barium-filled esophagus methods normal abnormities diseases
  18. 18. Size of the heart and great vessels /231 <ul><ul><li>Normal : C / T ≤0.5 </li></ul></ul><ul><ul><li>Slightly enlarged : 0.51- 0.55 </li></ul></ul><ul><ul><li>Moderately enlarged : 0.56- 0.60 </li></ul></ul><ul><ul><li>Massively enlarged :> 0.60 </li></ul></ul>methods normal abnormities diseases
  19. 19. Size of the heart and great vessels /231 a b C/T ratio = a+b / T = ≤ 0.5 T methods normal abnormities diseases
  20. 20. Influencing factor of the normal heart shadow <ul><li>Body type : oblique , transverse , vertical </li></ul><ul><li>Age : with age grows , globular — oblique — horizontal </li></ul><ul><li>Respiration : </li></ul><ul><ul><li>inspiration : dropping heart, normal heart shadow </li></ul></ul><ul><ul><li>expiration : heart shadow horizontal </li></ul></ul><ul><li>Patient position : </li></ul><ul><ul><li>erect position : heart shadow elongated </li></ul></ul><ul><ul><li>lying position : heart shadow enlargement </li></ul></ul>/231 methods normal abnormities diseases
  21. 21. Influencing factor of normal heart shadow --- body type <ul><li>horizontal heart </li></ul><ul><li>oblique heart </li></ul><ul><li>dropping heart </li></ul>/231 classification : horizontal heart oblique heart dropping heart C/T R > 0.5 ≈0.5 < 0.5 included angle of cardiac longitudinal < 45 0 ≈45 0 > 45 0 axis and horizontal Heart longest axis methods normal abnormities diseases
  22. 22. normal heart shadow /231 = 45 ° oblique heart horizontal heart dropping heart = 38° = 52° methods normal abnormities diseases
  23. 23. Influencing factor of normal heart shadow -- respiration <ul><li>inspiration expiration </li></ul>/231 methods normal abnormities diseases
  24. 24. Influencing factor of normal heart shadow -- position <ul><li>erect position supine position </li></ul>/231 methods normal abnormities diseases
  25. 25. Basic X-ray features <ul><li>Heart dislocation </li></ul><ul><li>Heart enlargement </li></ul><ul><li>Abnormal pulmonary blood flow </li></ul><ul><li>Changes of aorta </li></ul><ul><li>Pericardial anomalies </li></ul>/231 methods normal abnormities diseases
  26. 26. Basic X-ray features --- Heart dislocation <ul><li>Mirror image dextrocardias </li></ul>/231 methods normal abnormities diseases
  27. 27. Basic X-ray features Heart dislocation /231 dextrocardia methods normal abnormities diseases
  28. 28. /231 mirror image dextrocardias Basic X-ray features Heart dislocation methods normal abnormities diseases
  29. 29. Basic X-ray features <ul><li>Heart dislocation </li></ul><ul><li>Heart enlargement </li></ul><ul><li>Abnormal pulmonary blood flow </li></ul><ul><li>Changes of aorta </li></ul><ul><li>Pericardial abnormal </li></ul>/231 methods normal abnormities diseases
  30. 30. <ul><li>Enlargement of the heart chambers </li></ul><ul><ul><li>Left ventricular enlargement </li></ul></ul><ul><ul><li>Right ventricular enlargement </li></ul></ul><ul><ul><li>Left atrium enlargement </li></ul></ul><ul><ul><li>Right atrium enlargement </li></ul></ul><ul><ul><li>General cardiac enlargement </li></ul></ul>/231 Basic X-ray features Heart enlargement methods normal abnormities diseases
  31. 31. Left ventricular enlargement <ul><li>X-ray appearance ; </li></ul><ul><ul><li>cardiac apex extending to left and down </li></ul></ul><ul><ul><li>the point of opposite pulsation move down </li></ul></ul><ul><ul><li>left ventricle segment extended,rounded,expand to left </li></ul></ul><ul><ul><li>the aorta is prominent </li></ul></ul><ul><ul><li>Lat : retrocardiac space become narrowed or disappeared, esophageal space disappeaered Common disease : </li></ul></ul><ul><ul><li>high blood pressure </li></ul></ul><ul><ul><li>aortic incompetence 、 stenosis </li></ul></ul><ul><ul><li>mitral incompetence </li></ul></ul><ul><ul><li>congenital heart disease : PDA </li></ul></ul>/231 methods normal abnormities diseases
  32. 32. Left ventricular enlargement /231 methods normal abnormities diseases
  33. 33. If we draw a tangent line from the apex of the left ventricle to the aortic knob (red line) and measure along a perpendicular to that tangent line (yellow line) The distance between the tangent and the main pulmonary artery (between two small green arrows) falls in a range between 0 mm (touching the tangent line) to as much as 15 mm away from the tangent line
  34. 34. 0 mm Main Pulmonary Artery Ao 15 mm Main Pulmonary Artery Ao LV LV Main pulmonary artery ranges from 0 mm–15mm from tangent line
  35. 35. Right ventricular enlargement <ul><li>X-ray appearance : </li></ul><ul><ul><li>MPA prominent </li></ul></ul><ul><ul><li>Lat : contact between the front surface of heart and the sternum (anterior chest wall) >1/3 (narrow of the retrosternal space) </li></ul></ul><ul><li>Common disease : </li></ul><ul><ul><li>Mitral valve stenosis </li></ul></ul><ul><ul><li>Chronic pulmonary heart disease </li></ul></ul><ul><ul><li>Pulmonary stenosis </li></ul></ul><ul><ul><li>Pulmonary hypertension </li></ul></ul><ul><ul><li>Fallot’s tetralogy </li></ul></ul><ul><ul><li>ASD , VSD </li></ul></ul>/231 methods normal abnormities diseases
  36. 36. Right ventricular enlargement /231 methods normal abnormities diseases
  37. 37. Left atrium enlargement <ul><li>X-ray : enlarged LA bulges to back & right </li></ul><ul><ul><li>PA – right border : double density of left atrial enlargement </li></ul></ul><ul><ul><li>PA – left border : Indentation where the left atrium, when it enlarges, will appear on the left side of the heart </li></ul></ul><ul><ul><li>Lat & RAO : middle of esophagus compressed and displaced posteriorly </li></ul></ul><ul><ul><li>LAO : Elevation of left mainstem bronchus </li></ul></ul><ul><ul><li>Common disease : </li></ul></ul><ul><ul><li>mitral lesion </li></ul></ul><ul><ul><li>left ventricular failure </li></ul></ul><ul><ul><li>congenital heart diseases : </li></ul></ul><ul><ul><ul><li>PDA </li></ul></ul></ul><ul><ul><ul><li>VSD </li></ul></ul></ul>/231 methods normal abnormities diseases
  38. 38. Left atrium enlargement /231 methods normal abnormities diseases
  39. 39. Right atrium enlargement <ul><li>X-ray appearance : </li></ul><ul><ul><li>PA : inferior segment of right border of heart extending to right , bulge, high bulge point </li></ul></ul><ul><ul><li>LAO : the right atrial curvature at least half as long as the anterior border of heart , bulge </li></ul></ul><ul><li>Common disease : </li></ul><ul><ul><li>right heart failure </li></ul></ul><ul><ul><li>ASD </li></ul></ul><ul><ul><li>tricuspid disease </li></ul></ul><ul><ul><li>pulmonary vein ectopy drainage </li></ul></ul><ul><ul><li>atrial myxoma </li></ul></ul>/231 methods normal abnormities diseases
  40. 40. Right atrium enlargement /231 methods normal abnormities diseases
  41. 41. General cardiac enlargement <ul><li>X-ray appearance : </li></ul><ul><ul><li>PA : The cardiac shadow is increased to both sides, the transverse diameter increased </li></ul></ul><ul><ul><li>Lat and RAO : narrowing of both retrosternal space and retrocardiac space, the oesophagus is displaced backward </li></ul></ul><ul><ul><li>LAO : the trachea bifurcation is sprayed, the trachea is displaced backward </li></ul></ul><ul><li>Common disease : </li></ul><ul><ul><li>Pericardial effusion </li></ul></ul><ul><ul><li>Myocarditis </li></ul></ul><ul><ul><li>Total cardiac failure </li></ul></ul><ul><ul><li>Total cardiac failure, hyperthyroidism </li></ul></ul>/231 methods normal abnormities diseases
  42. 42. general cardiac enlargement -- Pericardial effusion /231 methods normal abnormities diseases
  43. 43. the five important cardiac contours are: <ul><li>   The ascending aorta </li></ul><ul><li>Indentation where double density of left atrial enlargement will appear </li></ul><ul><li>   Aortic knob </li></ul><ul><li>   Main pulmonary artery segment </li></ul><ul><li>   Indentation where the left atrium, when it enlarges, will appear on the left side of the heart </li></ul><ul><li>The right atrium and left ventricle are less important because we evaluate ventricular enlargement by looking at the outflow tracts for each ventricle. </li></ul>
  44. 44. Basic X-ray features <ul><li>Heart dislocation </li></ul><ul><li>Heart enlargement </li></ul><ul><li>Abnormal pulmonary blood flow </li></ul><ul><li>Changes of aorta </li></ul><ul><li>Pericardial abnormal </li></ul>/231 methods normal abnormities diseases
  45. 45. Five States of the Pulmonary Vasculature <ul><li>Normal </li></ul><ul><li>Pulmonary venous hypertension </li></ul><ul><li>Pulmonary arterial hypertension </li></ul><ul><li>Increased flow </li></ul><ul><li>Decreased flow </li></ul>
  46. 46. What We’re Going to Evaluate <ul><li>Right Descending Pulmonary Artery </li></ul><ul><li>Distribution of flow in the lungs </li></ul><ul><ul><li>Upper versus lower lobes </li></ul></ul><ul><ul><li>Central versus peripheral </li></ul></ul>
  47. 47. Venous Hypertension RDPA usually > 17 mm Upper lobe vessels equal to or larger than size of lower lobe vessels = Cephalization
  48. 48. Rapid cutoff in size of peripheral vessels relative to size of central vessels Central vessels appear too large for size of peripheral vessels which come from them = Pruning Pulmonary Arterial Hypertension 31
  49. 49. Increased Flow RDPA usually > 17 mm All of blood vessels everywhere in lung are bigger than normal
  50. 50. Increased Flow Normal
  51. 51. Increased Flow Distribution of flow is maintained as in normal Lower lobe vessels bigger than upper lobe Gradual tapering from central to peripheral
  52. 52. PAH Increased Flow
  53. 53. Unrecognizable most of the time Small hila Fewer than normal blood vessels Decreased Flow
  54. 54. Basic X-ray features <ul><li>Heart dislocation </li></ul><ul><li>Heart enlargement </li></ul><ul><li>Abnormal pulmonary blood flow </li></ul><ul><li>Changes of aorta </li></ul><ul><li>Pericardial abnormal </li></ul>/231 methods normal abnormities diseases
  55. 55. Changes of aortal shape and density <ul><li>elongation, widening ,calcification </li></ul><ul><ul><li>PA : </li></ul></ul><ul><ul><ul><li>Aorta distortion: the ascending and descending aorta displacement exceeding the heart boundary , intruding the lung field </li></ul></ul></ul><ul><ul><ul><li>The demarcation between the ascending aorta and right atrium descend </li></ul></ul></ul><ul><ul><ul><li>Aorta elongation: aortic knob is high , above the clavicula sometimes </li></ul></ul></ul><ul><ul><li>Lat : </li></ul></ul><ul><ul><ul><li>Ascending and descending aorta bend forward, backward respectively , </li></ul></ul></ul>/231 methods normal abnormities diseases
  56. 56. Aorta distortion and elongation /231 methods normal abnormities diseases
  57. 57. Aorta calcification /231 methods normal abnormities diseases
  58. 58. Aorta calcification /231 methods normal abnormities diseases
  59. 59. Coronary artery calcification /231 methods normal abnormities diseases
  60. 60. Dissection of aorta <ul><li>Symptom : </li></ul><ul><ul><li>Severe chest-back pain sudden ly, with tearing sensation , radiating to the neck and abdomen </li></ul></ul><ul><li>Pathology : Hemorrhage in the media separate media from adventitia, and form pseudocoele inside the aortal wall </li></ul>/231 Medical emergency <ul><li>Clue for diagnosis </li></ul><ul><li>intimal tear point </li></ul><ul><li>intimal flap </li></ul><ul><li>pseudocoele </li></ul>methods normal abnormities diseases
  61. 61. Dissection of aorta <ul><li>Types </li></ul><ul><li>      DeBakey Type I </li></ul><ul><li>        Involves entire aorta </li></ul><ul><li>    DeBakey Type II </li></ul><ul><li>       Ascending aorta only </li></ul><ul><li>     DeBakey Type III </li></ul><ul><li>          Descending aorta only    </li></ul>/231 methods normal abnormities diseases
  62. 62. Dissection of aorta <ul><li>Types </li></ul><ul><li>    Stanford Type A </li></ul><ul><li>    Ascending aorta involved  </li></ul><ul><li>  Stanford Type B </li></ul><ul><li>Ascending aorta NOT involved   </li></ul>/231 methods normal abnormities diseases
  63. 63. Dissection of aorta Usually medically Hypertension Atherosclerosis Descending aorta only  Stanford Type B DeBakey Type III (most common)  Usually surgically* Cystic medial necrosis e.g.Marfan’s Ehlers-Danlos Ascending aorta only  Stanford Type A (ascending aorta involved)  DeBakey Type II (least common)  Usually surgically* Hypertension Atherosclerosis Involves entire aorta  Stanford Type A (ascending aorta involved) DeBakey Type I   RX Common causes Portion of Aorta Involved Stanford Classification DeBakey Classification
  64. 64. Dissection of aorta True lumen methods normal abnormities diseases
  65. 65. Dissection of aorta True versus false channel methods normal abnormities diseases
  66. 66. Dissection of aorta methods normal abnormities diseases
  67. 67. Aneurysm <ul><li>ascending aorta > 5 cm </li></ul><ul><li>Descending aorta > 4 cm  </li></ul><ul><li>abdominal aorta >3 cm </li></ul><ul><li>Normal size of abdominal aorta >50 years of age: </li></ul><ul><ul><li>About 2 cm </li></ul></ul>
  68. 68. Abdominal aortic aneurysm /231 perianeurysmal fibrosis (10%) methods normal abnormities diseases
  69. 69. Aneurysm /231 methods normal abnormities diseases
  70. 70. Abdominal aortic aneurysm /231 methods normal abnormities diseases
  71. 71. CTA /231 angiocardiography CT MRI echocardiography X-ray methods normal abnormities diseases
  72. 72. Aneurysm of aorta ( syphilitic ) /231 methods normal abnormities diseases

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