呼吸系统影像诊断.ppt

呼吸系统影像诊断,BronchialObstruction,局部支气管狭窄stenosis支气管闭塞Obstruction肿块massinbronchialcavity管壁增厚thickenedofbronchialwall,directnesssigns,重点复习,Indirectnesssigns：阻塞性肺气肿：部分阻塞Incompleteobstructionobstructiveemphysema阻塞性肺不张：完全阻塞.Completeobstructionobstructiveatelectasis.,centrilobularemphysema,肺体积膨大Overinflation密度减低Densityreduce,panlobularemphysema,肺体积缩小Incompleteexpansionofthelung,Thesizeoflungshrunken密度增高Increaseddensity,obstructiveatelectasis.,obstructiveemphysema,X线表现x-rayappearances肺泡、肺小叶实变consolidation支气管气像（airbronchogram）Noanylossofvolume,渗出与实变Exudationandconsolidation,纤维化fibrosis,局部病灶纤维化Localfibrosis,弥漫性间质纤维化Diffuseinterstitialfibrosis,Calcification,noduleandmass,Benign,Malignant,lobulation,spiculation,血管集束征,病灶胸膜侧小片状浸润,支气管充气征,worm-eatencavities,Thin-walledcavity,thick-walledcavity,aircontainingspace,cavityandaircontainingspace,空气半月征Aircrescentsign,曲菌球,支气管血管束增粗peribronchovascularburdleinterstitialthicking,Signet-ringsign印戒征,小叶间隔增厚Interlobularseptalthicking,小叶核增大Lobularcorethicking,树芽征（tree-buddedsign）,肺间质病变,interstitialnodulesmultinodularandmiliarydiseases,air-spacenodule,磨玻璃影ground-glassopacity,GGO：肺内密度增高的模糊影，但肺纹理可见,胸腔积液（pleuraleffusion）游离性胸腔积液freepleuraleffusion少量积液中量积液：大量积液：局限性胸腔积液localizedpleuraleffusion包裹性积液叶间积液肺底积液,胸膜凹陷征,胸膜凹陷征pleuralindentationsign,支气管扩张bronchiectasis肺炎pneumonia大叶性肺炎小叶性肺炎间质性肺炎支原体肺炎肺结核Pulmonarytuberculosis肺癌Lungcancer纵隔肿瘤mediastinaltumor,本节课内容,支气管扩张bronchiectasis,支气管内径不同程度异常增宽多数为后天性，少数为先天性，好发于儿童及青壮年好发于段以下3-5级小支气管,bronchiectasis,临床表现：咳嗽、咳血、咳痰Continuouscough,purulentsputum,recurrenthaemoptysis分型：柱状型(Cylindricalbronchiectasis)、囊状型(Cysticbronchiectasis)、曲张型(Varicosebronchiectasis),病理：pathologicchangings,支气管壁组织破坏（慢性感染）管内压增高（分泌物淤积、长期剧烈咳嗽）外在性牵拉（肺不张、纤维化等）,bronchiectasis,平片：plainchestradiographicfindingsoftennonspecific肺纹理增粗紊乱，囊状透亮影，anincreaseoflungmarkingsSurroundinginfiltrateorfibrosis合并感染时有液平及囊壁增厚。dilatedbronchi,sometimeswithair-fluidlevels,bronchiectasis,支气管造影bronchography：支气管呈囊状、柱状囊柱状扩张Tubular,VaricoseorCysticbronchialdilatation,囊状、柱状,bronchiectasis,曲张型扩张,TubularandCysticbronchialdilatation,念珠状,粗细不均,囊柱状,bronchiectasis,平片价值有限,支气管造影病人痛苦,主要依靠CT诊断HRCT(highresolutionCT),bronchiectasis,戒指征Thesignetringsign,HRCT表现,轨道征,轨道征Tram-tracksign,囊柱状粗细不均念珠状,柱状型曲张型,bronchiectasis,葡萄串征clustersofgrapessign,囊状型,葡萄串征clustersofgrapessign,液平air-fluidlevels囊壁增厚,囊状型,bronchiectasis,Dilatationofthebronchus,BronchialwallthickeningSometimesair-fluidlevels,粘液栓塞-“指状征”Glovedfingersign,bronchiectasis,bronchiectasis,Bronchialwallthickening“戒指征Thesignetringsign和”“轨道征tracksign”支气管管径粗细不均-囊柱状改变Varicosetype葡萄串样囊状阴影，合并感染时有液平clustersofgrapessignwithair-fluidlevels粘液栓塞时呈“指状征”改变Glovedfingersign,AbstractCTfeatures,肺炎(pneumonia),Classficationofpneumonia,Accordingtotheanatomicpositionofthelesion:LobarpneumoniaBronchopneumoniaorLobularpneumoniaInterstitialpneumoniaAccordingtotheetiologyofthepneumonia,按病变分布分为：,大叶性肺炎Lobarpneumonia炎症累及肺叶或肺段支气管肺炎(小叶性肺炎)bronchopneumoniaorLobularpneumonia炎症累及多个肺小叶为主间质性肺炎Interstitialpneumonia炎症累及肺间质为主,Lobarpneumonia大叶性肺炎临床,Causedbypneumococcus肺炎链球菌致病Onsetsuddenly,rapiddevelopmentofhighpyrexia,pleuriticpaincoughAcharacteristicrustycolorsputum铁锈色痰,pathologicchangingsofLobarpneumonia,Thebasicpathologiclesion:Acuteinflammatoryexudationofthepulmonaryparenchyma病理分四期：充血期Thecongestivestage:毛细血管充血为主Inflammatoryedema红色肝样变期Theredconsolidationstage:肺泡内充满渗出液,有较多红细胞,肺组织切面呈红色灰色肝样变期Thegrayconsolidationstage:肺泡内有较多白细胞,肺组织切面呈灰色消散期Resolutionstage:肺泡内渗出物溶解,吸收,X线表现X-rayfeatures,影像学表现与病理改变密切相关,是病理改变在影像学上的反映充血期Thecongestivestage可无阳性发现,临床症状出现3-12小时后才出现X线征象NoX-raychanges病变区肺纹理增多，透亮度减低anincreaseoflungmarking,Lobarpneumonia,实变期（红色或灰色肝样变期）Theconsolidationstage密度均匀的致密影alargehomogeneousradiopaqueshadowinthelungfieldNovolumelossAirbronchogramiscommon,累及肺叶：以叶间裂为界的大片致密影,但体积不缩小,无叶间裂的移位,右中叶肺炎,Lobarpneumonia,Lobarpneumonia,TheX-rayfeatureisalargehomogenousradiopaqueshadowthereisnovolumelossairbronchogramiscommonBordersoftheshadowappearasasharplydefinedmargin,实变期（红色或灰色肝样变期）密度均匀的致密影homogeneousradiopaqueshadow,累及肺段：片状或三角形,尖端指向肺门,下叶节段性肺炎,Lobarpneumonia,Lobarpneumonia,实变期（红色或灰色肝样变期）,支气管气像Airbronchogram致密阴影内,可见透亮支气管影,Lobarpneumonia,消散期X线改变Resolutionstage,病变密度逐渐减低，呈大小不等、分布不规则的斑片状阴影Theshadowofconsolidationbecomesscatter可完全吸收或遗留少量索条影起病1周后病变开始吸收，多在2周内完全吸收，少数可延迟吸收或演变为机化性肺炎,发病10后,Lobarpneumonia,CT表现CTmanifestations,一般平片就可诊断,不需要CTCT优势是:充血期可发现磨玻璃样改变ground-glassopacity,GGO更容易发现支气管气像Airbronchogram如消散缓慢,反复发作,年龄较大的患者,与阻塞性肺炎鉴别,大叶性肺炎CT表现,支气管气象Airbronchogram,rightlowerlobepulmonaryconsolidationwithairbronchograms.,支气管肺炎（bronchopneumonia）,又称小叶性肺炎(lobularpneumonia)致病菌为链球菌、葡萄球菌、肺炎双球菌streptococcus,staphylococcus,pneumococcus多见于婴幼儿、老年及极度衰弱患者，或手术后,bronchopneumonia,临床表现Symptoms:起病急，高热寒战highpyrexia咳嗽、咳泡沫粘液脓性痰、胸痛cough,purulentsputum,pleuriticpain呼吸困难甚至紫绀shortnessofbreath,pathologicchangings病理变化,肺小叶渗出与实变lobularconsolidation小支气管壁充血水肿、间质内炎性浸润Smallbronchuswallcongestandswelling,interstitialinflammationimmersing小支气管壁充血水肿-不同程度阻塞-小叶性肺气肿、小叶性肺不张lobularemphysemaorlobularatelectasis,X线表现X-rayfeatures,bronchopneumonia,肺纹理增多、增粗、模糊Intensificationoflungmarkings病变多在两肺中下野的内中带,沿肺纹理分布的斑片状影，密度不均，边缘模糊，密集的病变可融合成较大的片状Smallpatchyopaqueshadowsinthemiddleandlowerlungfields,Confluenceofthesepatchyopacities,IntensificationoflungmarkingsSmallpatchyopaqueshadowsinthemiddleandlowerlungfields,Confluenceofthesepatchyopacities,Emphysemaofthebothlungsisusuallyvisible,金黄色葡萄球菌支气管肺炎,IntensificationoflungmarkingsSmallpatchyopaqueshadowsinbothlungfields,Pneumatoceles(肺气囊),支气管肺炎CT表现(CTfeatures),支气管血管束增粗peribronchovascularburdlethicking小片状影(小叶性实变或小叶性不张)Smallpatchyopaque大片状影(小片状影融合)Confluenceofthesepatchyopacities1-2CM小圆形透亮影(小叶性肺气肿)centrilobularemphysema,Lobularpneumonia.CTdemonstratesmultifocalareasofconsolidationandairbronchograms.,间质性肺炎（interstitialpneumonia）,累及肺间质为主的炎症，包括支气管壁及周围间质和肺泡壁Interstitialpneumoniainvolvesmainlytheinterstitialtissueoflungs,includingthebronchovascularbundlesandinterlobularandintralobularsepta,可由细菌或病毒引起viralorlacterialinfection多见于小儿，常继发于麻疹、百日咳、流行性感冒等急性传染病原发传染病症状+咳嗽、气急、紫绀shortnessofbreath,cough,cyanosis症状重，体征少、wbc不高,病理pathology,小支气管壁及肺间质炎性细胞浸润Interstitialinflammationimmersing炎症沿淋巴管扩展引起淋巴管炎和淋巴结炎Lymphatitis,lymphadenitis小支气管的炎症阻塞小叶性肺气肿肺不张Smallbronchusinflammation-obstructemphysemaandatelectasis肺泡内可有轻度炎性浸润,interstitialpneumonia,病变广泛，累及两肺尤中下肺肺纹理增粗、模糊，Intensificationoflungmarkings网状纹理finestreak-like,net-like,nodularornod-reticularshadows肺门密度增高，模糊，肺门增大enlargementofthehilarshadow小叶性肺气肿、肺不张，婴幼儿弥漫性肺气肿empyhsemaofthebothlungs磨玻璃影、小斑片状影GGO,Smallpatchyopaqueshadows,interstitialpneumonia,X-rayfeatures,interstitialpneumoniaCTandHRCT,广泛的支气管血管束增粗Intensificationofbronchovascularbundles小叶间隔增厚interlobularandintralobularseptathickening胸模下线Subpleuralline磨玻璃影、小片状影GGO,Smallpatchyopaqueshadows肺门、纵膈淋巴结可增大,广泛的支气管血管束增粗Intensificationofbronchovascularbundles小叶间隔增厚Interlobularandintralobularseptathickening胸模下线Subpleuralline,Ground-glassopacity,GGO,间质性肺炎与支气管肺炎鉴别支气管肺炎:以小片状影为主,累及中下肺野为主间质性肺炎:以肺纹理增粗模糊为主,病变更广泛,累及两肺,interstitialpneumonia,支原体肺炎Mycoplasmapneumonia,好发于青少年临床症状轻,常表现发热,咳嗽.白细胞总数正常或稍低痰鼻喉拭子培养可获支原体血清学检查:红细胞冷凝集试验大于1:32,补体结合试验大于1:16,间接凝血试验大于1:32,间接荧光试验大于1:16,病理pathology,急性间质性肺炎及支气管炎1-2周吸收病变自限性,影像学表现Imagingmanifestations,早期病变:肺纹理增粗、模糊Intensificationoflungmarkings网状纹理finestreak-like,ornod-reticularshadows病变发展后:Smallorlargepatchyopaque胸腔积液,肺门纵隔淋巴结肿大少见.,肺脓肿(lungabscess),由化脓性细菌引起,早期为化脓性肺炎,坏死液化,形成脓肿Purulencebacteria-inflammationfocus-Necrosisandfluidify-abscessinfectapproach：inhalehematogenousdirectspreedStage：acuteandchronicstage,lungabscess,临床急性期Acutestage：有急性化脓性肺炎的表现，高热寒战、咳嗽咳痰、胸痛、咳大量脓臭痰白细胞及中性粒细胞明显增高慢性期Chronicstage：After3monthstheabscesswasconsideredtobechronic经常咳嗽、咳脓痰和血痰，不规则发热及贫血消瘦等,lungabscess,病理化脓性肺炎（渗出和实变）细支气管阻塞、小血管炎性栓塞坏死液化形成空洞(脓腔)脓液破溃到胸腔脓气胸、支气管胸膜瘘持续不愈超过3个月转为慢性，脓腔周围炎性浸润减少但纤维组织增生,lungabscess,急性期Acutestage排脓之前：化脓性肺炎团状致密影,边缘模糊,X线表现,lu