胸部正常影像 -HR课件

1、胸部正常影像北京协和医院呼吸科黄 蓉胸 部 x-ray读片顺序胸壁/胸廓软组织：胸缩乳头肌及锁骨上皮肤皱褶、胸大肌、女性乳房及乳头骨骼：肋骨、肩胛骨、锁骨、胸骨、胸椎膈肌右高于左1-2cm，第9、10后肋/第6前肋间隙局限性膈膨升、波浪膈胸膜胸腔积液、气胸及液气胸、胸膜肥厚、粘连及钙化肺纵隔1. Trachea2. R main bronchus3. L main bronchus4. L pulm artery5. RUL pulm vein6. R (desc) pulm artery7. RLL and RML veins8. Aortic arch9. S. vena cava10.

2、Azygous vein1. Trachea2. R main bronchus3. LUL bronchus4. RUL bronchus5. L pulmonary artery6. R pulmonary artery7. Pulmonary vein8. Aortic arch9. Brachiocephalic vessels Note: Vascular details are variable from film to film左正侧位右上叶右中叶左上叶左下叶正常HRCT中央肺动脉。支气管与相邻肺动脉直径大致相等。肺动脉常分为两个直径相当的分支。肺静脉常分成许多细小的分支,这些分

3、支与主支构成直角。常见伪影双侧下肺近心脏处，肺血管脉动伪影。低密度区， 可以错当作扩大的支气管。 常见伪影主叶裂伪影。The Secondary Pulmonary Lobule肺小叶（直径1-2.5CM）小叶支气管、终末细支气管肺动脉pulmonary artery 小叶间隔interlobular septa 肺静脉pulmonary vein 腺泡pulmonary acini 正常小叶间隔normal septa 正常小叶中心动脉centrilobular artery 2肺静脉Pulmonary veins 胸部CT两个窗：纵隔窗和肺窗三个系统：管道系统；肺系统；淋巴系统断面：头臂干

4、层面；主动脉弓层面；主肺动脉层面；左肺动脉层面；右肺动脉层面；左心房层面（基底干上方层面）；四腔心层面（两下肺静脉层面）MediastinumAnterior: thymus, lymph nodes, mammary vesselsMiddle: pericardium, heart, great vessels, trachea, main bronchi, fat, nerves, lymph nodesPosterior: esophagus, descending aorta, nerves, azygos and hemiazygos veins, lymph nodesBrach

5、iocephalic Artery Level (Sterno-clavicular Joint Level)BA: brachiocephalic artery SCJ: Sterno-clavicular JointLCC: left common carotidLSA: left subclavian arteryRBV: right brachiocephalic veinLBV: left brachiocephalic vein LSALCCBALBVRBVSCJAortic Arch LevelSVC: superior vena cavaIMV: internal mammar

6、y vessels: pretracheal-retrocaval spacethymusarchtracheaesophagusSVCIMVAortopulmonary Window LevelSVC: superior vena cavaAA: ascending aortaDA: descending aortaAZ: azygosAADAAZarchcarinaSVCLeft Pulmonary Artery LevelSVC: superior vena cavaLPA: Left Pulmonary Artery LPASVCpericardiumRight Pulmonary A

7、rtery LevelRPA: Right Pulmonary ArteryA-ER: azygoesophageal recessRPAA-ERAortic Root LevelA: aortic rootLA: left atrium PA: pulmonary arteryPV: pulmonary vein PALAAPVCardiac LevelLV: left ventricleRV: right ventricleLA: left atrium RA: right atriumIS: interventricular septum RVLVRALAISLobesSegments

8、and Bronchi Each lobe is comprised of several smaller units referred to as pulmonary segments .It is important to remember that segmental anatomy is predicated on bronchial anatomy. Similar to bronchial nomenclature, each segment can be named numerically, using a S, and the same number of the corres

9、ponding bronchus that supplies it . Segment Bronchus Upper Lobe Apical S1 B1 Posterior S2 B2 Anterior S3 B3 Middle Lobe LateralS4 B4 MedialS5 B5 Lower Lobe Superior S6 B6 Medial BasalS7 B7 Anterior BasalS8 B8 Lateral BasalS9 B9 Posterior Basal S10 B10 Upper Lobe Apical Posterior S1+2 B1+2 AnteriorS3

10、 B3 Superior LingularS4 B4 Inferior LingularS5 B5 Lower Lobe SuperiorS6 B6 Anterior Medial BasalS8 B8 Lateral BasalS9 B9 Posterior BasalS10 B10 SegmentBronchusRight LungLeft LungRight Lung Segments The apical segment (or S1 segment ) is shaped like a truncated cone with its broadest base located sup

11、eriorly filling the cupula of the lung. This segment thus extends over the pulmonary apex but does not extend inferiorly to the interlobar (minor fissure) surface. The posterior segment (S2) extends from the right hilum, posteriorly and inferiorly and forms the posterior half of the interlobar surfa

12、ce relating to the right major fissure. The anterior segment (S3) of the right upper lobe, which like S2 extends from the right hilar area, is oriented anteriorly and somewhat superiorly. The anterior surface of S3 extends to the chest wall, while the broadest inferior surface borders the minor fiss

13、ure which separating S3 from the right middle lobe. The right lower lobe is comprised of five pulmonary segments : the superior segment (S6) is situated immediately inferior to the posterior segment of the right upper lobe (S2) from which it is separated by the right major fissure. S6 is bordered by

14、 the major fissure anteriorly and comprises a sizeable portion of the posterior margin of the right lower lobe superiorly. It is this segment that surprisingly occupies a sizeable area behind the anterior segment (S3) of the RUL. The right middle lobe has two pulmonary segments which are situated si

15、de by side; the more lateral segment (S4), approximates the size of its adjacent neighbor , S5 ( medial segment). S5 near the right heart border medially, while S4 extends to and comprises a portion of the lateral border of the right lung. Superiorly, both segments border the right minor fissure, an

16、d likewise, both abut the major fissure along their inferior margins. Both S4 and S5 touch the diaphragmatic surface at their anteroinferior edges. Anteriorly, both segments are adjacent to the anterior ribs ends of the 5th, 6th, and 7th ribs. Immediately anterior to S10 is the medial basal segment

17、(S7) which typically is the smallest pulmonary segment of the lower lobe. Along its superior margin, S7 forms a portion of the major fissure medially, and its location can be best thought of as being immediately inferior to the right hilum, abutting the major fissure ventrally. Inferior to S7 is the

18、 anterior basal segment S8, which tends to be rather large in size. This segment along with S6 comprise a large portion of the major fissure surface, laterally. S8 resides in a predominantly lateral location having a large peripheral surface. The lateral basal segment (S9), located between S8 and S1

19、0 is shaped like a triangle with its base directed laterally and as such forms a portion of the lateral surface of the right lower lobe. The pulmonary segments which border or touch the right hemidiaphragm are S4, S5, S7, S8, S9, and S10. S8 and S10 have the largest surface areas abutting the diaphr

20、agm. The posterior basal segment (S10) as its name implies occupies the posterior most and inferior most portion of the right lower lobe. As such, it can be best remembered as the pulmonary segment which occupies most of the posterior costophrenic gutter. S10 also comprises a large portion of the po

21、steromedial border of the right lower lobe and is the segment which is located immediately inferior to S6. S10 characteristically tends to be the largest segment of the right lower lobe.Left Lung Segments (S1+2) represents a combination of the two separate (apical and posterior) segments seen on the

22、 right upper lobe. It is referred to as the apical posterior segment. Combined, S1+2 anatomically is similar in shape to the two segments on the right. The S3 or anterior segment also is similar to the right S3 segment, having a large area directed anteriorly. The superior lingular segment (S4) is p

23、ositioned immediately inferior to S3 and is directly above the inferior lingular segment (S5). Both lingular segments have their greatest area directed anteriorly and inferiorly. Additionally, S4 tends to have more area directed laterally while S5 has more area directed medially, abutting the medias

24、tinum. Both segments extend anteroinferiorly to reach the ventral surface of the left hemidiaphragm, and hence border a large portion of the anteroinferior surface of the major fissure. Forming the remainder of the interlobar surface is the superior segment (S6). S6 is identical to its counterpart o

25、n the right. The left lower lobe segmental architecture is similar to that of the right lower lobe, however because the anterior and medial basal segments share a common bronchial supply, these two segments are characteristically combined, forming an anterior medial basal segment (S8). Therefore, th

26、e anterior segment is combined with the medial segment but may be denoted by SX7. The anterior medial basal segment is bordered anteriorly by the interlobar (major fissure), and abuts the visceral pleural surfaces of the two lingular segments located anterosuperiorly. The lateral basal segment, S9 a

27、nd the posterior basal segment, S10 also closely approximate the same segments in the right lower lobe. S9 (lateral basal segment) has its broadest surface area exposed posterolaterally, and may be slightly larger than S9 on the right. S9, not in continuity with the major fissure, occupies much of t

28、he posterior costophrenic sulcus posterolaterally. Like its contralateral counterpart, S10 (posterior basal segment) is quite large and occupies the posterior and inferior most portion of the right lower lobe occupying the posteromedial costophrenic gutter. The course of B1+2 has vertically and hori

29、zontally oriented components as bronchial rami divide to supply the apical posterior segment. The B3 bronchus will have a more horizontal course, similar to that seen on the right side. B3 supplies the anterior segment of the left upper lobe. The right mainstem bronchus is considered to extend no fa

30、rther inferiorly than the origin of the right upper lobe bronchus. The airway distal to the upper lobe bronchus is referred to as the bronchus intermedius (BI). BI generally averages 2 cm in length and terminates at the point at the origin of the right middle lobe bronchus. The lingular segmental bronchi are some of the most difficult segmental bronchi to visualize on CT. Their inconspicuousness is a result of their oblique course. If seen, B4 has a more horizontal c