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1、1,Foundations of Medical Practice:Chest Imaging,2,Overview,Imaging Methods CXR: Main Focus Others: Computed Tomography, MRI, Ultrasound, Nuclear Medicine Approach to CXR Densities Anatomy and approach Technical Factors,3,Overview contd,Abnormal CXR findings Bone Cardiovascular Airspace Disease and S

2、ilhouette Sign Interstitial Disease with emphasis on pulmonary edema Other Lung Disease: Atelectasis, Nodule Pleura Mediastinal,4,Other Imaging Methods,CXR-Will be discussed later Computed Tomography MRI Ultrasound Mainly for procedures Nuclear Medicine,5,Computed Tomography,Numerous protocols/techn

3、iques depending on clinical history Helical/spiral versus high resolution Contrast Renal failure Allergy,6,Computed Tomography,Role of CT Main further investigation for most CXR abnormality (eg nodule/mass) or to exclude disease with normal CXR Main investigation for certain scenarios (PE, dissectio

4、n, trauma),7,Radiation Dose,Compare dose to normal background radiation (3mSv/year) CXR PA view:3 days CXR PA Lat:18 days Low Dose CT:0.5 year HRCT:1 year Helical CT:2-3 years,8,MRI,Multiple planes No radiation Common Indication Pancoast tumour Brachial plexus Cardiac Vascular (aorta) Usually target

5、ed examination (unlike CT),Coronal,9,Nuclear Medicine,Variety of tests: functional rather than anatomic V/Q specific to chest imaging Others: bone scan, gallium, WBC etc.,10,Ultrasound,Limited use in thorax (non cardiac) due to air in lungs Assess pleural effusions Mainly used for procedures,11,Ches

6、t 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),12,Chest Radiograph: Approach andNormal Anatomy,THERE IS NO ONE

7、APPROACH: BE SYSTEMATIC Bone and Soft Tissue including abdomen Heart Mediastinum-aorta, trachea Hila Pulmonary Vasculature Lungs Pleura,13,Normal Anatomy,14,Bone-CT Reconstruction,PA View,15,Bone Anatomy,16,Heart Size,Normal is 50% on PA upright radiograph,17,Lateral view,18,Cardiac Anatomy: Right S

8、ided Chambers,19,Cardiac Anatomy: Left Sided Chambers,20,isnpexp,21,inspexp,Lungs posteriorly should get darker as you go down more inferiorly,22,Airway Anatomy,Trachea Cartilage Membranous posteriorly Carina Bifurcation Bronchus Left and right Lobar (RUL,RML,LUL,LLL) Segmental (8 left, 10 right),23

9、,24,Lung Anatomy,Lobes are separated by fissures Right Upper Lobe Middle Lobe Lower Lobe Left Upper Lobe (includes lingula) Lower Lobe,25,26,27,28,29,30,Pleura and Fissures,Pleura Lubricates and prevents friction during respiration Potential Space Dont see unless abnormal Parietal pleura: Lines ches

10、t wall, mediastinal and diaphragmatic surfaces Visceral pleura: Lines lungs, fissures,31,Parietal Pleura,Visceral pleura,32,normaldiag,Diaphragms,Normal: Sharp costophrenic sulcus,33,normaldiag,34,Which is right and left diaphragm?,35,36,Approach to Chest Radiograph:Technical Factors,Patient Identif

11、ication (name and date) Markers (Left vs right) Assess for rotation (clavicles vs spinous process) Penetration (thoracic spine should be visible) Degree of Inpiration: 6th anterior or 10th posterior,37,isnpexp,38,Inspiration/Expiration Images,Expiration Heart size appear larger Mediastinum is wider

12、Pulmonary vasculature indistinct,39,40,Inspiration: Same Patient,Expiration,41,Abnormal Cases,Bone Cardiovascular Airspace Disease including Silhouette Sign Interstitial Disease and Pulmonary Edema Atelectasis Pulmonary Nodule Pleura and Diaphragm Mediastinal Mass,42,Bone and Soft Tissues,43,product

13、ive1stribs,Productive 1st rib changes: Can simulate nodule,44,Lordotic View,Better assess apices without bone overlap,45,Rib Fracture,46,47,Presenting CXR,48,49,MRI,Computed Tomography,Pancoast Tumour,50,Cardiovascular,51,Increased Cardiac Size: Can be Cardiac or Pericardial,Pericardial Effusion,Dil

14、ated Cardiomyopathy,What imaging would you use to differentiate between the two ?,52,Left Ventricular Enlargement,Enlargement of Left Ventricle,Left Ventricle,IVC,53,Airspace Disease and Silhouette Sign,54,Airspace Disease,Filling in of acini (air space) Air space (acinar) nodules Coalesce to consol

15、idation Air bronchograms Silhouette Sign,55,Air Space Disease: Etiology,Water-Pulmonary Edema Pus-Infections, Non-infectious inflammatory process Blood-Pulmonary Hemmorhage Protein-Alveolar Proteinosis Tumour-BAC, Lymphoma,56,Bronchopneumonia Pattern: Airspace Nodules,57,Acinar Nodules,Computed Tomo

16、graphy,58,Air Bronchogram,Airways are not normally seen in a normal chest radiograph because they are an air structure within an aerated lung When the aerated lung opacify, the bronchii become visualized because of the surrounding contrast effect.,59,airbronch,60,61,CT Consolidation: Air Bronchogram

17、s,62,Silhouette Sign,Definition: The effacement of a normal structure Example: Airspace disease may silhouette: right heart margin with right middle lobe pneumonia diaphragm with lower lobe pneumonia,63,Where is the Pneumonia?,64,65,Right Lower Lobe Pneumonia,66,Left Lower Lobe Pneumonia,67,Where is

18、 the pneumonia?,68,69,Oblique(major) fissure,Horizontal (minor fissure),70,Right Middle Lobe Pneumonia,71,Interstitial Disease with Emphasison Pulmonary Edema,72,Interstitial Disease: Pulmonary Fibrosis,73,Interstitial Disease,Reticular=net-like Nodular Reticulonodular: Combination of the two patter

19、ns,74,Reticular Pattern,75,Honeycombing in patient with single lung transplant for pulmonary fibrosis,Normal Transplanted Lung,Honeycomb Native Lung,76,Miliary histo,Nodular Pattern: Miliary,77,Pulmonary Edema,Pleural Effusions/Cardiomegaly Vascular Redistribution / Enlargement Interstitial Changes

20、Indistinct pulmonary vasculature Kerly lines Fissural Thickening Bronchial Cuffing Alveolar Edema Perihilar air space disease “Batwing” or “butterfly” appearance,78,Normal,Normal bronchus,79,Pulm edema,80,81,cuffing,82,83,cuffing,84,Normal,85,Kerly B,Kerly B Lines,86,edemakerlya,Pulmonary Edema,87,e

21、demakerlya,Septal Lines,88,Alveolar Edema,Alveolar Pulmonary Edema,89,Other Lung Disease,90,Bullous Emphysema,91,Atelectasis,92,93,Left lower lobe collapse,Further investigations?,94,95,96,Diagnosis: LLL Collapse,Collapse secondary to central obstructing tumour,97,Pulmonary Nodule,98,Solitary Pulmon

22、ary Nodule: What Would You Do Next?,1) Compare with Any Available Previous,2) Computed Tomography,99,Solitary Pulmonary Nodule can be:,Benign: Densely calcified nodule,Malignant: Adenocarcinoma,100,Multiple Nodules: Diagnosis?,Metastases,101,Pleura,102,Pleura and Diaphragm,Pleural Effusion Lateral d

23、ecubitusLateralPA in sensitivity Pneumothorax Upright Deep sulcus sign in supine,103,Small Pleural Effusion,104,Small Pleural Effusion,Normal: Sharp Angles,Blunted posterior costophrenic sulcus,105,Large Pleural Effusion,106,Lateral Decubitus,107,Supine Patient,108,Pleural Effusion in Supine Patient

24、,Pleural effusion layers posteriorly in a supine position Cause diffuse increased density,109,Diagnosis?,110,111,Which is a pneumothorax?,112,ptxinspexp,Inspiration,Expiration,113,hugeptx,Collapsed Right Lung,Tension Pneumothorax: Requires chest tube,What would you do with this patient?,114,ptxdeeps

25、ulcus,Supine Patient,Deep Sulcus,115,Non Dependent Portion of Lung in at Base in Supine Patient,Deep Sulcus: What can you do to confirm?,116,pxtdeepsulcuslatdecub,Left lateral decubitus,117,Mediastinum: Overview,Classification of Mediastinum Examples of mediastinal masses,118,Classification of Media

26、stinum,Anatomic Superior: above sternal angle Anterior Middle: heart and pericardium Posterior There are radiographic classification e.g. Felsons,119,ANATOMIC CLASSIFICATION The mediastinum is divided into 4 parts,Superior mediastinum Apex of thorax to a plane passing through the manubrio-sternal ju

27、nction and fourth dorsal vertebral body,Anterior mediastinum Is anterior to heart & great vessels,Middle mediastinum Contains heart & great vessels, lymph nodes,Posterior mediastinum Contains descending thoracic aorta, azygous/hemiazygous veins,esophagus, thoracic duct, nerves & lymph nodes,Classifi

28、cation of Mediastinum,120,Anterior Mediastinal Mass,The 4 Ts Thyroid Thymus (Thymoma) Teratoma Terrible Lymphoma (Tumour),121,Thyroid Goiter,Most common superior mediastinal mass extending to thoracic inlet,122,benignthymoma,Normal,123,Lateral shows mass is anterior,NORMAL,124,Computed Tomography,Thymoma:,Do you know of any associated clinical syndrome?,125,Hiatus hernia,126,Lymphadenop