Transcript Chest Radiology Plain Film and CT

Chest Radiology
Plain Film and CT- Beyond the Basics
John W. Renner, M.S., M.D.
Clinical Professor of Radiology
UCSD Medical Center
Brendan Kidder, M.S. IV
UCSD School of Medicine
Chest Radiology
Goals
• Review the basics of Chest Imaging
• Examine the modalities of the Chest “Plain
Film” and Computed Tomography
• Review basic disease entities and their
imaging evaluation
• Allow Hospitalists to better understand “How
to talk to a radiologist in a hospital setting if
you must!”
Chest Radiology
Normal Radiographic Anatomy
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Normal frontal and lateral views
Cross-sectional anatomy
Symmetry and asymmetry
Interfaces, lines and junction stripes
Chest compartments
Densities
Normal Chest
Pre-Vascular Space
Anterior Junction Line
Right Paratracheal Stripe
Carina
Basal Segmental Anatomy
Main Pulmonary Artery
Aortic Valve
Inferior Pulmonary Veins
Left Coronary Artery
Right Coronary Artery
Secondary pulmonary lobule
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Chest Radiology
Patterns of Disease
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Honeycombing
Cystic lesions
Nodules
Ground-glass opacities
Mosaic pattern
Tree-in-bud
Interlobular septal thickening
Honeycombing
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Centrilobular Emphysema
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Centrilobular Emphysema
Centrilobular Emphysema
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Centrilobular Nodules
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Sarcoidosis
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Sarcoidosis
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Hypersensitivity Pneumonitis
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Ground-Glass Opacities
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Pulmonary Edema
Bronchopneumonia
Mosaic Perfusion
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Mosaic Perfusion
Mosaic Perfusion
Transplant Lung
Transplant Lung
Tree-in-Bud
Tree-in-Bud
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Interlobular Septal Thickening
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Interlobular Septal Thickening
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Lymphangitic Carcinomatosis
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Lymphangitic Carcinomatosis
Bronchiectasis
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Air Trapping
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Head Cheese Sign
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Crazy Paving Pattern
Idiopathic Pulmonary
Hemosiderosis
Idiopathic Pulmonary
Hemosiderosis
Idiopathic Pulmonary
Hemosiderosis
Aspergilomas
Bronchogenic Cyst
Interstitial Pulmonary Fibrosis
Interstitial Pulmonary Fibrosis
Interstitial Pulmonary Fibrosis
Neurofibromatosis
Neurofibromatosis
Neurofibromatosis
Chest Radiography
• Congenital Pulmonary Abnormalities
– Tracheal bronchus
– Pulmonary arteriovenous malformation
– Partial anomalous pulmonary venous return
– Bronchopulmonary sequestration
– Congenital lobar emphysema and cysts
Right Upper Lobe Bronchus
Tracheal Bronchus
Hypogenetic Lung
Pulmonary Sequestration
Pulmonary Sequestration
Thrombosed Aneurysm
Pulmonary Sequestration
Pulmonary Artery Sling
Pulmonary Artery Sling
Hilar Lymphadenopathy
Pneumocystis Pneumonia
Pneumocystis Pneumonia
Pneumocystis Pneumonia
Pulmonary Tuberculosis
Chest Radiology
Critical Care Radiography
• Pulmonary Embolism
– Chest radiograph
• Normal vs. abnormal
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Westermark’s sign
Enlargement of the central pulmonary arteries
Hampton’s hump-pulmonary infarction
Atelectasis, consolidation and elevation of the ispilateral
hemidiaphragm
– Pleural effusion
Chest Radiography
Critical Care Radiography
• Pulmonary Thromboembolism-Catheter
Angiogram
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Pulmonary angiography-former “gold standard”
Invasive with known morbidity-mortality
High specificity—approaching 100%
Right heart catheterization-useful data
Negative exam excludes the diagnosis
Allows for treatment—
• Thrombolytics
• IVC filter placement
Chest Radiology
Critical Care Radiography
• Pulmonary Thromboembolism-CTA
– High sensitivity (>90%), specificity (>95%)
– CTA limited in sub-segmental arteries
– Evaluation of upstream findings-right heart
strain
– CT findings
• Intra-luminal filling defect or
• Vessel cutoff
• Mosaic perfusion
Chest Radiology
Critical Care Radiography
• Pulmonary Thromboembolism-CTA
– CT Pulmonary Angiogram
• Requires MDCT, helical scan
• Requires iodinated contrast—high concentration of
iodine, non-ionic or iso-osmolar contrast agents
• Requires apnea during scan
• Requires normal renal function
• Relatively high radiation dose!
Massive Thromboembolism
Massive Thromboembolism
Massive Thromboembolism
Pulmonary Thromboembolism
Chest Radiology
• Chronic Thromboembolism
– Organizing thromboemboli
– Adherent clots to vessel wall
– Lack of recanalization of a vessel
– Webs, bands
– Abrupt caliber change
– Pulmonary arterial hypertension
– Mosaic perfusion
Type A Aortic Dissection
Primary Pulmonary Hypertension
Chest Radiology
• Pulmonary Arterial Hypertension
– Dilation of central pulmonary arteries
– Rapid tapering of peripheral pulmonary
arteries
– Dilation of right interlobar pulmonary artery to
> 18 mm on PA chest view
– Dilation of left pulmonary artery to > 18 mm
on lateral chest view
– Dilation of RA, RV
Primary Pulmonary Arterial
Hypertension
Primary Pulmonary Artery
Hypertension
Tricuspid Regurgitation
Chest Radiology
Idiopathic Interstitial Pneumonias
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Idiopathic Pulmonary Fibrosis-IPF
Non-specific Interstitial Pneumonia-NSIP
Cryptogenic Organizing Pneumonia-COP
Respiratory Bronchiolitis-associated
Interstitial Lung Disease-RB-ILD
• Desquamative Interstitial Pneumonia
• Lymphoid Interstitial Pneumonia-LIP
• Acute Interstitial Pneumonia-AIP
Idiopathic Pulmonary Fibrosis
Idiopathic Pulmonary Fibrosis
Non-specific Interstitial Pneumonia
IPF vs. NSIP
Cryptogenic Organizing Pneumonia
Respiratory Bronchiolitis-ILD
Desquamative Interstitial
Pneumonia
Lymphoid Interstitial Pneumonia
Organizing Pneumonia
ILS plus GGO
Chest Radiology
Critical Care Radiography
• CXR may be done on a daily basis
• Evaluate “life-support” lines, tubes catheters,
devices, monitoring equipment
• Evaluate changes in cardiopulmonary status
• Determine why a patient has undergone “clinical
deterioration”—
– Hypoxia
– Hypotension
– Sepsis
Chest Radiology
Critical Care Radiography
• Pulmonary Edema
– Hydrostatic
– Increased capillary permeability
– Diffuse alveolar damage –(DAD)
– Differential diagnosis
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Atelectasis
Pneumonia
Aspiration
Pulmonary embolism and hemorrhage
Chest Radiology
Critical Care Radiography
• Hydrostatic Pulmonary Edema
– Pulmonary venous hypertension and vascular
redistribution
– Interstitial pulmonary edema
– Alveolar pulmonary edema
– Cardiomegaly
– Pleural effusion
– Vascular pedicle
Chest Radiology
Critical Care Radiography
• Pulmonary Edema
– Interstitial pulmonary edema
– Kerley A, B and C lines
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Interlobular septal thickening
Subpleural edema along fissures,pleura
Peribronchial cuffing
Perihilar haze
Interstitial veiling
Ground-glass opacities
Interstitial Pulmonary Edema
Chest Radiology
Critical Care Radiography
• Alveolar Edema
– Air-space consolidation
– Acinar or air-space ill-defined nodules
– Peri-hilar or “batwing” distribution
– Peripheral sparing
– Rapid clearance with theraphy
– Occasionally a clinical lag in onset and
clearance
Chest Radiology
Critical Care Radiography
• Increased Permeability Edema or ARDS and
DAD
– Alveolar-capillary leak, normal left atrial pressure
• Multiple etiologies
• Occurs in stages
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Latent period
Air-space consolidation
Homogeneous confluence and air bronchogram
Decreased lung volumes and pulmonary compliance
compliance
– Slow clearance
– Organizing chronic changes--fibrosis
Chest Radiology
Critical Care Radiography
• Barotrauma
– Mechanical ventilation and increased airway
resistance, high ventilatory pressures, CPAP
and others
– Extra-alveolar air
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Pulmonary interstitial emphysema
Pneumomediastinum
Pneumothorax
Subcutaneous emphysema
Chest Radiology
Cardiac
• Cardiac CT
– Calcium scoring
– Coronary artery angiography-CTA
– Congenital Heart Disease
– Anatomical applications
– Triple rule-out
LAD Stenosis
CT Coronary Angiography
LAD Stenosis
Calcium LAD
3D Workstation
CTA Coronary Artery
Right Coronary Artery
LAD-Soft Plaque
Multiplanar Reconstruction
Anomalous Left Coronary Artery
Consensus
• A negative test may be consistent with a
low risk of a cardiovascular event in the
next two to five years
• A high calcium score may be consistent
with a moderate to high risk of a
cardiovascular event within the next two to
five years
Chest Radiology
• Airways Disease
– Trachea
– Bronchiectasis-cylindrical, varicose, cystic
– Cystic Fibrosis
– ABPA and asthma
– Chronic bronchitis
– Bronchiolitis
Chest Radiology
• Emphysema
– Centrilobular emphysema
– Panlobular emphysema
– Paraseptal emphysema
– Bullous emphysema
– Saber-sheath trachea
Chest Radiology
Pneumonia
• Lobar pneumonia
– Peripheral opacity to homogenous
consolidation
• Bronchopneumonia
– Airway mucosa to alveoli
• Interstitial pneumonia
– Reticular opacities to confluent infection
• Lung abscess
– Cavitation
Chest Radiology
Tuberculosis
• Primary tuberculosis
• Post-primary tuberculosis
• HIV-associated tuberculosis
Chest Radiology
Lung Cancer
• Early Detection
– National Lung Cancer Screening Trial
• Chest x-ray vs. low-dose CT
– International Early Lung Cancer Action
Project—I-ELCAP
• Low-dose screening CT
• 92% survival rate, stage I
• NEJM 355:1763-1771, Oct. 26, 2006
Chest Radiography
Cardiac
• Cardiac MRI
– Myocardial function
– Myocardial viability
– Valvular heart disease
– Systolic heart failure
– Diastolic heart failure
– Myocarditis
– Pericardial diseases
Chest Radiology
• Thank you
John W. Renner, M.S., M.D.
Clinical Professor of Radiology
Department of Radiology
UCSD Medical Center
San Diego, California