Chest Radiology Plain Film and CT- Beyond the Basics John W. Renner, M.S., M.D. Clinical Professor...

Chest RadiologyPlain Film and CT- Beyond the Basics

John W. Renner, M.S., M.D.Clinical Professor of Radiology

UCSD Medical Center

Brendan Kidder, M.S. IVUCSD School of Medicine

Chest RadiologyGoals

• 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 RadiologyNormal Radiographic Anatomy

• 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

Webb, R : Radiology 2006

Chest RadiologyPatterns of Disease

• Honeycombing

• Cystic lesions

• Nodules

• Ground-glass opacities

• Mosaic pattern

• Tree-in-bud

• Interlobular septal thickening

Honeycombing

Chest X-Ray .com

Centrilobular Emphysema

Webb, R. Radiology 2006

Centrilobular Emphysema

Centrilobular Emphysema

Webb, R. Radiology 2006

Centrilobular Nodules

Webb, R. Radiology 2006

Sarcoidosis

Chest X-Ray. com

Sarcoidosis

Webb, R. Radiology 2006

Hypersensitivity Pneumonitis

Webb, R. : Radiology 2006

Ground-Glass Opacities

Chest X-Ray. com

Pulmonary Edema

Bronchopneumonia

Mosaic Perfusion

Chest X-Ray. com

Mosaic Perfusion

Mosaic Perfusion

Transplant Lung

Transplant Lung

Tree-in-Bud

Tree-in-Bud

Webb, R. : Radiology 2006

Interlobular Septal Thickening

Webb, R. Radiology 2006

Interlobular Septal Thickening

Webb, R. Radiology 2006

Lymphangitic Carcinomatosis

Webb, R. Radiology 2006

Lymphangitic Carcinomatosis

Bronchiectasis

Chest X-Ray. com

Air Trapping

Chest X-Ray. com

Head Cheese Sign

Webb, R. : Radiology 2006

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 RadiologyCritical Care Radiography

• Pulmonary Embolism– Chest radiograph

• Normal vs. abnormal– 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 RadiographyCritical Care Radiography

• Pulmonary Thromboembolism-Catheter Angiogram– 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 RadiologyCritical 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 RadiologyCritical 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 RadiologyIdiopathic Interstitial Pneumonias

• 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 RadiologyCritical 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 RadiologyCritical Care Radiography

• Pulmonary Edema– Hydrostatic– Increased capillary permeability– Diffuse alveolar damage –(DAD)– Differential diagnosis

• Atelectasis• Pneumonia• Aspiration • Pulmonary embolism and hemorrhage

Chest RadiologyCritical Care Radiography

• Hydrostatic Pulmonary Edema– Pulmonary venous hypertension and vascular

redistribution– Interstitial pulmonary edema– Alveolar pulmonary edema– Cardiomegaly– Pleural effusion– Vascular pedicle

Chest RadiologyCritical Care Radiography

• Pulmonary Edema– Interstitial pulmonary edema– Kerley A, B and C lines

• Interlobular septal thickening• Subpleural edema along fissures,pleura• Peribronchial cuffing• Perihilar haze• Interstitial veiling• Ground-glass opacities

Interstitial Pulmonary Edema

Chest RadiologyCritical 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 RadiologyCritical Care Radiography

• Increased Permeability Edema or ARDS and DAD– Alveolar-capillary leak, normal left atrial pressure

• Multiple etiologies• Occurs in stages

– Latent period

– Air-space consolidation

– Homogeneous confluence and air bronchogram

– Decreased lung volumes and pulmonary compliance compliance

– Slow clearance

– Organizing chronic changes--fibrosis

Chest RadiologyCritical Care Radiography

• Barotrauma– Mechanical ventilation and increased airway

resistance, high ventilatory pressures, CPAP and others

– Extra-alveolar air• Pulmonary interstitial emphysema• Pneumomediastinum• Pneumothorax• Subcutaneous emphysema

Chest RadiologyCardiac

• 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 RadiologyPneumonia

• Lobar pneumonia– Peripheral opacity to homogenous

consolidation

• Bronchopneumonia– Airway mucosa to alveoli

• Interstitial pneumonia– Reticular opacities to confluent infection

• Lung abscess– Cavitation

Chest RadiologyTuberculosis

• Primary tuberculosis

• Post-primary tuberculosis

• HIV-associated tuberculosis

Chest RadiologyLung 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 RadiographyCardiac

• 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