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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