A mellkasi radiológia belgyógyászati vonatkozásai

Chest
Dr. Karlinger Kinga PhD
Department of the Radiolgy and Oncotherapeutic
Clinic, Semmelweis University
The radiologic evaluation is the
extension of the physical examination
• Percussion and auscultation
– Heart : size, configuration, signs of
decompensation
– Pulmonal diseases: airways,
parenchymal, blood vessel origin
– Pleural pathological lesions:
pleuritis, hydrothorax
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Radiological methods to evaluate
the chest
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Chest x-ray and fluoroscopy
CT
MR
Nuclear medicine
US
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The x-ray film summarize
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Different direction of the beam:
–PA (postero-anterior),
–laterolateral,
–AP (antero-posterior),
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Fluoroscopy- gives functional information, we
ask the patient to turn slowly to one and the
other side
Anatomy: the normal appearance of the
lung parenchyma is caused by the
summation of the blood vessels, lymphatic
vessels and bronchi.
From the hilus toward the chest wall the
markings of the lung parenchyma show a
gradual diminution.
There is a fine background reticular
pattern.
Normally there are just linear structures,
except the vessels and bronchi if they are
in ortoroentgenograd position.
Dichotomy of the airways
Hilar assimetry
Right side- major and minor fissure, three
lobes
Extrathoracic/extrapulmonal shadows:
nacklace, piercing, brest, mamilla,
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bandage…
Transparent (black)- air
What can we see on the CXR?
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The anamnesis is important, because not
everything is obvious
Abnormal (?) shadows:
e.g. wart in the armpit, hairpin, hair tuft
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Chest „deformities”
• Paralytic thorax (tight apex,
acute costovertebral angles)
• Emphysematic thorax
(asthma, the apex is wide,
„roman”, horizontal ribs,
wide intercostal spaces)
• Baby thorax
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Evaluation of the heart:
size, configuration, signs of decompensation
wiews of investigation: frontal, latero-lateral, RAO LAO
what can be seen as an edge near the „normal” heart shadow?:
at mitral stenosis, mitral insuffitientia, tricuspidal stenosis,tricuspidal
insuffitientia, a.pulm. stenosis
Right ventricle enlargement: primary pulm. hypertony, chr. pulm. emb.
Left ventricle enlargement: aortic” configuration. e.g.: Aortic valve
stenosis,decompensated aorta stenosis with lung oedema
Left atrium enlargement: mitral stenosis (pulmonal veins in upper lobedilated), thickened interlobar septums (oedema),+interstitial fluid, Kerley lines
(induration brunea)
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Anomalies in hilar caliber
Dilated vessels (veins + arteries)
• Hyperaemia
– ASD (atrial septum defect)
– VSD (ventricular septum defect)
– Ductus Botalli persistens
Fine, hypoplastic hilar and peripheral vessels
• Pulmonal arterial hypertony
• sarcoidosis, pneumoconiosis, panarteritis nodosa, primer pulmonal hypertony
Centroperipheral caliber discrepantia (cpcd)
• Increased hilar caliber , fine peripheral vessels, abrupt stenosis
• Pulmonal arterial hypertony with vessel proliferation: ASD, VSD, Ductus Botalli.
Apicobasal caliber discrepantia (abcd)
• Increased hilar caliber, mainly the upper lobes’ vein are dilated, in the basal segments
the vessels are fine (abrupt stenosis)
• Increased pulmonary venous pressure :
• early mitral stenosis, decompensation, atrial tumor, decompensated aortic stenosis.
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+cpcd : pulmonal arterial hypertony, late mitral stenosis, chronic decompensation
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Pericardium: CT: calcium, fluid
Constrictive pericarditis(cast)
MRI: Triple IR FSE Black Blood
Evaluation of the coronaries:
Conventional coronarography, Angiography with catheter, CTA: MIP
(maximum internsity), VR (volumen), MPR(multiplanar), Ca scoring, MRA
(MR Angio)……..
Evaluation of the myocardium: Cardio MR
transversal (white blood) end diastole, end systole, jet sign
Myocarditis, a.m.i.: myocardium perfusion, late enhancement = avitality (fat
supression)
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Evaluation of the lung
Lung parencyhmal pattern
• The normal appearance of the lung parenchyma is caused by the
summation of the blood vessels, lymphatic vessels (not the wall of
the normal bronchi).
• From the hilus toward the chest wall the markings of the lung
parenchyma (like a spider web) show a gradual diminution.
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The bronchial tree:
Right main bronchus/trachea: 120º (foreign body, aspiration)
Left main bronchus/trachea: 90º
Peripheral branching: (dust, powder)
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The bronchial tree
• Right main bronchus/trachea: 120º
(foreign body, aspiration)
• Left main bronchus/trachea: 90º
• Peripheral branching: (dust, powder )
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Bronchus tree 3D
Csillag, Anatomy of the Living Human, Könemann 1999
CT and HRCT (vessels):
Different question-different technical method
Postprocessing
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Separation of lobes
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Secondary lobules
Terminal bronchioles
ductuli terminales
acini
alveoli
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Alveoli & acini:
can not seen on CXR, unless….
Barium aspiration
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Secondary lobules
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Secondary lobules
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Secondary lobules:
in case of airtrapping / obstruction it is well visible
exspiration: „mosaic pattern”
Inspiration
Exspiration / with magnification
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Secondary lobules:
Centrilobular GGO
Bronchiolitis (cellular)
Centrilobular emphysema
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Monostori
Emphysema
bullous cxr
centrilobular
paraseptal
CT (coronal
reconstruction)
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PIE
interstitial
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PoMo CT
IRDS PIE
Sektionsnummer: 47133
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Autopsy
Sektionsnummer: 47133
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Atelectasia
Atelectasia
ddx
The volume of the affected
side of the lung decrease :
traction (the mediastinum
shifts toward the abnormal
side)
Hydrothorax
The fluid needs more
place=Mass effect: the
mediatinum moves
toward the normal side.
Resorptive: local- tumour
Compressive (empyaema) pleuritis fibrinosa
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Hydrothorax
with atelectatic lung segments
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Fleischner atelectasia
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CXR: IRDS
micro- or adhesive atelectasia
• aerobronchogram
hyalin membrane
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ARDS ~ DAD (diffuse alveolar damage)
hyalin membrane
Later:
pneumocyta II. proliferation
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Bronchi: bronchiectasis - saccular, fusiform
Pulmonary thrombembolia: in typical case does’nt cause visible sign
on CXR
Westermark sign :
dicreased vascularisation,oligaemia
Fleischner sign :
dilated pulmonal artery on the affected side /praestenotic/
Hampton sign /hump
Lung scintigraphy: nuc.med (V/Q scan)
Suspicion of pulmonal embolia: Angio CT !
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Goodpasture syndrome
alveolar hemorrhage :the wall of the alveolar sac is not damaged.
haemorrhage
regression
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Inflammation
• Pneumonia lobar, segmental
• Bronchopneumonia
(lingular pneumonia)
( Aspiration pneumonia)
• Abscess (basket sign)
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Boeck sarcoidosis, chest x-ray
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Severe lung parenchymal
damage (fibrosis)
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(http://www.szote.u-szeged.hu/radio/mellk1/mellk7a.htm)
honeycombing
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Independently from the
cause the end stage is:
honey combing.
Upper lobes: signs of activity (GGO)
Lower lobes : honeycombing
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Fibrosis after irradiation, 43 years old woman
43 é emlőcc postirrad fibr
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Bronchial carcinoma
Operable?
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Pancoast-tumor
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In the apex
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Infiltrates the chest wall: can destruate the posterior arch of the first and
second ribs, the vertebral bodies.
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Bronchial carcinoma
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Symptoms: pain in the shoulder, Horner-trias, paralytic diaphragm on the
affected side)
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Scar carcinoma
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Pulmonal metastases
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Pleural lesions
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Pleural fluid
1.
Transudatum- cardiac or kidney failure, hypoproteinaemia,
overloading.
2.
Exsudatum – tbc and other inflammations, subphrenical abscess, lung
cancer, SLE, RA.
3.
Haemothorax (HTX) – chest trauma, haematologic diseases
4.
„Redish” pleural fluid: pulmonal embolia, lung cancer.
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Ptx: pleuritis fibrinosa
Total ptx
Hydro-ptx
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Ptx (pleura) CT
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MR angiograpy
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Conclusion-take home
messages
• You should evaluate all together the radiologic signs in
the chest: lung, heart, bony structures, soft tissues.
• You must know the clinical story of the patient.
• Even a simple conventional chest x-ray can cause
surprise.
• The work of the radiologist is less difficult and more
accurate if the requesting physician gives enough
information about the patient, even in face to face.
• Radiological examination = consilium
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