Download Chest

Chest
Prof. Karlinger Kinga MD, CSc, PhD,
Dr.med.habil.
Department of Radiolgy and Oncotherapeutic Clinic, Semmelweis University
The radiologic evaluation is the extension of the physical examination
•Percussion and auscultation are still important
–Heart : size, configuration, signs of decompensation
–Pulmonary diseases: airways, parenchymal, blood vessels
–Pleural pathological lesions: pleuritis, hydrothorax
Radiological methods to evaluate the chest
•Chest x-ray and fluoroscopy
•CT
•MR
•Nuclear medicine
•US (new!)
The x-ray film summarizes
•Different
direction of the beam:
(postero-anterior),
–laterolateral,
–AP (antero-posterior),
–PA
–
•Fluoroscopy-
gives functional information, we ask the patient to turn slowly to one and the
other side
•
What can we see on the CXR?
normal lung (US): seashore sign
The anamnesis is important, because there are some surprises (pictures)
Chest deformities (pictures) : Paralytic thorax (tight apex, acute costovertebral angles)
Emphysematic thorax (asthma, the apex is wide, „romanh, horizontal ribs, wide intercostal
spaces)
Baby thorax
Evaluation of the heart: size, configuration, signs of decompensation
frontal
latero-lateral
Pictures:
Right ventricle enlargement , Left ventricle enlargement, Elongated, widened aorta,
Mitral stenosis: left atrium, pulmonal veins in the upper lobes are dilated
Mitral stenosis
LUNG: Thickened interlobar septums (oedema), + interstitial fluid
Decompensation (left) cardial insuffitientia: LV, LA dilation, Dilated veins in the upper lobes,
interstitial oedema (Kerley A), Anomalies in hilar caliber Dilated vessels (veins + arteries)
–ASD
(atrial septum defect)
–VSD (ventricular septum defect)
–Ductus Botalli persistens
Cause tipical alterations ont he lung images
•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, veins 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.
+cpcd (centro-periferal-caliber-dyscrepancy) : pulmonal arterial hypertony, chronic
mitral stenosis, chronic decompensation
Pulmonal congestion:
Numerous B3 lines in all lung fields in a patient with pulmonary oedema.
PERICARDIUM
Evaluation of the coronaries
Evaluation of the myocardium
Cardio MR : pictures transversal (white blood) MR : myocarditis
Cardiac muscle viability after ami, MRI evaluation
LUNG
Evaluation of the lung pictures
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.
The bronchial tree
Right main bronchus/trachea: 120º (foreign body, aspiration)
Left main bronchus/trachea: 90º
Peripheral branching: (dust, powder )
The pulmonary ligament (CT picture)
CT and HRCT (vessels) :Different question-different technical method ! and postprocessing
IMPORTANT , NEW !!
The concept of the secondary lobule (anatomical and functional)
Secondary lobules: can not seen on CXR, unless the wall are thickened
In case of airtrapping / obstruction it is well visible : exspiration: „mosaic” pattern
Tree in bud pattern (tbc, BAC)
GGO Ground glasopalescency : Centrilobular GGO
Emphysema
Centrilobular /centroacinar emphysema, panlobular, paraseptal,
Bullous emphysema
Interstitial : newborn (hyalin membrane – positive endpressure)
Atelektasia forms:
Resorption, compression, local /segmental Important! (pictures: Empyema thoracis, compression
form of atelectasia, Hydrothorax with atelectatic lung segments, Atelectasia caused bypleuritis
fibrinosa)
Fleischner-type of atelectasia – abdominal sign!
IRDS: micro- or adhesive atelectasia, picture : aerobronchogram (newborns)
ARDS ~ DAD (diffuse alveolar damage) severely burned, multiorgan failure (grownups)
BRONCHI:
bronchiectasis
bronchitis chronica
Pulmonary thrombembolism: life threatening!
Blood vessels in the lung (aa. pulmonales) obstracted suddenly . Invetigating method: CT
Case: afer cesarean section nearly deadly! CTangio - thrombolysis
Lung scintigraphy (V/Q scan)
Pulmonary thombembolia with haemorrhage and infarction
Alveolar haemorrhage: Goodpasture syndrom (pictures: hemorrhage and regression)
Inflammations
Lobar Pneumonia (e.g. pictures: segment pneumonias, lingular pneumonia)
Brochoneumonia is another entity
Aspiration pneumonia :a case at the Intensive care station: (at 8 o’clock, at 10 o’clock)
Interstitial diseases:
Boeck sarcoidosis, chest x-ray , HRCTpictures
Restrictive lung disease
Fibrosis, severe lung parencyhmal damage (pictures)
Fibrosis can be caused by several damages: a case: after irradiation, 43 years old woman (picture)
TUMOURS
Bronchial carcinoma
Pulmonal carcinoma: central, periferal (pictures, pictures)
Pancoast-tumor (picture), in the apex, Infiltrates the chest wall: can destruate the posterior arch
of the first and second ribs, the vertebral bodies. Symptoms: pain in the shoulder,Horner-trias,
paralytic diaphragm on the affected side
Pulmonary metastases! The most often pulmonary tumours (pictures)
PLEURA
Pleural lesions
•Pleural fluid
Transudatum- cardiac or kidney failure, hypoproteinaemia, overloading.
Exsudatum – tbc and other inflammations, subphrenical abscess, lung cancer, SLE, RA.
Haemothorax (HTX) – chest trauma, haematologic diseases
Redish pleural fluid: pulmonal embolia, lung cancer.
Ptx (Pneumothorax) pictures
MR angiography (Picture)
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 a 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