Evaluation of the chest

Transcription

1 Evaluation of the chest part 1 Nagy Endre SZEGEDI TUDOMÁNYEGYETEM ÁOK, RADIOLÓGIAI KLINIKA, SZEGED

2 Indication In case of complaints or symptoms: In suspicion of lesions, diseases or injuries of the chest organs and On the basis of complaints, clinical signs and lab findings

3 Indication If free of complaints: In case of such diseases of distant organs that may cause even symptomless lesions of the chest (e.g. metastasis)

4 Indication For prevention: Exclusion of lung and heart diseases before operation and complex anesthesia In case of unconsciousness or polytrauma.

5 Indication In healthy patients: for screening or evaluation of fitness for work; before settling down or having a job.

6 Limited indication Follow-up of previously detected lesions (e.g. pneumonia) Thoracal diseases inducing dullness (US instead) Supposedly mediastinal lesions (MRI instead)

7 Contraindication Only cardiopulmonary resuscitation in progress ( it can be performed in recumbent position or even on an unconscious patient!)

8 Chest X-ray Apart from the bones, the air content and blood vessels of the lungs, the hilus and the central shadow (heart and aorta) are evaluated

9 Chest X-ray The tiny vessels are visualized because they are surrounded by air

10 For the interpretation of the image it is helpful to know: age sex physical activity occupation smoking, alcohol, drug abuse clinical data

11 Clinical background presumes extended shadow in the lung + fever pneumonia + foreign body aspiration atelectasis + difficulty breathing and thrombophlebitis infarction + cough, smoking cancer + unconsciousness, vomiting aspiration + penetrating injury hematoma in the lung

12 Basic examination of the chest Two-wiev image: such lesion can be detected on the lateral image that could not be detected on the postero-anterior image

13 Additional X-ray procedures Fluoroscopy Oblique images Images in lateral position Images in exspiration fluorography (conventional tomography) Digital radiography dual energy technique

14 Fluoroscopy Visualizes motions and provides spatial information

15 Oblique image For the evaluation of covered or complex structures

16 Exspiration For the evaluation of pneumothorax or bronchostenosis

17 Fluorogram small size analogous or digital picture made directly from the fluoroscope in order to screening

18 (conventional tomography) Confusing details can be excluded

19 Digital radiogram It provides more equilibrated images with less radiation exposure Possibility of post-processing and simple measurements

20 Dual energy -technique Elimination of disturbing bone-shadows in the chest that cover 75% of the lungs, with different energy, double exposure and subtraction Summation image reversed bone-image

21 Dual energy technique After subtraction of the bones, lung components can be evaluated

22 Application of contrast materials water-soluble iodinated contrast materials are used in the bronchi: bronchography blood vessels: arteries: pulmonary or bronchial veins: pulmonary or systemic

23 Bronchography (in pulmonology) intervention and contrastmaterial are needed for the evaluation of locations cannot be reached with bronchoscope if there is no HRCT

24 Pulmonary arteriography verification of congenital anomalies, and pulmonary embolism

25 Cavography digital subtraction angiography: VCS syndrome

26 Native and contrast enhanced CT at first: axial images without contrast-material more precisely: reconstruction in different plains with iv. water-soluble iodinated contrast-material

27 Incremental or sequential (Slice) CT High radiation exposure: 1 exposition = 1 slice reconstruction: in different plains

28 HRCT* High resolution higher radiationexposure longer exposition Good imaging: periphery of the lung interstitium */ high resolution computed tomography

29 Spiral, multi slice (volume) CT 1 exposition = more slice full chest imaging with one breathing in 2D recontructions in any plains

30 Spiral CT Spatial reconstructions as well

31 Spiral CT reconstructions with cutting out the unwanted parts, coloring; the image can be turned

32 CTangiography i. v. iodinated contrastmaterial Visualization of the blood vessel lumen + parenchymal visualization 3D reconstruction in any plains

33 Functional CT i. v. iodinated contrastmaterial perfusion (flow intensity) enhancement (process of interstitial filling)

34 Dynamic 3D CT Visualization of physical borders of structures with different radiation absorption It can be evaluated from many angles, can be rotated as a 3D model virtual bronchoscopy: advantage: no injury or infection disadvantage: doesn t show the actual mucosa, bleeding etc.

35 Virtual bronchoscopy

36 Good to know for the indication of a CT scan: Radiation exposure of the population mostly arises from the medical applications, One CT examination has the radiation exposure equivalent with 400 chest X-rays

37 Hybrid techniques For the visualization of the morphology and function at the same time: SPECTCT (Single Photon Emission Tomography) PETCT (Positron Emission Tomography)

38 SPECTCT Localization of tumor metabolism

39 PETCT Localization of tumor metabolism

40 MR-examination Visualizes the proton (H-nuclei) density and their relation to the surrounding structures The water and fat are best visualized with this method inflammation, edema, and the fat-layers surrounding the organs are seen And it shows the distribution of proper contrastmaterials Because it is sensitive to motions, the circulating blood can also be evaluated

41 MR-examination The lungs are poorly visualized: lack of hydrogen, too much movement

42 MR-angio without contrast-material black blood technique: there is no signal from the nonexcited blood

43 MR-angio with contrast-material i. v. gadolinium contrastmaterial visualizes the circulating blood Non-selective

44 Functional MR Changing of blood flow in time, contrast-material: the iron in the hemoglobin

45 Functional MR Evaluation of ventilation, contrast-material: 3He-isotope

46 Radiologic signs of diseases There is no sign, because the lesion is too small or too slight is not radiopaque, reflective enough, or doesn t contain enough H doesn t provide enough contrast with the surrounding structures is moving too fast or too slow cannot be detected with the given modality

47 Radiologic signs of diseases By radiation absorption: Enhanced radiation absorption = shadow Reduced radiation absorption = transparency-enhancement, enlightenment, negative shadow By tissue characteristic: air (accumulation or diminution) soft tissue (accumulation or diminution) fluid (in the interstitium, alveolus, pleural space)

48 Shadows in the chest X-rays intrapulmonary: alveolar interstitial Shadow of a vessel Shadow of a bronchus extrapulmonary pleural extrathoracal

49 Typical shadows As mentioned in the findings: nodular lesion infiltration linear shadow opacity

50 Nodular lesions Some mm or cm sized, well circumscribed shadows

51 Nodular lesion benign: Round or lobulated, with sharp edge, central calcification, well defined malignant: Irregular or spiculated, Blurry contoured, Eccentric calcification

52 Infiltrative shadows ill-defined, homogenous or inhomogeneous shadow with some cms in size

53 Infiltrative shadows Lobar pneumonia: respects the borders of the lobe, airbronchogram bronchopneumonia: patchy structure, multifocal

54 Linear shadow band band Bronchial shadow Vascular shadow stripe

55 Other typical shadows Air-filled cyst reticulogranular pattern Double pleura ( interlobar space ) Fluid-filled cyst Kerley s lines Hilar mass shadow Honey combing lung

56 Other typical shadows basket Calcified foci and lymph nodes comet dumbbell rails ring lamellar atelectasis

57 Negative shadows (enlightenment) Westermark sign: Behind vascular occlusions or in valvular bronchial stenoses, the lung is lighter air bronchogram: If there is no air in the alveoli, lumen of the bronchi are visualized

58 Covering, blur The extrapulmonary shadows won t make the vascular pattern disappear

59 Regular settling TBC: in the apex (ventilation ) metastasis: In the base (perfusion )

60 Changing of the volume the intrapulmonary inflammation, haemorrhage, or the pleural fluid- or blood accumulation, ptx needs more space than usual atelectasis, shrinking processes occupy less space

61 Inflammation and atelectasis Volume is increasing Volume is decreasing

62 Pushing and pulling fluid accumulation is pushing atelectasis is pulling

63 Typical shapes Free pleural fluid accumulation hydropneumothorax

64 The Ellis Damoiseau-line is a concept in internal medicine X-ray image: concave With percussion: convex

65 o f T f i h e r s t

66 Evaluation of the chest part 1 Nagy Endre SZEGEDI TUDOMÁNYEGYETEM ÁOK, RADIOLÓGIAI KLINIKA, SZEGED 1

67 Indication In case of complaints or symptoms: In suspicion of lesions, diseases or injuries of the chest organs and On the basis of complaints, clinical signs and lab findings 2

68 Indication If free of complaints: In case of such diseases of distant organs that may cause even symptomless lesions of the chest (e.g. metastasis) 3

69 Indication For prevention: Exclusion of lung and heart diseases before operation and complex anesthesia In case of unconsciousness or polytrauma. 4

70 Indication In healthy patients: for screening or evaluation of fitness for work; before settling down or having a job. 5

71 Limited indication Follow-up of previously detected lesions (e.g. pneumonia) Thoracal diseases inducing dullness (US instead) Supposedly mediastinal lesions (MRI instead) 6

72 Contraindication Only cardiopulmonary resuscitation in progress ( it can be performed in recumbent position or even on an unconscious patient!) 7

73 Chest X-ray Apart from the bones, the air content and blood vessels of the lungs, the hilus and the central shadow (heart and aorta) are 8 evaluated

74 Chest X-ray The tiny vessels are visualized because they are surrounded by air 9

75 For the interpretation of the image it is helpful to know: age sex physical activity occupation smoking, alcohol, drug abuse clinical data 10

76 Clinical background presumes extended shadow in the lung + fever pneumonia + foreign body aspiration atelectasis + difficulty breathing and thrombophlebitis infarction + cough, smoking cancer + unconsciousness, vomiting aspiration + penetrating injury hematoma in the lung 11

77 Basic examination of the chest Two-wiev image: such lesion can be detected on the lateral image that could not be detected on the postero-anterior image 12

78 Additional X-ray procedures Fluoroscopy Oblique images Images in lateral position Images in exspiration fluorography (conventional tomography) Digital radiography dual energy technique 13

79 Fluoroscopy Visualizes motions and provides spatial 14 information

80 Oblique image For the evaluation of covered or complex15structures

81 Exspiration For the evaluation of pneumothorax16or bronchostenosis

82 Fluorogram small size analogous or digital picture made directly from the fluoroscope in order to screening 17

83 (conventional tomography) Confusing details can be excluded 18

84 Digital radiogram It provides more equilibrated images with less radiation exposure Possibility of post-processing and simple measurements 19

85 Dual energy -technique Elimination of disturbing bone-shadows in the chest that cover 75% of the lungs, with different energy, double exposure and subtraction Summation image reversed bone-image 20

86 Dual energy technique After subtraction of the bones, lung components can be evaluated 21

87 Application of contrast materials water-soluble iodinated contrast materials are used in the bronchi: bronchography blood vessels: arteries: pulmonary or bronchial veins: pulmonary or systemic 22

88 Bronchography (in pulmonology) intervention and contrastmaterial are needed for the evaluation of locations cannot be reached with bronchoscope if there is no HRCT 23

89 Pulmonary arteriography verification of congenital anomalies, and pulmonary embolism 24

90 Cavography digital subtraction angiography: VCS syndrome 25

91 Native and contrast enhanced CT at first: axial images without contrast-material more precisely: reconstruction in different plains with iv. water-soluble iodinated contrast-material 26

92 Incremental or sequential (Slice) CT High radiation exposure: 1 exposition = 1 slice reconstruction: in different plains 27

93 HRCT* High resolution higher radiationexposure longer exposition Good imaging: periphery of the lung interstitium */ high resolution computed tomography 28

94 Spiral, multi slice (volume) CT 1 exposition = more slice full chest imaging with one breathing in 2D recontructions in any plains 29

95 Spiral CT Spatial reconstructions as well 30

96 Spiral CT reconstructions with cutting out the unwanted parts, coloring; the image can be turned 31

97 CTangiography i. v. iodinated contrastmaterial Visualization of the blood vessel lumen + parenchymal visualization 3D reconstruction in any plains 32

98 Functional CT i. v. iodinated contrastmaterial perfusion (flow intensity) enhancement (process of interstitial filling) 33

99 Dynamic 3D CT Visualization of physical borders of structures with different radiation absorption It can be evaluated from many angles, can be rotated as a 3D model virtual bronchoscopy: advantage: no injury or infection disadvantage: doesn t show the actual mucosa, bleeding etc. 34

100 Virtual bronchoscopy 35

101 Good to know for the indication of a CT scan: Radiation exposure of the population mostly arises from the medical applications, One CT examination has the radiation exposure equivalent with 400 chest X-rays 36

102 Hybrid techniques For the visualization of the morphology and function at the same time: SPECTCT (Single Photon Emission Tomography) PETCT (Positron Emission Tomography) 37

103 SPECTCT Localization of tumor metabolism 38

104 PETCT Localization of tumor metabolism 39

105 MR-examination Visualizes the proton (H-nuclei) density and their relation to the surrounding structures The water and fat are best visualized with this method inflammation, edema, and the fat-layers surrounding the organs are seen And it shows the distribution of proper contrastmaterials Because it is sensitive to motions, the circulating blood can also be evaluated 40

106 MR-examination The lungs are poorly visualized: lack of hydrogen, too much movement 41

107 MR-angio without contrast-material black blood technique: there is no signal from the non42 excited blood

108 MR-angio with contrast-material i. v. gadolinium contrastmaterial visualizes the circulating blood Non-selective 43

109 Functional MR Changing of blood flow in time, contrast-material: the 44 iron in the hemoglobin

110 Functional MR Evaluation of ventilation, contrast-material: 3He-isotope 45

111 Radiologic signs of diseases There is no sign, because the lesion is too small or too slight is not radiopaque, reflective enough, or doesn t contain enough H doesn t provide enough contrast with the surrounding structures is moving too fast or too slow cannot be detected with the given modality 46

112 Radiologic signs of diseases By radiation absorption: Enhanced radiation absorption = shadow Reduced radiation absorption = transparency-enhancement, enlightenment, negative shadow By tissue characteristic: air (accumulation or diminution) soft tissue (accumulation or diminution) fluid (in the interstitium, alveolus, pleural space) 47

113 Shadows in the chest X-rays intrapulmonary: alveolar interstitial Shadow of a vessel Shadow of a bronchus extrapulmonary pleural extrathoracal 48

114 Typical shadows As mentioned in the findings: nodular lesion infiltration linear shadow opacity 49

115 Nodular lesions Some mm or cm sized, well circumscribed shadows 50

116 Nodular lesion benign: Round or lobulated, with sharp edge, central calcification, well defined malignant: Irregular or spiculated, Blurry contoured, Eccentric calcification 51

117 Infiltrative shadows ill-defined, homogenous or inhomogeneous shadow with some cms in size 52

118 Infiltrative shadows Lobar pneumonia: respects the borders of the lobe, airbronchogram bronchopneumonia: patchy structure, multifocal 53

119 Linear shadow band band Vascular shadow stripe Bronchial shadow 54

120 Other typical shadows Air-filled cyst reticulogranular pattern Double pleura ( interlobar space ) Fluid-filled cyst Kerley s lines Hilar mass shadow Honey combing lung 55

121 Other typical shadows basket Calcified foci and lymph nodes comet dumbbell rails ring 56 lamellar atelectasis

122 Negative shadows (enlightenment) Westermark sign: Behind vascular occlusions or in valvular bronchial stenoses, the lung is lighter air bronchogram: If there is no air in the alveoli, lumen of the bronchi are visualized 57

123 Covering, blur The extrapulmonary shadows won t make the vascular pattern disappear 58

124 Regular settling TBC: in the apex (ventilation ) metastasis: In the base (perfusion ) 59

125 Changing of the volume the intrapulmonary inflammation, haemorrhage, or the pleural fluid- or blood accumulation, ptx needs more space than usual atelectasis, shrinking processes occupy less space 60

126 Inflammation and atelectasis Volume is increasing Volume is decreasing 61

127 Pushing and pulling fluid accumulation is pushing atelectasis is pulling 62

128 Typical shapes Free pleural fluid accumulation hydropneumothorax 63

129 The Ellis Damoiseau-line is a concept in internal medicine X-ray image: concave With percussion: convex 64

130 o f T h e f i r s t p a r t 65