RADIOLOGY - IMAGING OF
THE THORAX
THE CHEST
METHODS OF EXAMINATION
Radiography
Standard examination :
- PA + lateral projection;
- tube-film distance – 1,5 m to minimize divergent distorsion
and magnification;
- full inspiration.
Apical lordotic view –
- is used to see diseases in the pulmonary apices, which may
be obscured by the clavicle and the first rib;
- AP wiew with the patient leaning backward on the cassette
holder.
Supine radiographs – intensive care units.
DIGITAL RADIOGRAPHY
THE CHEST
METHODS OF EXAMINATION
Fluoroscopy
–dynamic study of the cardiovascular system,
diafragmatic motion. Disadvantage: high radiation dose.
Bronchography
– the study of the bronchial tree by means of the
introduction of opaque material into the bronchi.
Replaced by CT, fiberoptic bronchoscopy, brush biopsy,
percutaneous biopsy
Tomography
– it is possible to examine a single layer of tissue and to
blur the tissues above and below the level by motion
(the tube and the film move in opposite directions).
- replaced by CT.
THE CHEST
METHODS OF EXAMINATION
Fluoroscopy
1933
2000
THE CHEST
METHODS OF EXAMINATION
Tomography
Tub
Rx
Caseta/film
THE CHEST
METHODS OF EXAMINATION
• Computed tomography – indications for the lung:
• - Evaluation and staging of primary pulmonary neoplasms
• - Detection of metastasis from non-pulmonary primary
tumors.
• Characterization of solitary pulmonary nodules as benign
or malignant
• Characterization of focal and diffuse lung disease for
• diagnosis.
THE CHEST
METHODS OF EXAMINATION
Computed tomography
Indications for the mediastinum:
- Causes of mediastinal widening
- Staging of tumors that spread to the mediastinum
- Characterization of mediastinal masses – cysts, solid,
vascular, fat.
Other indications:
Pleura plaques, masses, loculated fluid, occult
calcification, chest wall masses.
High-resolution CT – evaluation of interstitial lung
disease, bronchiectasis, emphysema, cystic lung disease.
THE CHEST
METHODS OF EXAMINATIONComputed tomografy
1975
1995
THE CHEST
METHODS OF EXAMINATION
Ultrasonography
– fluid can be localized and differentiated
from solid pleural masses;
- mediastinal lesions in contact with the chest
wall
- lesions near the diafragm.
THE CHEST
METHODS OF EXAMINATION
-
Magnetic resonance imaging – indications:
dissection of the aorta, aneurysm
congenital and acquired heart conditions
-
intracardiac and paracardiac masses.
- pericardial diseases.
- brachial plexopathy.
- diafragm and peridiafragmatic processes.
- chest-wall lesions.
- breast implants and breast masses.
- Extention of the posterior mediastinal masses, especially
those with intraspinal extension.
MRI
MAGNET
Coils
THE CHEST
METHODS OF EXAMINATION
Pulmonary and bronchial angiography – arterial or
venous anomalies; thromboembolic disease.
Scintigraphy
Single Photon Emission Computed Tomography (SPECT )
- Tc 99m – iv injection - pulmonary perfusion
- Xe gas is inhaled – pulmonary ventilation
How to analyze the chest X-ray
- Soft tissues
- Bony thorax – ribs, clavicles, scapulae, thoracic vertebrae
- Mediastinum
- Lungs – hilum, vessels, apices
- Pleura
- Diafragm
Roentgen observations must be correlated with all the
available clinical information
Gr.I
Nodular opacities
MILIARY tuberculosis
Lesion in the mediastinum
FELSON sign
Lesion in the lung
PNEUMONIA
ATELECTASIS
Diffuse opacities
PLEURAL FLUID
PLEURAL FLUID
ATELECTASIS
LINEAR OPACITIES
EMPHYSEMA
PNEUMOTHORAX
DIFFUSE HYPERLUCENCIES
1
3
1
Chist hidatic
2
2
3
3
4
CIRCUMSCRIBED
HYPELUCENCIES
1.Bulla
2. Aeric cyst
3. Cavity- TB
4. Cvity - cancer
ABSCESS
RUPTURED
HYDATID CYST
CHEST INFECTIONS
Acute pulmonary infections
1. Lobar pneumonia – the organism reaches the periphery of
the lung via the airways.Alveolar transudation is followed
by migration of leucocytes into the alveolar fluid.
2. Bronchopneumonia (lobular pneumonia) – often observed
in staphyloccocal infection of the lung. The disease
originates in the airways and spreads to peribronchial
alveoli.
3. Interstitial pneumonia – usually caused by a virus or a
mycoplasma.
4. Mixed pneumonia – is a combination of lobar,
bronchopneumonia and interstitial pneumonia.
Pneumococcal pneumonia
- Caused by S.pneumoniae.
- roentgen findings can be observed within 6 to 12 hours after
onset of symptoms.
- Chest x-ray:
- triangular opacity, the tip towards the hilum, the base
towards the periphery of the lung.
- all the elements in the diseased lobe may be affected except the
large bronchi– “air bronchogram”.
- Resolution is rapid if there are not complications – the
opacity becomes more irregular and patchy, the intensity
decreases.
- Complications – delayed resolution, lung abscess, pleural
effusion.
Bronchopneumonia
– staphyloccocal infection of the lung
- It is the most commonly found in the very young or very
old
- The inflammatory disease does not cross septal boundaries
 the pattern of disease is discontinous or patchy.
-Chest x-ray:
-nodular opacities, 1-10mm,
-poorly defined
-with the center more opaque compared to the periphary.
- It is particularly difficult to define and diagnose when it
occurs as a complication in case of cardiac failure.
Staphylococcal pneumonia
– caused by Staphylococcus aureus
- the infection may be primary in the lungs or secondary to a
primary staphylococcal infection elsewhere in the body.
- Usually occurs in debilitated adults or in the first year of life.
- Consolidation rapidly spreads to involve a whole lobe and
bronchi are obscured by exudate, so the air brohogram is
rarely seen.
- Abscess formation may occur; coalescense of small
abscesses is frequent.
- Pleural effusion, empyema and pneumothorax are frequent
- Pneumatocele – a check-valve obstruction develops between
the lumen of a small bronchus and the pulmonary parenchyma.
- The disease is usually bilateral
Interstitial pneumonia
- usually caused by a virus or Mycoplasma pneumoniae (is
responsible for a significant percentage of primary atypical
pneumonia in children and young adults).
- Roentgen findings:
- Peribronchial or interstitial type – streaky densities
extending from the hilum following the vascular markings.
- Bronchopneumonic type.
- Segmental or lobar types
- Diffuse type – bilateral reticulo-nodular pattern
DD - interstitial pneumonia  bacterial pneumonia:
- delay in radiological onset
- lack of pleural involvement,
- the tendency to clear in one area and to spread in another,
bilaterality.
Acute interstitial pneumonia : influenza
Acute interstitial pneumonia
Acute interstitial
pneumonia
COMPLICATIONS
BRONHOPNEUMONIA
SEGMENTAL
PNEUMONIA
Lung abscess
- lung abscess = when an acute pulmonary infectious process
breaks down to form a cavity.
- Primary / secondary.
-Chest x-ray
- opacity confined to one segment, round, irregular borders.
- When bronchial communication is established the fluid
content of the cavity is replaced by air – hydro-aeric
image with orizontal fluid level.
-CT – Very useful to define the inner and outer walls, for
complications (rupture into the pleural space).
-Differential diagnosis:
-early stage – pneumonia;
-cavity – tbc, cancer, hydatid cyst, fungal infection
TUBERCULOSIS
- Transmitted by inhalation of infected droplets of
Mycobacterium tuberculosis
- Target population: patients of low economic scale,
alcoholics, elderly, AIDS
Primary TB
Rancke (primary) complex :
1. Ghon focus – nodular opacity (1-7cm), irregular
borders, non-homogeneous, low intensity, lower lobe
2. Lymphadenopathy – hilar and paratracheal, 95%
3. Lymphangitis – linear opacities
Primary TB
Evolution:
- Healing
- Fibrosis
- Calcification
- Cavitation
Complications:
- Miliary TB
- TB pneumonia
- TB bronchopneumonia
- Pleural effusion
Secondary TB
- active disease in adults most commonly represents
reactivation of a primary focus; the disease tends to be
progressive
- Typically limited to the upper lobes
- No adenopathy
Radiographic features
•Early infiltrate – low intensity, poorly defined opacities
•Cavitation – 40%
•Fibro-caseous TB
•Fibrotic TB – sharply circumscribed linear densities radiating
to hilum;
•Fibrothorax, tuberculoma
Secondary TB
Complications:
1.
2.
3.
4.
5.
6.
Miliary TB
Bronchogenic spread
Bronchial stenosis
Bronchiectasis
Pneumothorax
Pleural effusion – often loculated
ASPERGILOMA
AIDS
Known routes of HIV transmission:
- Blood and blood products
- Sexual activity
- In utero transmission
- During delivery
Clinical:
- Lymphadenopathy
- Incidental infections
- Tumors: lymphoma, Kaposi sarcoma
- Other manifestations: interstitial pneumonia,
spontaneous pneumothorax, septic emboli
AIDS
Spectrum of chest manifestations:
Nodules – Kaposi sarcoma (usually associated with skin
lesions), septic infarcts, fungal infections (Cryptoccocus,
Aspergillus)
Large opacity: consolidation, mass – hemorrhage,
pneumonia
Linear or interstitial opacities – atypical pneumonia,
Kaposi sarcoma
Lymphadenopathy – Mycobacterial infections, Kaposi
sarcoma, lymphoma
Pleural effusion – Kaposi sarcoma, fungal infection,
pyogenic empyema