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Imaging of Thoracic Hernias: Types and Complications

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Imaging of Thoracic Hernias: Types and Complications Insights into Imaging (2018) 9:989–1005 https://doi.org/10.1007/s13244-018-0670-x PICTORIAL REVIEW Imaging of thoracic hernias: types and complications Abhishek Chaturvedi1 & Prabhakar Rajiah2 & Alexender Croake1 & Sachin Saboo2 & Apeksha Chaturvedi1 Received: 12 May 2018 /Revised: 6 October 2018 /Accepted: 18 October 2018 /Published online: 27 November 2018 # The Author(s) 2018 Abstract Thoracic hernias are characterised by either protrusion of the thoracic contents outside their normal anatomical confines or extension of the abdominal contents within the thorax. Thoracic hernias can be either congenital or acquired in aetiology. They can occur at the level of the thoracic inlet, chest wall or diaphragm. Thoracic hernias can be symptomatic or fortuitously discovered on imaging obtained for other indications. Complications of thoracic hernias include incarceration, trauma and strangulation with necrosis. Multiple imaging modalities are available to evaluate thoracic hernias. Radiographs usually offer the first clue to the diagnosis. Upper gastrointestinal radiography can identify bowel herniation and associated complications. CT and occasionally MR can be useful for further evaluation of these abnormalities, accurately identifying the type of hernia, its contents, associated complications, and provide a roadmap for surgical planning. In this article, we review the different types of thoracic hernias and the role of imaging in the evaluation of these hernias. Teaching Points • Protrusion of lung contents beyond the anatomic confines of the thorax constitutes a hernia. • Complications of thoracic hernias include incarceration, trauma and strangulation with necrosis. • Multiple imaging modalities are available to evaluate thoracic hernias. • CT is the imaging modality of choice for identifying thoracic hernias and their complications. • Imaging can provide a roadmap for surgical planning. Keywords Lung hernia . Diaphragmatic hernia . Sternal dehiscence . Pericardial hernia Introduction wall or diaphragm [1]. Diaphragmetic hernias can be either mediastinal or intrapleural. These hernias can be symptomatic Thoracic hernias are characterised by either protrusion of the or incidentally detected during routine imaging of the chest or thoracic contents outside their normal anatomical confines or abdomen for other indications. Complications of thoracic her- extension of the abdominal contents into the thorax. Thoracic nias include incarceration, trauma and strangulation with ne- hernias can be congenital or acquired in aetiology. When ac- crosis. These complications can mimic cardiovascular or gas- quired, these are usually post-traumatic or post-surgical trointestinal causes of chest and abdominal pain, some of (Fig. 1). They can occur at the level of the thoracic inlet, chest which often necessitate urgent intervention or surgery. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s13244-018-0670-x) contains supplementary material, which is available to authorized users. Imaging thoracic hernias * Abhishek Chaturvedi Different imaging modalities can be useful in identification of [email protected] thoracic hernias, with their advantages and disadvantages (Table 1), including radiographs, upper gastrointestinal series, 1 Imaging Science, University of Rochester Medical Center, 601, ultrasound, computed tomography (CT) and magnetic reso- Elmwood Avenue, Rochester, NY 14642, USA nance imaging (MRI). The roles of imaging in the evaluation 2 Radiology, University of Texas Southwestern Medical Center, of hernias (Table 2) include establishing the diagnosis, Dallas, TX, USA characterising the type, delineating the extent, identifying the 990 Insights Imaging (2018) 9:989–1005 Fig. 1 Flowchart depicting the different types of thoracic hernias seen on imaging contents, detecting complications and providing a roadmap Gastrointestinal tract radiography for intervention/surgery. Gastrointestinal contrast radiography under fluoroscopy is a useful modality in identifying bowel herniation into the tho- Radiographs rax. Upper gastrointestinal imaging with oral contrast (UGI) is useful in identification and classification of the hiatal hernias. Chest radiographs (CXR) are usually the first imaging modal- Lower gastrointestinal radiography (contrast enema) is useful ity used in adults with any suspected thoracic pathology and in identifying herniation of the large bowel into the thorax and may offer the first clue to a thoracic hernia. complications of large bowel conduits. In patients with Table 1 Different imaging modalities used in the evaluation Advantages Disadvantages Indications of thoracic hernias Chest Inexpensive; readily available Limited sensitivity and Reasonable first test screening radiograph specificity Ultrasound Portable; inexpensive; widely Operator dependent; Prenatal and paediatric group, available; real-time data limited by acoustic where radiation dose is a window in the chest, concern especially in large patients CT Good spatial resolution Radiation exposure; Comprehensive evaluation of providing anatomical potentially nephrotoxic thoracic hernia-establishing detail; wide field of view; iodinated contrast diagnosis; characterising the multi-planar reconstruction type; identifying contents; detecting complications; providing road map to intervention/surgery MRI Good spatial resolution; Limited to a few of centres; Further classification of excellent contrast time-consuming; diaphragmatic hernias and resolution; multi-planar expensive; hernias, particularly those acquisition; wide field of contraindications involving cardiac structures view Fluoroscopy Real-time anatomical and Radiation exposure; Evaluation and classification of physiological information requires patient hiatal hernias; cooperation gastrointestinal leaks Insights Imaging (2018) 9:989–1005 991 Table 2 Summary of different types of thoracic hernias, their imaging findings, mimics, and brief description of the treatment Type Imaging features Mimics Treatment Superior thoracic aperture Apical/cervical lung CXR: lateral deviation of trachea by unilateral lucency Supraclavicular emphysema, Imaging follow-up in asymptomatic patients CT/MRI: supraclavicular protrusion of lung posterior to apical bulla Congenital hernias in infants may resolve the subclavian vessels. Enlargement with Valsalva spontaneously manoeuvre Elective surgical repair in symptomatic patients or those with incarcerated hernia Cervical aortic arch CXR: absence of aortic knob, tracheal deviation to Aneurysm of carotid arteries Increased risk of dilation and aneurysm that may contralateral side Vascular rings require follow-up imaging, endovascular or CT/MRI: elongated aortic arch extending into the neck surgical repair Chest wall Intercostal CT: protrusion of lung parenchyma or other viscera Chest wall emphysema No intervention for asymptomatic hernia beyond the intercostal space Eloesser reconstruction Elective surgical repair for incarcerated hernia Emergent surgical repair for strangulated hernia Sternal CXR: lateral view may identify presternal opacity Postoperative sternal Elective surgical repair with musculocutaneous CT: protrusion of pericardium, cardiac chambers or great infection, haematomas or grafts. Radical sternectomy for vessels through the sternal dehiscence seroma post-sternotomy mediastinitis Pericardiocutaneous fistula Spinal CXR: widening of mediastinum, paraspinal opacity, Foregut duplication Cyst Elective surgical repair associated vertebral anomalies Cystic neoplasms CT/MRI: protrusion of meninges with CSF and occasionally spinal cord or nerves into posterior mediastinal, pleura or chest wall Transmediastinal Transmediastinal CXR/CT: lung herniation across anterior-posterior Post-pneumonectomy May require placement of tissue expander for junction lines Atelectasis from bronchial bronchial narrowing/stenosis Pleural sac or fluid herniation across posterior junction obstruction line Transdiaphragmatic Intrapleural CXR: bowel loops in the hemithorax, elevated Diaphragmatic mass, lipomas Laparotomy with repair during the acute phase hemidiaphragm, NG tube above the left Transthoracic or thoracoabdominal approach for hemidiaphragm chronic hernia CT: direct sign: Defect in the diaphragm, dangling diaphragm Indirect: herniation of abdominal fat or viscera into the pleural cavity, collar sign Mediastinal CXT: opacity at the anterior cardiophrenic angle. Pericardial cyst, prominent No treatment for asymptomatic hernia CT/MRI: small defect in between pars sternalis and pars pericardial fat or Elective repair for herniated viscera or bowel costalis with herniation of omentum or bowel loops mediastinal lipomatosis Pericardial CXR: air fluid level from herniated bowel in the Pericardial haematoma, Elective repair for herniated viscera or bowel retrosternal region primary tumour, metastasis CT/MRI: herniation of abdominal organs, omentum or bowel loops into the pericardium Type I hiatal hernia Oesophagogram/ CT: displacement of oesophagogastric No surgery for asymptomatic hernia junction into thorax Medical treatment of reflux disease Antireflux procedure Type II hiatal hernia Oesophagogram/ CT: Epiphrenic or traction Symptomatic hernia: elective surgical repair GE junction in normal position, fundus herniates into diverticulum thorax Oesophageal fistula Type III hiatal hernia Both GE junction and fundus herniate Epiphrenic or traction Elective surgical repair diverticulum Gastric or oesophageal fistula Type IV hiatal hernia Other viscera also
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