Evaluation of the Chest

EvaluationEvaluation ofof thethe chestchest

partpart 11

NagyNagy EndreEndre

SZEGEDISZEGEDI TUDOMÁNYEGYETEMTUDOMÁNYEGYETEM ÁOK,ÁOK, RADIOLÓGIAIRADIOLÓGIAI KLINIKA,KLINIKA, SZEGEDSZEGED

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

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)

Indication

For prevention:

• Exclusion of lung and heart diseases before operation and complex anesthesia • In case of unconsciousness or polytrauma.

Indication

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

Limited indication

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

Contraindication

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

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 Chest X-ray

• The tiny vessels are visualized because they are surrounded by air For the interpretation of the image it is helpful to know:

• age • sex • physical activity • occupation • smoking, alcohol, drug abuse • clinical data

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…

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

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

Fluoroscopy

Visualizes motions and provides spatial information Oblique image

For the evaluation of covered or complex structures

Exspiration

For the evaluation of pneumothorax or

bronchostenosis Fluorogram

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

(conventional tomography)

• Confusing details can be excluded

Digital radiogram

• It provides more equilibrated images – with less radiation exposure • Possibility of post-processing and simple measurements

„Dual energy”-technique

• Elimination of disturbing bone-shadows in the chest that cover 75% of the lungs, with different energy, double exposure and subtraction

reversed bone-image Summation image „Dual energy” technique

After subtraction of the bones, lung components can be evaluated 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

Bronchography

(in pulmonology) • intervention and contrast- material are needed • for the evaluation of locations cannot be reached with bronchoscope • if there is no HRCT

Pulmonary arteriography

verification of congenital anomalies, and pulmonary embolism Cavography

digital subtraction angiography: VCS − syndrome

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

Incremental or sequential (Slice) CT

High radiation exposure: 1 exposition = 1 slice reconstruction: in different plains

HRCT*

High resolution higher radiation- exposure longer exposition Good imaging: periphery of the lung interstitium

*/ high resolution computed tomography Spiral, multi slice (volume) CT

1 exposition = more slice full chest imaging with one breathing in

2D recontructions in any plains

Spiral CT

Spatial reconstructions as well

Spiral CT

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

CT- angiography

i. v. iodinated contrast- material Visualization of the blood vessel lumen + parenchymal visualization 3D reconstruction in any plains

Functional CT

i. v. iodinated contrast- material

perfusion (flow intensity)

enhancement (process of interstitial filling)

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.

Virtual bronchoscopy

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

Hybrid techniques

• For the visualization of the morphology and function at the same time:

– SPECTCT (Single Photon Emission Tomography) – PETCT (Positron Emission Tomography)

SPECTCT

Localization of tumor metabolism PETCT

Localization of tumor metabolism 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 contrast- materials • Because it is sensitive to motions, the circulating blood can also be evaluated

MR-examination

The lungs are poorly visualized: lack of hydrogen, too much movement

MR-angio – without contrast-material

„black blood” technique: there is no signal from the non-

excited blood MR-angio – with contrast-material

i. v. gadolinium contrast- material visualizes the circulating blood Non-selective

Functional MR

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

3 Evaluation of ventilation, contrast-material: He-isotope 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

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)

Shadows in the chest X-rays

intrapulmonary: • alveolar • interstitial • Shadow of a vessel • Shadow of a bronchus extrapulmonary • pleural • extrathoracal

Typical shadows

• As mentioned in the findings: – nodular lesion – infiltration – linear shadow – opacity

Nodular lesions

Some mm or cm sized, well circumscribed shadows

Nodular lesion

benign: Round or lobulated, with sharp edge, central calcification, well defined

malignant: Irregular or spiculated, Blurry contoured, Eccentric calcification Infiltrative shadows

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

Infiltrative shadows

Lobar pneumonia: broncho- respects the pneumonia: borders of the patchy lobe, air- structure, bronchogram multifocal

Linear shadow

band

band Vascular shadow

Bronchial shadow stripe

Other typical shadows

Air-filled cyst Hilar mass reticulogranular pattern shadow Double pleura („interlobar space”) Fluid-filled cyst Honey Kerley’s lines combing lung

Other typical shadows

basket

Calcified foci and lymph nodes comet dumbbell rails ring

lamellar atelectasis Negative shadows (enlightenment)

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

Covering, blur

The extrapulmonary shadows won’t make the vascular pattern disappear Regular settling

TBC: in the apex

(ventilation )

metastasis: In the base

(perfusion )

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

Inflammation and atelectasis

Volume is increasing Volume is decreasing

Pushing and pulling

fluid accumulation is pushing atelectasis is pulling

Typical shapes

Free pleural fluid hydro- accumulation pneumothorax

The Ellis−Damoiseau-line is a concept in internal medicine X-ray image: concave

With percussion: convex oo f f T T h h e e

ff i i r r s s t t pp a a r r t t Evaluation of the chest

part 1

Nagy Endre

SZEGEDI TUDOMÁNYEGYETEM ÁOK, RADIOLÓGIAI KLINIKA, SZEGED

1 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 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 Indication

For prevention:

• Exclusion of lung and heart diseases before operation and complex anesthesia • In case of unconsciousness or polytrauma.

4 Indication

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

5 Limited indication

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

6 Contraindication

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

7 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) are8 evaluated Chest X-ray

• The tiny vessels are visualized because they are surrounded9 by air For the interpretation of the image it is helpful to know:

• age • sex • physical activity • occupation • smoking, alcohol, drug abuse • clinical data

10 Clinical background presumes extended shadow in the lung

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

13 Fluoroscopy

Visualizes motions and provides spatial information 14 Oblique image

For the evaluation of covered or complex structures 15 Exspiration

For the evaluation of pneumothorax or 16 bronchostenosis Fluorogram

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

17 (conventional tomography)

• Confusing details can be excluded 18 Digital radiogram

• It provides more equilibrated images – with less radiation exposure • Possibility of post-processing and simple measurements 19 „Dual energy”-technique

• Elimination of disturbing bone-shadows in the chest that cover 75% of the lungs, with different energy, double exposure and subtraction

reversed bone-image Summation image 20 „Dual energy” technique

After subtraction of the bones, lung components can be evaluated 21 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 Bronchography

(in pulmonology) • intervention and contrast- material are needed • for the evaluation of locations cannot be reached with bronchoscope • if there is no HRCT

23 Pulmonary arteriography

verification of congenital anomalies, and pulmonary embolism 24 Cavography

digital subtraction angiography: VCS − syndrome 25 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 Incremental or sequential (Slice) CT

High radiation exposure: 1 exposition = 1 slice reconstruction: in different plains

27 HRCT*

High resolution higher radiation- exposure longer exposition Good imaging: periphery of the lung interstitium

28 */ high resolution computed tomography Spiral, multi slice (volume) CT

1 exposition = more slice full chest imaging with one breathing in

2D recontructions in any plains 29 Spiral CT

Spatial reconstructions as well 30 Spiral CT

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

31 CT- angiography

i. v. iodinated contrast- material Visualization of the blood vessel lumen + parenchymal visualization 3D reconstruction in any plains

32 Functional CT

i. v. iodinated contrast- material

perfusion (flow intensity)

enhancement (process of interstitial filling)

33 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 Virtual bronchoscopy

35 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 Hybrid techniques

• For the visualization of the morphology and function at the same time:

– SPECTCT (Single Photon Emission Tomography) – PETCT (Positron Emission Tomography)

37 SPECTCT

Localization of tumor metabolism38 PETCT

Localization of tumor metabolism39 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 contrast- materials • Because it is sensitive to motions, the circulating blood can also be evaluated

40 MR-examination

The lungs are poorly visualized: lack of hydrogen, too much movement 41 MR-angio – without contrast-material

„black blood” technique: there is no signal from the non- 42 excited blood MR-angio – with contrast-material

i. v. gadolinium contrast- material visualizes the circulating blood Non-selective 43 Functional MR

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

3 Evaluation of ventilation, contrast-material: He-isotope45 Radiologic signs of diseases

46 Radiologic signs of diseases

47 Shadows in the chest X-rays

intrapulmonary: • alveolar • interstitial • Shadow of a vessel • Shadow of a bronchus extrapulmonary • pleural • extrathoracal

48 Typical shadows

• As mentioned in the findings: – nodular lesion – infiltration – linear shadow – opacity

49 Nodular lesions

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

benign: Round or lobulated, with sharp edge, central calcification, well defined

malignant: Irregular or spiculated, Blurry contoured, Eccentric calcification 51 Infiltrative shadows

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

Lobar pneumonia: broncho- respects the pneumonia: borders of the patchy lobe, air- structure, bronchogram multifocal 53 Linear shadow

band

band Vascular shadow

Bronchial shadow stripe

54 Other typical shadows

Air-filled cyst Hilar mass reticulogranular pattern shadow Double pleura („interlobar space”) Fluid-filled cyst Honey Kerley’s lines combing lung

55 Other typical shadows

basket

Calcified foci and lymph nodes comet dumbbell rails ring

lamellar56 atelectasis Negative shadows (enlightenment)

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

57 Covering, blur

The extrapulmonary shadows won’t make the vascular pattern disappear 58 Regular settling

TBC: in the apex

(ventilation )

metastasis: In the base

(perfusion )

59 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 Inflammation and atelectasis

Volume is increasing Volume is decreasing 61 Pushing and pulling

fluid accumulation is pushing atelectasis is pulling 62 Typical shapes

Free pleural fluid hydro- accumulation pneumothorax

63 The Ellis−Damoiseau-line is a concept in internal medicine X-ray image: concave

With percussion: convex 64 o f T h e 65 f i r s t p a r t