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Evaluation of the Chest

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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 TT 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
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