Evaluation of the chestEvaluation of the chest

part 1part 1

Nagy EndreNagy Endre

SZEGEDI TUDOMÁNYEGYETEM SZEGEDI TUDOMÁNYEGYETEM ÁOK, RADIOLÓGIAI KLINIKA, ÁOK, RADIOLÓGIAI 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

Summation image reversed bone-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 resolutionhigher radiation-

exposurelonger expositionGood imaging:

periphery of the lunginterstitium

*/ high resolution computed tomography

1 exposition = more slice

full chest imaging with one breathing in

2D recontructions in any plains

Spiral, multi slice (volume) CT

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

Evaluation of ventilation, contrast-material: 3He-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

bronchusextrapulmonary• 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 lesionbenign:

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: respects the

borders of the lobe, air-

bronchogram

broncho-pneumonia: patchy structure, multifocal

Linear shadow

band

stripe

bandVascular shadow

Bronchial shadow

Other typical shadows

Air-filled cystreticulogranular patternDouble pleura

(„interlobar space”)Fluid-filled cystKerley’s lines

Hilar mass shadow

Honey combing lung

Other typical shadows

Calcified foci and lymph

nodescometdumbbellrailsring

lamellar atelectasis

basket

Negative shadows (enlightenment)

air bronchogram:

If there is no air in the alveoli, lumen of

the bronchi are visualized

Westermark sign:

Behind vascular occlusions or in valvular bronchial stenoses, the lung is lighter

Covering, blur

The extrapulmonary shadows won’t make the vascular pattern disappear

Regular settling

(ventilation )

(perfusion )

TBC: in the apex

metastasis:

In the base

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 shapesFree pleural fluid accumulation

hydro- pneumothorax

The Ellis−Damoiseau-line is a concept in internal medicine

With percussion: convex

X-ray image: concave

o f T h e o f T h e

f i r s t f i r s t p a r tp a r t

1

Evaluation of the chestEvaluation of the chest

part 1part 1

Nagy EndreNagy Endre

SZEGEDI TUDOMÁNYEGYETEM SZEGEDI TUDOMÁNYEGYETEM ÁOK, RADIOLÓGIAI KLINIKA, ÁOK, RADIOLÓGIAI KLINIKA,

SZEGEDSZEGED

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 contrast-

material 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 resolutionhigher radiation-

exposurelonger expositionGood imaging:

periphery of the lunginterstitium

*/ high resolution computed tomography

29

1 exposition = more slice

full chest imaging with one breathing in

2D recontructions in any plains

Spiral, multi slice (volume) CT

30

Spiral CT

Spatial reconstructions as well

31

Spiral CT

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

32

CT-angiography

i. v. iodinated contrast-material

Visualization of the blood vessel lumen

+ parenchymal visualization

3D reconstruction in any plains

33

Functional CT

i. v. iodinated contrast-material

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 contrast-

materials• 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 non-excited blood

43

MR-angio – with contrast-material

i. v. gadolinium contrast-material 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

bronchusextrapulmonary• 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 lesionbenign:

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, air-

bronchogram

broncho-pneumonia: patchy structure, multifocal

54

Linear shadow

band

stripe

bandVascular shadow

Bronchial shadow

55

Other typical shadows

Air-filled cystreticulogranular patternDouble pleura

(„interlobar space”)Fluid-filled cystKerley’s lines

Hilar mass shadow

Honey combing lung

56

Other typical shadows

Calcified foci and lymph

nodescometdumbbellrailsring

lamellar atelectasis

basket

57

Negative shadows (enlightenment)

air bronchogram:

If there is no air in the alveoli, lumen of

the bronchi are visualized

Westermark sign:

Behind vascular occlusions or in valvular bronchial stenoses, the lung is lighter

58

Covering, blur

The extrapulmonary shadows won’t make the vascular pattern disappear

59

Regular settling

(ventilation )

(perfusion )

TBC: in the apex

metastasis:

In the base

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 shapesFree pleural fluid accumulation

hydro- pneumothorax

64

The Ellis−Damoiseau-line is a concept in internal medicine

With percussion: convex

X-ray image: concave

65o f T h e o f T h e

f i r s t f i r s t p a r tp a r t