RADIOLOGY - IMAGING OF

THE THORAX
 THE CHEST
METHODSOFEXAMINATION

Radiography
Standard examination:
-PA+lateralprojection;
-tube-filmdistance1,5mtominimizedivergentdistorsion
andmagnification;
-fullinspiration.
Apical lordotic view
-isusedtoseediseasesinthepulmonaryapices,whichmay
beobscuredbytheclavicleandthefirstrib;
-APwiewwiththepatientleaningbackwardonthecassette
holder.
Supine radiographsintensivecareunits.
DIGITAL
DIGITAL RADIOGRAPHY
RADIOGRAPHY
 THE CHEST
METHODSOFEXAMINATION

Fluoroscopy
dynamicstudyofthecardiovascularsystem,
diafragmaticmotion.Disadvantage:highradiationdose.
Bronchography
thestudyofthebronchialtreebymeansofthe
introductionofopaquematerialintothebronchi.
Replaced by CT,fiberopticbronchoscopy,brushbiopsy,
percutaneousbiopsy
Tomography
itispossibletoexamineasinglelayeroftissueandto
blurthetissuesaboveandbelowthelevelbymotion
(thetubeandthefilmmoveinoppositedirections).
- replaced by CT.
 THE CHEST
METHODSOFEXAMINATION
Fluoroscopy

1933 2000
 THE CHEST
METHODSOFEXAMINATION
Tomography

Tub
Rx

Caseta/film
 THE CHEST
METHODSOFEXAMINATION
Computed tomography indicationsforthelung:
-Evaluationandstagingofprimarypulmonaryneoplasms
-Detectionofmetastasisfromnon-pulmonaryprimary
tumors.
Characterizationofsolitarypulmonarynodulesasbenign
ormalignant
Characterizationoffocalanddiffuselungdiseasefor
diagnosis.
 THE CHEST
METHODSOFEXAMINATION

Computed tomography
Indicationsforthemediastinum:
-Causesofmediastinalwidening
-Stagingoftumorsthatspreadtothemediastinum
-Characterizationofmediastinalmassescysts,solid,
vascular,fat.
Otherindications:
Pleuraplaques,masses,loculatedfluid,occult
calcification,chestwallmasses.
High-resolution CT evaluationofinterstitiallung
disease,bronchiectasis,emphysema,cysticlungdisease.
 THE CHEST
METHODSOFEXAMINATION-
Computedtomografy

1975 1995
 THE CHEST
METHODSOFEXAMINATION
Ultrasonography
fluidcanbelocalizedanddifferentiated
fromsolidpleuralmasses;
- mediastinallesionsincontactwiththechest
wall
- lesionsnearthediafragm.
 THE CHEST
METHODSOFEXAMINATION

Magnetic resonance imaging indications:

-dissectionoftheaorta,aneurysm
-congenitalandacquiredheartconditions
-intracardiacandparacardiacmasses.
-pericardialdiseases.
-brachialplexopathy.
-diafragmandperidiafragmaticprocesses.
-chest-walllesions.
-breastimplantsandbreastmasses.
-Extention of the posterior mediastinal masses, especially
thosewithintraspinalextension.
MRI

MAGNET

Coils
 THE CHEST
METHODSOFEXAMINATION

Pulmonary and bronchial angiography arterial or

venousanomalies;thromboembolicdisease.

Scintigraphy

Single Photon Emission Computed Tomography(SPECT)

-Tc99mivinjection-pulmonaryperfusion
-Xegasisinhaledpulmonaryventilation
 How to analyzethe chest X-ray
-Softtissues
-Bonythoraxribs,clavicles,scapulae,thoracicvertebrae
-Mediastinum
-Lungshilum,vessels,apices
-Pleura
-Diafragm

Roentgen observations must be correlated with all the

available clinical information
Gr.I

Nodularopacities

MILIARYtuberculosis
Lesioninthemediastinum Lesioninthelung
FELSON sign
 PNEUMONIA

ATELECTASIS Diffuseopacities PLEURALFLUID

PLEURALFLUID ATELECTASIS
LINEAROPACITIES
EMPHYSEMA PNEUMOTHORAX

DIFFUSEHYPERLUCENCIES
 1

3
1

Chisthidatic
2
3

2 3 4
CIRCUMSCRIBED
HYPELUCENCIES

1.Bulla
2.Aericcyst
3.Cavity-TB
4.Cvity-cancer
 RUPTUREDHYDATID
ABSCESS CYST
 CHEST INFECTIONS
Acute pulmonary infections

1. Lobarpneumoniatheorganismreachestheperipheryof
thelungviatheairways.Alveolartransudationisfollowed
bymigrationofleucocytesintothealveolarfluid.
2. Bronchopneumonia(lobular pneumonia)oftenobserved
instaphyloccocalinfectionofthelung.Thedisease
originates in the airwaysandspreadstoperibronchial
alveoli.
3. Interstitial pneumoniausuallycausedbyavirusora
mycoplasma.
4. Mixed pneumoniaisacombinationoflobar,
bronchopneumoniaandinterstitialpneumonia.
 Pneumococcal pneumonia
-CausedbyS.pneumoniae.
-roentgenfindingscanbeobservedwithin6to12hoursafter
onsetofsymptoms.
-Chestx-ray:
-triangularopacity,thetiptowardsthehilum,thebase
towardstheperipheryofthelung.
-alltheelementsinthediseasedlobemaybeaffectedexceptthe
largebronchiairbronchogram.
- Resolutionisrapidiftherearenotcomplicationsthe
opacitybecomesmoreirregularandpatchy,theintensity
decreases.
-Complicationsdelayedresolution,lungabscess,pleural
effusion.
 Bronchopneumonia
staphyloccocalinfectionofthelung
-Itisthemostcommonlyfoundintheveryyoungorvery
old
-Theinflammatorydiseasedoesnotcrossseptalboundaries
thepatternofdiseaseisdiscontinousorpatchy.
-Chestx-ray:
-nodularopacities,1-10mm,
-poorlydefined
-withthecentermoreopaquecomparedtotheperiphary.
-Itisparticularlydifficulttodefineanddiagnosewhenit
occursasacomplicationincaseofcardiacfailure.
 Staphylococcal pneumonia

causedbyStaphylococcusaureus
-theinfectionmaybeprimaryinthelungsorsecondarytoa
primarystaphylococcalinfectionelsewhereinthebody.
-Usuallyoccursindebilitatedadultsorinthefirstyearoflife.
-Consolidationrapidlyspreadstoinvolveawholelobeand
bronchiareobscuredbyexudate,sotheairbrohogramis
rarelyseen.
-Abscessformationmayoccur;coalescenseofsmall
abscessesisfrequent.
-Pleuraleffusion,empyemaandpneumothoraxarefrequent
-Pneumatoceleacheck-valveobstructiondevelopsbetween
thelumenofasmallbronchusandthepulmonaryparenchyma.
-Thediseaseisusuallybilateral
 Interstitial pneumonia
-usuallycausedbyavirusorMycoplasmapneumoniae(is
responsibleforasignificantpercentageofprimaryatypical
pneumoniainchildrenandyoungadults).
-Roentgenfindings:
-Peribronchialorinterstitialtypestreakydensities
extendingfromthehilumfollowingthevascularmarkings.
-Bronchopneumonictype.
-Segmentalorlobartypes
-Diffusetypebilateralreticulo-nodularpattern
DD-interstitialpneumoniabacterialpneumonia:
-delayinradiologicalonset
-lackofpleuralinvolvement,
-thetendencytoclearinoneareaandtospreadinanother,
bilaterality.
Acute
Acuteinterstitial
interstitialpneumonia
pneumonia::influenza
influenza
Acute interstitial pneumonia
 Acute
Acuteinterstitial
interstitial
pneumonia
pneumonia
COMPLICATIONS
COMPLICATIONS

BRONHOPNEUMONIA

SEGMENTAL
PNEUMONIA
 Lung abscess
-lungabscess=whenanacutepulmonaryinfectiousprocess
breaksdowntoformacavity.
-Primary/secondary.
-Chestx-ray
-opacityconfinedtoonesegment,round,irregularborders.
-Whenbronchialcommunicationisestablishedthefluid
contentofthecavityisreplacedbyairhydro-aeric
imagewithorizontalfluidlevel.
-CTVeryusefultodefinetheinnerandouterwalls,for
complications(ruptureintothepleuralspace).
-Differentialdiagnosis:
-earlystagepneumonia;
-cavitytbc,cancer,hydatidcyst,fungalinfection
 TUBERCULOSIS

-Transmittedbyinhalationofinfecteddropletsof
Mycobacteriumtuberculosis
-Targetpopulation:patientsofloweconomicscale,
alcoholics,elderly,AIDS
Primary TB

Rancke (primary) complex :

1.Ghon focusnodularopacity(1-7cm),irregular
borders,non-homogeneous,lowintensity,lowerlobe
2.Lymphadenopathyhilarandparatracheal,95%
3.Lymphangitislinearopacities
 Primary TB

Evolution:
-Healing
-Fibrosis
-Calcification
-Cavitation

Complications:
-MiliaryTB
-TBpneumonia
-TBbronchopneumonia
-Pleuraleffusion
 Secondary TB

- activediseaseinadultsmostcommonlyrepresents
reactivationofaprimaryfocus;thediseasetendstobe
progressive
-Typicallylimitedtotheupperlobes
-Noadenopathy

Radiographic features
Early infiltrate lowintensity,poorlydefinedopacities
Cavitation40%
Fibro-caseous TB
Fibrotic TB sharply circumscribed linear densities radiating
to hilum;
Fibrothorax, tuberculoma
 Secondary TB

Complications:

1. MiliaryTB
2. Bronchogenicspread
3. Bronchialstenosis
4. Bronchiectasis
5. Pneumothorax
6. Pleuraleffusionoftenloculated
ASPERGILOMA
 AIDS
KnownroutesofHIVtransmission:
-Bloodandbloodproducts
-Sexualactivity
-Inuterotransmission
-Duringdelivery

Clinical:
-Lymphadenopathy
-Incidentalinfections
-Tumors:lymphoma,Kaposisarcoma
-Othermanifestations:interstitialpneumonia,
spontaneouspneumothorax,septicemboli
 AIDS
Spectrumofchestmanifestations:

NodulesKaposisarcoma(usuallyassociatedwithskin
lesions),septicinfarcts,fungalinfections(Cryptoccocus,
Aspergillus)
Large opacity:consolidation,masshemorrhage,
pneumonia
Linear or interstitial opacitiesatypicalpneumonia,
Kaposisarcoma
LymphadenopathyMycobacterialinfections,Kaposi
sarcoma,lymphoma
Pleural effusionKaposisarcoma,fungalinfection,
pyogenicempyema