Radiology, CMU

Juntima Euathrongchit, MD.Department of RadiologyFaculty of Medicine, CMU

June 17, 2014.Juntima.eua@cmu.ac.th

Saranair Vorapitirangsi

Welcome to Radiology world 2014

Radiology, CMU

Objective

• Introduction to Investigation Methods for Chest

• Limitation vs Precaution on chest film

Radiology, CMU Radiology, CMU

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Anterior junctional lineoblique course crossing the upper two-thirds of the sternum from the upper right to lower left and does not extend above the manubriosternaljoint

Posterior junctional linethin, vertical line projecting through

the trachea that extends to the pleural dome above the clavicles to the level of the aortic arch

Azygoesophagealal recess straight stripe running from the azygos

arch to the level of the right hemidiaphram

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On Chest Films

Apical lordotic

PA upright Lateral AP supinePA upright Lateral

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Dual Energy Subtraction

• Find out calcification.• Find bone, rib lesion.

Standard soft tissue bone

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Digital tomosynthesis

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Special Imaging Tools

VQ scanUltrasoundAngiography

MRA MRI

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MRIAdvantage: No Iodine contrastDisadvantage: Time consuming, Expensive, not good for lung detection

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MRI: Oxygen-Enhanced MR Ventilation

http://www.ajronline.org/content/177/1/185.full Radiology, CMU

CT scans -

HRCT

CT chest

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Special CT scans

CT pulmonary angiogram MIP –Av IP

3DVR Virtual bronchoscopyRadiologyadadRadRadRadRadRaR ioliolioliolioliologyogyogyogggogog

MnIPRadiology, CMU

New CT technique: Perfusion• An iodine map from dual-energy CT can showed

the distribution of pulmonary perfusion• Photoelectric effect of Iodine

*R Kaewlai http://radiologyinthai.blogspot.com/2010/12/dual-energy-ct-2.html M Riedel, An introduction to dual energy CTKang et al RadioGraphics 2010; 30:685–698

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New CT technique: Ventilation

Air trapping

Chae et al Radiology: Volume 248: Number 2—August 2008 Radiology, CMU

PET – CT (FDG – glucose)

http://www.ajronline.org/content/194/1/W91.full

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CT CHEST

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MDCT

• CT scans– Incremental

– Spiral single

– MDCT

Volume images

images

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MDCT

• 4-slice to 16-slice 64-slice multidetector CT

• Progressively No of detectors

scan acquisition times. • In clinical use now, 64-slice CT systems

– gantry rotation times = 0.33 sec. – a spatial resolution = 0.4 mm.

Radiology, CMU

Indication of CT chest• ACR: American College of Radiology• SCBT-MR: Society of Computed Body

Tomography and Magnetic Resonance• SPR: Society for Pediatric Radiology

PRACTICE GUIDELINE FOR THE PERFORMANCE OF THORACIC COMPUTED TOMOGRAPHY (CT)

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Indications1. Evaluation of abnormalities discovered on chest images [1].2. Evaluation of clinically suspected cardiothoracic pathology.3. Staging and follow-up of lung cancer and other primary thoracic malignancies, and

detection and evaluation of metastatic disease [2-5].4. Evaluation of cardiothoracic manifestations of known extrathoracic diseases [6-9].5. Evaluation of known or suspected thoracic cardiovascular abnormalities (congenital or

acquired), including aortic stenosis, aortic aneurysms, and dissection [10-12].6. Evaluation of suspected acute or chronic pulmonary emboli [13-22].7. Evaluation of suspected pulmonary arterial hypertension [23].8. Evaluation of known or suspected congenital cardiothoracic anomalies [24,25].9. Evaluation and follow-up of pulmonary parenchymal and airway disease [26-33].10. Evaluation of blunt and penetrating trauma [34,35].11. Evaluation of postoperative patients and surgical complications [36,37].12. Performance of CT-guided interventional procedures [38-41].13. Evaluation of the chest wall [42-44].14. Evaluation of pleural disease [45,46].15. Treatment planning for radiation therapy [47,48].16. Evaluation of medical complications in the intensive care unit or other settings [49,50].

Radiology, CMU

HRCT:- Indication vs contraindication

Indications 1. Evaluation of diffuse pulmonary

disease discovered on chest radiographs, conventional CT of the chest or other CT examinations that include portions of the chest, including selection of the appropriate site for biopsy of diffuse lung disease.

2. Evaluation of the lungs in patients with clinically suspected pulmonary disorders with normal or equivocal chest radiographs.

3. Evaluation of suspected small and/or large airway disease.

4. Quantification of the extent of diffuse lung disease for evaluating effectiveness of treatment.

Contraindications1. There are no absolute

contraindications to HRCT of the lungs.

2. Precaution in Pregnancy

Unable hold breathing

Radiology, CMU

Lobe

RLL: superior, RLL: superior, anterior~,posterioror~, lateral~, anterior ,postemedial basal

RUL: apical, anterior, posterior

RML: lateral, medial

LUL: apicoposterior, anterior,lingula(superior&inferior)

LLL: superior, anteromedial~, posterior~, lateral basal

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Chest lobe, segment

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Radiology Anatomy: CT chest

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CT images: Mediastinum window

http://www.med.wayne.edu/diagradiology/Anatomy_Modules/Mediastinum/Mediastinum.html

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CT anatomy

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Chest Xray, PA upright Normal, after mastectomy

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Abnormality on film• Increased density, Opacity

– Infiltration– Mass– Pleural effusion– Atelectasis

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Interesting case• 17 – year-old man • Chronic cough and dyspnea on exertion for 3 months,

– Clear sputum, no pus, no hemoptysis, no fever• Physical examination:-

– T36.7 C , PR 100/min , RR 18/min , BP 110/60 mmHg , O2 sat 98% (Room air)

– Chest: Decrease chest wall movement Lt. ,no accessory muscle use

– Lung: BS decrease entire Lt. lung, Dullness on percussion, Decrease tactile fremitus and Vocal resonance, no egophony, no adventitious sound (wheezing, Rhonchi)

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Chest PA upright

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Chest PA upright, what is this lesion?

A. Large pleural effusionB. Total left lung atelectasisC. Combined effusion and

atelectasisD. Huge lung massE. Huge mediastinal mass

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Chest PA & Left lateral

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Chest PA upright, what is this lesion?

A. Large pleural effusionB. Total left lung

atelectasisC. Combined effusion

and atelectasisD. Huge lung massE. Huge mediastinal mass

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Answer

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Unilateral hemithorax opacityDifferential Diagnosis• Positioning: rotation or scoliosis• Large pleural effusion, pleural thickening,

mesothelioma• Lung: consolidation, mass, collapse, fibrosis, agenesis• Pneumonectomy, thoracoplasty• Chest wall: mass (breast, chest wall musculatures)• Extrathoracic: external structures

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Total lung opacity

RadioloLt. lateral decubitus film

Massive pleural effusionRadiology, CMU

Total opacity

http://myweb.lsbu.ac.uk/dirt/museum/simon/68-74-gsb2.jpg

Massive pleural effusion Atelectasis + pleural effusion Atelectasis

A B C

Radiology, CMURadiology, CMU

A

Which one is a lung pathologic lesion?

Radiology, CMURadiology, CMU

Which one is a lung pathologic lesion?

B

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C

Which one is a lung pathologic lesion?

Radiology, CMURadiology, CMU

D

Which one is a lung pathologic lesion?

Radiology, CMUogy, CMU

A B

C D

Which one is a lung pathologic lesion?

Radiology, CMU

Adequate quality image - A• Remove object

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Adequate quality image

• Removable vs non removableobject

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Mimiced nodule - B

• Chest wall lesion • Bone island

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Additional techniques• Repeat film with changed position• Dual energy subtraction• Digital tomosynthesis• CT scan

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Chest wall abnormality - C

• Pectus excavatum– depression of the sternum– Incidence - 0.13 – 0.4% of general population (Fraser et al. 1999)– PA chest: left-sided heart deviation & rotation a mitral

configuration. Parasternal opacity liked RML infiltration or mediastinal mass

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Blind areas – D

As complexity of thoracic organs overlying each other in the same plane on each view, they could obscure the lung pathology , these areas called blind areas.

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Blind areas

• On PA view – Central airway– Apical lung– Mediastinum– Hila– Retrocardiac field– Inferior lung base– Thoracic cage– Upper abdomen

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Tracheal lesion

Min IP 3DVRRadiology, CMU

Sub- diaphragmatic lesion

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CT

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Steak artifact from Dense CM, CTA - PE

http://radiology.casereports.net/index.php/rcr/article/viewArticle/233/563

Right sided venous approach

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Conventional – routine CT• Cover range – thoracic

inlet to whole lung• Scan type – Helical• KV, mA, rotation time

Machine, • Respiratory – inspiration• Image reconstruction: 5

mm thickness, axial mediastinum and lung / coronal

• IV contrast + delayed 40 sec (arterial phase liver)

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CTA – systemic circulation

Hemoptysis, Aortic disease

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CTA A –– pulmonary circulation

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HRCT

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HRCT

Radiology, CMURadRadRadRadRadRadRadioliolioliolioliolologyogyogyygygyogyogyogyogygygy, , , ,,,,,,,,,,,,,,,

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Plain arterial liver portovenous lung image

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CT Chest for SPN protocol - CMU

Cover range – Inlet upper abdomenRepeat nodules at delayed phase

Frist study: Plain nodule + Post contrast scan thorax + delayed 30 sec, 1, 2, 3, 4 min

Reconstruction -* CMUSlice thickness: 5 mm, at leastInterval 5 mm no skip Axial imagesSoft tissue W 1 set - 5 mm slice thickness Lung W 1 set – 5 mmSoft tissue W 1 set – 1 mm slice thickness and intervalCoronal vs sagittal – up to PACS systemReconstruction nodule, 1 – 2 mm thickness for each series

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CT for solitary pulmonary nodule

Plain 1-2 mm slice thickness 30 sec D

1 min 2 min 3 min 4 min

Total Iodine contrast 420 mgI / kg, 2 ml/sec injection rate

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Low dose CT• The National lung screening trial (NLST)• LDCT screening could reduce lung cancer

mortality to 20% when compared with chest X-ray screening

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Risk groupsRisk criteria Screening

RecommendationHigh risk• yr-old, and• yrs yrs)

Get baseline LDCT

High risk• yr-old, and• yrs of smoking, and • One other risk factor (except for second-hand smoke)

Get baseline LDCT

Moderate risk• yr-old, and• yrs of smoking or second-hand smoke, and • No other risk factors

No screening at this time

Low risk• < 50 yr-old, and/or• < 20 pack yrs smoking

No screening at this time

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Low dose CT scan• Hypothesis: Generic factor and/or indirect receiving carcinogen or second

smoker could be cause of lung cancer• Cost – effectiveness analysis

Parameter Hs) SLST (care dose)Somatom definition CT

Voltage (kVp) 120 – 140 120

Tube current time product (mAs) 40 – 80 25

Slice thickness (mm) 1.0 – 3.2 1.0 – 5.0

Reconstruction interval (mm) 1 – 2.5 0.8 – 1.0

Number of studies 26,722 60

RiskFamily Hx (closed relative)

20 – 65 YrsNo other cancer

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Compare, normal dose vs low dose

Low dose - noise

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Tumor growth

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Hemoptysis – bronchial a. systemic a.In over 90% of cases of hemoptysis requiring intervention with arterial embolization or surgery,the bronchial arteries are responsible for the bleeding

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Protocol

Radiology, CMUR ddR dRadRaddR dRRRaR i li li llolioliiio

Bronchial a enlargement

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Bronchiectasis, HRCT

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Airway

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AirwayTracheal Stenosis •• Bronchial Stenosis • Tracheal-Esophageal Fistula

• Suspected Tracheal or Bronchial Injury or Fracture

• Tracheomalacia• Tracheobronchomalacia• Mounier-Kuhn Syndrome

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Protocol CT bronchi - CTISUS

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Tracheomalacia: Full inspired vs expired

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D VR

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Reconstruction

Radiology, CMURadRadRadRaddRadRadRadRaddRadRadRadRadadR ddRadRadRadddR dRadRadR dR ddR dRadRaaRRRaR ioliolioliolioliollioliololioliollolioioiioioioooiooii ogyogyyogyyogyooooo CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCMUMUMUMUMUMMMMMMMMMMMMMMMMMMMMM

Tracheal bronchus

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Abnormal chest wall

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Pectus excavatum

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Early filled aorta – CTA PE

ASD

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Cardiac arrest

• During exam – not uncommon• Awareness• Risk factors

– Unstable patient : previous shock, poor station– Multiple trauma– To much monitors– Drug allergy *

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Normal not cardiac arrest

• Motion normal artifact

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Normal respiration – can control

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Except cardiac gating

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• At cardiac arrest

• CT features characterized by a

in the dependent parts of

the right side of the body, including the

venous system and the right lobe of the liver.

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• --yr man, cardiac arrest st –– polytrauma•

r man, cardiac aryryMarked enhanced

rresstac ard d azygos

polytraumaptss v., pooling CM in dependent part of IVC, hepatic v., right Marked enMMMarked enMarkMar

renal v.; •

e a ;renal v.; no CM in Lt heart, aorta, kidney

Ref: Indian J Radiol Imaging, May 2010.

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26- yr man, accident.• Dense contrast opacified azygos v, SVC, great cardiac v, hemiazygos v, right

lumbar v, back venues, Rt atrium, Rt hepatic v, Rt kidney, splenic v, SMV, • No CM in aorta, left heart.• Ref: Indian J Radiol Imaging, May 2010.

Great cardiac v

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Near arrest –hypotension.

• Contrast layering in IVC, in cardiogenic shock.

• Note bilateral pleural effusions and pericardial effusion without tamponade.

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Cardiac tamponade• Gross pericardial effusion with pressure effect to the heart.• Mod. bilateral pleural effusions.

aaaRaRaaaRaRaRaRaRaRaRRRRRRRRRRRRRRRRRRRRRRRRR Radiology, CMU

Contrast layering in abdomen:- IVC & Rt renal vein• 30 –year-old male with disseminated Tb,

hypotension and worsening of breathlessness.• Pt developed cardiogenic shock within a few hours

and died.

RadRadRadRadRadRadRadRRRRR ioliolioliollollolllioioioo ogyogyogyogyyy CCCCCCCCCCCCCCCCCCCCCCCCMUUMUMUMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM

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What happen ?

• Injection: - right side• Regurgitation of CM

to the left system: jugular, subclavian, back venules, and hemiazygos v.

A

B

SVC obstruction

AJR:178, May 2002

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Rt brachiocephalic venous obstruction with collateral vessels

Radiology, CMULayering in SVC, reflux CM into the azygos v, hemiazygos v. AJR:178, May 2002 Radiology, CMU

Opacification of right ventricle, right atrium, right hepatic veins, and vena cava. Note regurgitation of contrast agent into coronary sinus (arrowhead)

AJR:178, May 2002