Chest

Congenital Pulmonary Abnormalities

Mohamed ZaitounAssistant Lecturer-Diagnostic Radiology Department , Zagazig University HospitalsEgyptFINR (Fellowship of Interventional Neuroradiology)-Switzerlandzaitoun82@gmail.com

Knowing as much as possible about your enemy precedes successful battle and learning about the disease process precedes successful management

Congenital Pulmonary Abnormalities1-Bronchopulmonary Foregut Malformations2-Congenital Lobar Emphysema3-Pulmonary Underdevelopment4-Scimitar Syndrome5-Bronchial Atresia6-Congenital Diaphragmatic Hernia7-Kartageners Syndrome

1-Bronchopulmonary Foregut Malformations :-Is a term that encompases :1-CCAM2-Pulmonary Sequestration3-Foregut Duplication Cysts

1-Congenital Cystic Adenomatoid Malformation (CCAM) :a) Incidenceb) Pathologyc) Typesd) Locatione) Clinical Picturef) Radiographic Featuresg) Differential Diagnosis

a) Incidence :-They account for approximately 25% of congenital lung lesions

b) Pathology :-The condition results from failure of normal broncho-alveolar development with hamartomatous proliferation of terminal respiratory units in a gland-like pattern (adenomatoid) without proper alveolar formation

c) Types :1-Macrocystic (Stocker types 1 and 2) :-Single cyst or multiple cysts >5 mm confined to one hemithorax ; better prognosis ; common2-Microcystic (Stocker type 3) :-Homogeneous echogenic mass without discernible individual cysts ; closely resembles pulmonary sequestration or intrathoracic bowel from a diaphragmatic hernia ; less common

d) Location :-Lesions are usually unilateral and involve a single lobe-They appear less frequently in the right middle lobe

e) Clinical Picture :-The diagnosis is usually either made on antenatal ultrasound or in the neonatal period on investigation of progressive respiratory distress-If large , they may cause pulmonary hypoplasia with resultant poor prognosis

f) Radiographic Features :1-Antenatal Ultrasound2-Plain Radiography3-CT

1-Antenatal Ultrasound :-These lesions appear as an isolated cystic or solid intrathoracic mass-There can be mass effect where the heart may appear displaced to the opposite side-Hydrops fetalis orpolyhydramniosmay develop

Longitudinal prenatal sonogram of the right thorax obtained at 27 weeks of amenorrhea , A large typical type II CCAM (c) is shown in the right lung associated with marked ascites (a) ; d indicates diaphragm

2-Plain Radiography :-Multiple cystic pulmonary lesions of variable size-The cysts may be completely or partially fluid filled in which case the lesion may appear solid or with air fluid levels -Variable thickness of cyst wall

3-CT :-The same as Plain Radiography

Plain chest radiograph in this newborn shows three separated cysts in the right hemithorax , CT shows a large septated cyst containing air and fluid

g) Differential Diagnosis :-General imaging differential considerations include :1-Bronchogenic cyst2-Pulmonary sequestration3-Congenital diaphragmatic herniation4-Congenital lobar emphysema

2-Pulmonary Sequestration :a) Incidenceb) Pathologyc) Typesd) Locatione) Clinical Picturef) Radiographic Featuresg) Differential Diagnosis

a) Incidence :-The estimated incidence is at 0.1% -The age of presentation is dependent on the type of sequestration-ELS more commonly presents in newborns whereas ILS presents in late childhood or adolescence

b) Pathology :-Also called(accessory lung)-Refers to aberrant formation of segmental lung tissue that has no connection with thebronchial tree-The anomalous lung tissue has a systemic arterial supply which is usually a branch of the aorta-Venous supply is variable and dependant on the type of sequestration : 1-ILS : Via the pulmonary veins 2-ELS : Through the systemic veins (IVC , Azygos , Portal) into the right atrium

c) Types :1-Intralobar Sequestration (ILS)2-Extralobar Sequestration (ELS)

1-Intralobar Sequestration (ILS) :-Accounts for the majority (75-85% of all sequestrations-Present later in childhood with recurrent infections2-Extralobar Sequestration (ELS) :-Less common (15-25% of all sequestrations)-Usually present in the neonatal period with respiratory distress , cyanosis and / or infection-More in males , M:F ratio 4:1-Can be infra diaphragmatic in 10 % of cases

d) Location :-Overall , sequestration preferentially affects the lower lobes-60% of ILS affect theleft lower lobe and 40%theright lower lobe-ELS almost always affect the left lower lobe , however approximately 10% of ELS can be sub-diaphragmatic

e) Clinical Picture :-Recurrent pulmonary infections

f) Radiographic Features :1-Ultrasound2-Plain Radiography3-CT4-MRI5-Angiography

1-Ultrasound :-The sequestrated portion of lung is usuallymore echogenicthan the rest of the lung-ELS may be seenas early as 16 weeks gestation and typically appears as a solid well defined triangular echogenic mass-Colour Doppler may identify a feeding vessel (in-utero cases) from the aorta-If the sequestration is sub diaphragmatic , it may appear as an echogenic intra abdominal mass

2-Plain Radiography :-Will often show an opacity in the affected segment-Recurrent infection can lead to the development of cystic areas within the mass-Both ILS and ELS can rarely have air bronchograms as they may be connected with the GIT

CXR shows opacity in the posterior segment of the left lower lobe behind the cardiac silhouette , projecting over the spinal column and not bordering the left diaphragm

Homogenous dense opacity (red arrow) in right cardiophernic angle

Well-defined mass in the left lower lobe which determines loss of volume of the left lung and mediastinal shift to the right , the lesion corresponded to an extralobar sequestration

CT shows area of lobulated opacity in the posterior segment of the left lower lobe , note in the 2D reconstruction the thoracic aorta branch directed towards the opacity

3-CT :-Large solid mass that may be homogeneous or heterogeneous , sometimes with cystic changes (>5 cm) near diaphragm-Air fluid levels if infected-Surrounding pulmonary consolidation-Sequestration may communicate with GIT-3D reconstructions can beparticularly helpfulin detecting :a) Anomalous arterial vesselsb) Concurrent anomalous veinsc) Differentiating between intra-lobarand extra-lobar sequestrations

CT+C shows an ILS , the yellow arrow in upper figures shows a hyperdense region in the left lower lobe of the lung with small cystic lesions containing air within it the red arrows in the lower figures show a contrast enhanced vessel arising from the aorta and supplying the area of hyperdensity in the lung

CT+C shows a homogeneous mass in the posterior segment of the left lower lobe , feeding artery (arrow) is seen arising from the aorta , a finding that is diagnostic for sequestration

ELS

4-MRI :*T1 :-The sequestrated segment tends to be of comparatively high signal to normal lung tissue*T2 :-Also tends to be of comparatively high signal*MRA :-Can be helpful in demonstrating anomalous arterial supply

5-Angiography :-Not part of routine investigation but is the gold standard in determining arterial supply

g) Differential Diagnosis :-See CCAM

3-Foregut Duplication Cysts :a) Bronchogenic Cystb) Esophageal Duplication Cystc) Neuroenteric Cyst

a) Bronchogenic Cyst :1-Incidence2-Pathology3-Location4-Clinical Picture5-Radiographic Features6-Differential Diagnosis

1-Incidence :-Bronchogenic cysts are rare congenital lesions accounting for only 5-10% ofpediatric mediastinal masses

2-Pathology :-Bronchogenic cysts form as a result of abnormal budding of the bronchial tree during embryogenesis (between 4th-6thweeks) and as such they are lined by secretory respiratory epithelium (cuboid or columnar ciliated epithelium)

3-Location :-The most common location is the middle mediastinum-subcarinal , right paratracheal and hilar locations most common

4-Clinical Picture :-In many instances , bronchogenic cysts are asymptomatic and are found incidentally when the chest is imaged-When large , mass effect may result in bronchial obstruction leading to air trapping and respiratory distress-An alternative presentation may occur when the cyst becomes infected

5-Radiographic Features :a) Plain Radiographyb) CT

a) Plain Radiography :-Findings are nonspecific , mediastinal masses should be evaluated further using CT scanning or MRI to confirm the presence of fluid -The cysts usually appear as soft-tissue density rounded structures

The chest X-ray showed a non calcified homogeneous opacity lateral to the trachea with a well defined interface with the lung , cervicothoracic sign indicated the posterior localisation of the mass.

Azygoesophageal recess reflection , (a) PA chest radiograph shows the azygoesophageal line (arrowheads) , (b)CT shows the azygoesophageal recess (white arrow) formed by the esophagus anteriorly (black arrow) and the azygos vein posteriorly (arrowhead) , the azygoesophageal line inarepresents the interface between this recess and the lung

(a)PA chest radiograph demonstrates a subcarinal abnormality with increased opacity (*) , splaying of the carina and abnormal convexity of the upper and middle thirds of the azygoesophageal line (arrowheads) , (b)Corresponding CT scan helps confirm a subcarinal mass (arrow) which proved to be a bronchogenic cyst

(a)PA chest radiograph shows the posterior junction line (arrow) projecting through the tracheal air column , (b)CT shows the posterior junction line (arrow) which is formed by the interface between the lungs posterior to the mediastinum and consists of four pleural layers

(a)PA chest radiograph shows a mass (arrow) obliterating the posterior junction line , note that the mass extends above the level of the clavicle and has a well demarcated outline due to the interface with adjacent lung (arrowhead) , (b)CT helps confirm the posterior location of the mass (arrow), which proved to be a bronchogenic cyst

Bronchogenic cyst , conventional radiograph demonstrates a right paratracheal mass

Bronchogenic cyst , conventional radiograph shows a subcarinal mass

Bronchogenic cyst , conventional radiograph demonstrates a thin walled cyst in the left lower lobe with an air fluid level

b) CT :-Typically appear as well circumscribed spherical or ovoid masses of variable attenuation-Approximately 50% are fluid density (0-20 HU) , however a significant proportion are of soft tissue density (>30 HU) or even hyperdense to surrounding mediastinal soft tissues -CT is better able to detect calcium oxalate (milk of calcium) layering dependently-Usually no solid contrast enhancement

CT+C : well circumscribed unilocular water attenuation cyst in the middle mediastinum , the cyst has smooth imperceptible walls with no enhancement

Bronchogenic cyst , CT shows a subcarinal mass with fluid density

CT with and without contrast media showed a large homogeneous mass of low attenuation arising in the right paratracheal space extending posteriorly , thin wall and absence of enhancement suggested the diagnosis of Bronchogenic cyst

6-Differential Diagnosis :-From oesophageal duplication cysta) Clinical Picture :-Asymptomatic bronchogenic cyst-Symptomatic oesophageal cyst in case of peptic ulceration

b) Plain Radiography :-Bronchogenic cysts appear at a subcarinal location (most commonly)-Oesophageal cysts appear more tubular and in close relation to the esophagusc) CT :-Thin walled bronchogenic cyst-Thick walled oesophageal cyst (due to presence of smooth muscle)

Bronchogenic Cyst (subcarinal) Esophageal Duplication Cyst ( in close relation to esophagus)

Bronchogenic Cyst Esophageal Duplication Cyst

b) Oesophageal Duplication Cyst :1-Incidence2-Clinical Picture3-Radiographic Features4-Differential Diagnosis

1-Incidence :-It is the second most common GIT duplication after that of the ileum-As a congenital abnormality , if symptomatic , it is usually identified soon after birth

2-Clinical Picture :-Presentation of large duplication cysts is usually in the newborn or infant with symptoms referable to pressure on the adjacent lung or esophagus leading to :1-Respiratory difficulties2-Dysphagia3-Vomiting-Smaller cysts can be asymptomatic and only found incidentally at any time

3-Radiographic Features :a) Plain Radiographyb) Barium Swallowc) CTd) MRI

a) Plain Radiography :-They are usually seen as rounded fluid / soft tissue densityposterior mediastinal masses

Esophageal duplication cyst in a 3 year old girl with cough and dyspnea , (a) Chest radiograph shows homogenous opacification of the right hemithorax (arrows) at the time of first admission , (b) Follow-up CT 3 years later shows a large cystic periesophageal mass (arrows)

b) Barium Swallow :-In cystic esophageal duplication , the oesophagogram shows the esophagus to be displaced to the side opposite the mass

c) CT :-Duplication cysts appear as is sharply marginated masses with homogeneous fluid density-No enhanced after intravenous contrast administration is visible

d) MRI :-MRI demonstrates features of a cyst*T1 :-Low signal*T2 :-High signal*T1+C :-No solid enhancement

T1 T2

4-Differential Diagnosis :-From Bronchogenic cyst-See before

c) Neuroenteric Cyst :1-Incidence2-Radiographic Features

1-Incidence :-Neurenteric cysts are rare posterior mediastinal lesions that may be connected to the meninges through a midline defect in one or more vertebral bodies-This abnormality may be associated with vertebral anomalies such as hemivertebra , butterfly vertebra or spina bifida

2-Radiographic Features :a) Plain Radiographyb) CTc) MRI

a) Plain Radiography :-Well circumscribed rounded mediastinal mass

Neurenteric cyst in a 30 year old female with flank pain , (a) Chest radiograph shows a well defined round mass (arrow) in the lower thoracic region , (b- c) Both axial T1 and coronal T2 show a large mass that is of homogenous high signal intensity in the right paravertebral region (arrow) , the cyst presumably contains proteinaceous fluid

b) CT :-The cyst is seen as hypoattenuating lesion which may show soft tissue attenuation

c) MRI :-The appearance depends on the variable protein content :*T1 & T2 : of variable signal intensities

2-Congenital Lobar Emphysema :a) Incidenceb) Pathologyc) Associationsd) Locatione) Clinical Picturef) Radiographic Featuresg) Differential Diagnosis

a) Incidence :-More common in males (M:F = 3:1)

b) Pathology :-Is acongenital lung abnormalitythat results in progressive overinflation of one or more lobes of a neonate lung-Idiopathic , 50%-Obstruction of airway with valve mechanism , 50% :1-Bronchial cartilage deficiency or immaturity2-Mucus3-Web , stenosis4-Extrinsic compression

c) Associations :-May be associated withcongenital heart defectssuch as :1-Ventricular septal defect (VSD)2-Patent ductus arteriosus (PDA)3-Tetralogy of Fallot

d) Location :-Left upper lobe : most common 40-45%-Right middle lobe : 30%-Right upper lobe : 20%-May involve more than a single lobe in 5%-Much rarer in the lower lobes-Therefore despite the left upper lobe being most commonly affected , the right hemithorax is the most common side to be affected

e) Clinical Picture :-Patients typically present with respiratory distress most commonly in the neonatal period and usually within the first 6 months of life

f) Radiographic Features :1-Plain Radiography2-CT

1-Plain Radiography :a) Immediate postpartum period :-The affected lobe tends to appear opaque and homogeneous because of fetal lung fluid or it may show a diffuse reticular pattern that represents distended lymphatic channels filled with fetal lung fluid

b) Later Findings :-Appears as an area of hyperlucency in the lung with a paucity of vessels-Mass effect with mediastinal shift and hemidiaphragmatic depression-Lateral film may demonstrate posterior displacement of the heart

Chest radiographs demonstrates increased translucency of the left lung with mild mediastinal shift to the right side , on the lateral view the hyperlucency is confined to the left upper lobe, shifting the oblique fissure posteroinferiorly

Low density and expanded left lung with important mass effect (mediastinal shift to the right , contralateral atelectasis and increased of the left intercostal space)

A large hyperlucent area (red arrow) in the left upper , mid and lower zone with attenuated vascular markings within the lucency (green arrow)

2-CT :-Hyperlucent lobe (hallmark)-As Plain Radiography

g) Differential Diagnosis :1-General Differential Diagnosis includes:a) CCAMb) Pulmonary artery hypoplasiac) Bronchial atresia

2-Unilateral Hypertransradiant Hemithorax :a) Rotationb) Chest Wallc) Pleurad) Lunge) Pulmonary Vessels

a) Rotation :-The hypertransradiant hemithorax is the side to which the patient is turned 1-Poor technique2-Scoliosisb) Chest Wall :1-Mastectomy2-Poliomyelitis3-Polands syndrome (unilateral congenital absence of pectoral muscles +/- rib defects)c) Pleura :-Pneumothorax

d) Lung :1-Compensatory Hyperelaxation :-Following lobectomy2-Air way Obstruction :-Air trapping on expiration results in increased lung volume and shift of the mediastinum to the contralateral side-Foreign body , bronchial atresia , endobronchial mass & bronchial compression3-Unilateral Bullae , pneumatocele4-Swyer-James (McLeod) Syndrome5-Congenital Lobar Emphysema6-Schimitar Syndromee) Pulmonary Vessels :-Pulmonary embolus to a major pulmonary artery

3-Pulmonary Underdevelopment :a) Typesb) Radiographic Features

a) Types :1-Pulmonary Agenesis :-Complete absence of the lung parenchyma , bronchus & pulmonary vasculature-Abnormal blood flow in the dorsal aortic arch during the 4th week of gestation (embryonic phase) causes pulmonary agenesis-More than 50% of affected fetuses have other abnormalities involving the cardiovascular (patent ductus arteriosus , patent foramen ovale) , gastrointestinal (tracheoesophageal fistula , imperforate anus) , genitourinary or skeletal (limb anomalies , vertebral segmentation anomalies) system

2-Pulmonary Aplasia :-Blind ended rudimentary bronchus is present without lung parenchyma or pulmonary vasculature3-Pulmonary Hypoplasia :-Bronchus and rudimentary lung are present , however the airways , alveoli & pulmonary vessels are decreased in size & number

-Can be primary or secondary , primary pulmonary hypoplasia in which a cause cannot be elucidated is much less common than secondary hypoplasia-The majority of cases of pulmonary hypoplasia are secondary to a process limiting the thoracic space for lung development which can be either intrathoracic or extrathoracic

-The most common intrathoracic cause is congenital diaphragmatic hernia which is left sided in 75%90% of cases-The most common extrathoracic cause of pulmonary hypoplasia is severe oligohydramnios , skeletal dysplasias in which a small and rigid thoracic cage causes pulmonary hypoplasia

b) Radiographic Features :1-Pulmonary Agenesis :-Postnatal radiography demonstrates diffuse opacification of the involved hemithorax with ipsilateral mediastinal shift , severe volume loss and opacity on the side of agenesis often with close spacing of the ribs , the bronchus and PA to the affected lung are absent and blood flow to the contralateral lung is increased -CT helps confirm the absence of the lung parenchyma , bronchus and pulmonary artery on the involved side

Pulmonary Agenesis

2-Pulmonary Aplasia :-Imaging findings in pulmonary aplasia and agenesis are similar except for the presence of a short blind-ending bronchus in aplasia

Pulmonary aplasia , (a) Chest radiograph depicts the trachea (white arrow) and the right main bronchus (arrowhead) however , the left main bronchus is not seen , there is leftward mediastinal shift , compensatory hyperinflation of the right middle lobe extending into the left hemithorax is also noted (black arrow) , (b) CT shows a blind-ending left main bronchus (arrowhead) with absence of the left lung parenchyma

3-Pulmonary Hypoplasia :-The ribs may appear crowded with a low thoracic-to-abdominal ratio -Films may also show features of the neonate's underlying condition-There may be mediastinal shift with a homogenous density on the involved hypoplastic side and compensatory herniation of the contralateral lung across the mediastinum

Chest radiograph of a newborn with primary pulmonary hypoplasia of the right lung showing shift of the mediastinum to the right hemithorax

Radiograph showing left pulmonary hypoplasia

Chest Radiograph of a 3-month-old infant with primary pulmonary hypoplasia of the right lung

White left lung with diffuse interstitial opacity and hyperexpansion of the right lung , the trachea is deviated to the left as is the cardiac silhouette

A chest radiograph of a newborn with diaphragmatic hernia in the right hemithorax shortly after birth , CT shows the presence of abdominal contents in the right hemithorax , note the presence of the left lower bronchus and its main branches (horizontal arrow) and absence of the right lower lobe bronchus , the liver in the right hemithorax is indicated by the upper arrow

AP and lateral chest radiographs in a patient with skeletal dysplasia show the short dysplastic ribs and narrowed thorax

A chest radiograph of a newborn with achondroplasia and small chest causing hypoplasia of both lungs

4-Scimitar Syndrome :a) Pathologyb) Locationc) Associationsd) Radiographic Features

a) Pathology :-Also known as Hypogenetic Lung Syndrome , Pulmonary Venolobar Syndrome-Characterized by a hypoplastic lung that is drained by an anomalous vein into the systemic venous system (IVC)-A combination ofpulmonary hypoplasia and partial anomalous pulmonary venous return (PAPVR)

b) Location :-It almost exclusively occurs on the right side

c) Associations :1-Accessory diaphragm , diaphragmatic hernia2-Bony abnormalities : hemivertebrae , rib notching & rib hypoplasia3-CHD : ASD , VSD , PDA & tetralogy of Fallot

d) Radiographic Features :1-Plain Radiography2-CT

1-Plain Radiography :-Small lung with ipsilateral mediastinal shift and in one third of cases the anomalous draining vein may be seen as a tubular structure paralleling the right heart border in the shape of a Turkish sword (scimitar)-The right heart border maybe blurred

2-CT :-As Plain Radiography

(a) CXR shows volume loss in the right hemithorax with rightward mediastinal shift , the right heart border is not well seen , an anomalous vessel (arrowheads) is seen in the right cardiophrenic angle , this vessel increases in caliber in the caudal direction (scimitar sign) , (b) CT+C shows the lower lobe pulmonary vein (scimitar vein) draining into the intrahepatic IVC (arrows) , (c) Volume-rendered CT clearly depicts the anomalous vein (arrow)

5-Bronchial Atresia :a) Pathologyb) Locationc) Radiographic Featuresd) Differential Diagnosis

a) Pathology :-Bronchial atresia is a rare anomaly resulting from focal obliteration of a segmental , subsegmental or lobar bronchus-The bronchi distal to the stenosis are dilated and filled with mucus with mild hyperinflation of the adjacent lung due to air trapping

b) Location :-Commonly occurs at the apico-posterior segment of the left upper lobe

c) Radiographic Features : HRCT-Atretic bronchial stump(s) often become mucus plugged and can give afinger in gloveappearance-Distal lung parenchyma supplied by the atretic segment can be emphysematous due to air trapping

Central mass surrounded by hyperlucent lung (blue arrow)

Bronchial atresia , CT shows mucoid impaction (arrow) just distal to bronchial atresia in the right upper lobe , distal air trapping is also noted

CXR in inspiration/expiration show hyperlucency of the left lung , the heart is displaced towards the right and there is shifting of the mediastinum towards the right on expiration confirming air trapping of the left lung , in addition , a tubular structure is visible in the left lower lung (arrow) , CT shows hyperlucency of the left lower lung limited by normal upper lung (white arrows) , there is a non-enhancing tubular structure in the centre of the left lower lung (red arrows) , the displacement of the heart towards the right is due to the expanded left lung plus a marked pectus excavatum

CXR shows an area of hyperlucency in the left upper lung with branching serpiginous shadows within (arrows) , CT confirms the unenhanced mucous plug within the area of hyperlucency , expiratory film confirms air trapping

d) Differential Diagnosis :1-Congenital Lobar Emphysema2-Allergic Bronchopulmonary Aspergillosis (ABPA) : for finger in glove appearance

6-Congenital Diaphragmatic Hernia :a) Incidenceb) Associationsc) Types

a) Incidence :-1 in 2000 to 3000 births-Mortality rate of isolated hernias is 60% (with postnatal surgery) and higher when other abnormalities are present

b) Associations :1-Pulmonary hypoplasia (common)2-CNS abnormalities :-Neural tube defects : spina bifida , encephalocele-Anencephaly

c) Types :1-Morgagni Hernia2-Bochdalek Hernia

1-Morgagni Hernia :a) Incidenceb) Pathologyc) Locationd) Radiographic Featurese) Differential Diagnosis

a) Incidence :-Is one of the congenitaldiaphragmatic hernias-It is rarer than the Bochdalek herniaand accounts for approximately 2% of all congenital diaphragmatic hernias

b) Pathology :-It is characterized by herniation through theforamen of Morgagni (anterior opening in the diaphragm that extends between the sternum medially and the eighth rib laterally)-As compared to the Bochdalek hernia , the Morgagni hernia is rare , small & anterior

c) Location :-This hernia occurs in the anterior midline (retrosternal or parasternal) through the foramen of Morgagni with 90% of cases occurring on the right side-Morgagni hernias typically occur medially

d) Radiographic Features :-Anterior herniation of bowel loops on a lateral chest radiograph is the typical finding-Other herniated viscera include the liver , spleen and omentum

Morgagni hernia in a 2 year old child , lateral chest radiograph shows herniation of a bowel loop (arrows) in a classic location through an anteromedial defect

e) Differential Diagnosis :-Cardiophrenic angle lesions :-Thecardiophrenic spaceis usually filled with fat , however lesions originating above or lower to the diaphragm can present as cardiophrenic angle lesions :1-Pericardial fat pad2-Pericardial cyst3-Pericardial fat necrosis4-Morgagnis hernia5-Lymphadenopathy : metastases , lymphoma6-Pericardial lipomatosis

2-Bochdalek Hernia :a) Incidenceb) Pathologyc) Locationd) Radiographic Features

a) Incidence :-Is one of the congenitaldiaphragmatic hernias-More common than Morgagni hernia-It is more common in infants (90%)

b) Pathology :-They occur posteriorly and are due to a defect in the posterior attachment of thediaphragmwhen there is a failure of pleuroperitoneal membrane closure in utero-Retroperitonealstructures may prolapse through the defect , e.g. retroperitoneal fat ,spleenor leftkidney

c) Location :-They occur posteriorly-It occurs most frequently on the left side with approximately 80% being left-sided and 20% right-sided

d) Radiographic Features :1-Plain Radiography2-CT

1-Plain Radiography :-On conventional radiographs , the hernia may appear as a lung base soft-tissue opacity lesion seen posteriorly on lateral images

Intrathoracic kidney

2-CT :-CT usually demonstrates fat above the diaphragm and is extremely beneficial in revealing organ entrapment-Coronal and sagittal reformatted images show the defect to best advantage

7-Kartageners Syndrome :a) Pathologyb) Clinical Picturec) Radiographic Features

a) Pathology :-Kartagener's syndrome (immotile cilia syndrome) is due to the deficiency of the dynein arms of cilia causing immotility of respiratory , auditory and sperm cilia

b) Clinical Picture :-Kartagener syndrome is characterized by the clinical triad of :1-Situs inversus2-Chronic sinusitisand / or nasal polyposis3-Bronchiectasis-Other features include :1-Telecanthus : widened interpupillary distance by a nasal polyp2-Infertility in male3-Subfertility in female

c) Radiographic Features :-Complete thoracic and abdominal situs inversus-Bronchiectasis-Sinus hypoplasia and mucosal thickening