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LINEAR LUNG MARKINGS
Dr AHMED ESAWY
Dr Ahmed Esawy
LINEAR AND BAND SHADOWS
Normal structures such as the blood vessels and fissures form linear shadows within the lung fields
However there are many disease processes which may result in linear shadows
Linear shadows are less than 5 mm wide
Band shadows are greater than 5 mm thick
Dr Ahmed Esawy
Causes for linear shadows
bull 1-Kerleyrsquos lines 2-Plate atelectasis ( Fleischner Lines) etc bull 3-Pulmonary infarcts bull 4-Thickened fissures bull 5-Pulmonary pleural scars bull 6-Bronchial wall thickening bull 7-Sentinel lines bull 8-Anamolous vessels bull 9-Artefacts 10-Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Linear interstitial patterns
Linear interstitial patterns are seen in processes that thicken the axial (bronchovascular) interstitium or the peripheral pulmonary interstitium axial diffuse thickening along the bronchovascular tree seen as parallel opacities radiating from the hila (seen transversely) or peri-bronchial cuffing (seen en-face) peripheral thickening of the peripheral interstitium (either medially or laterally) produces Kerley lines Axial interstitial thickening is difficult to distinguish from airways disease that result in bronchial wall thickening (eg bronchiectasis asthma) and most often seen ininterstitial pulmonary oedema Peripheral interstitial involvement is seen in interstitial pulmonary oedema lymphangitis carcinomatosis and acute viral or atypical bacterial pneumonia Dr Ahmed Esawy
ATELECTASIS
Dr Ahmed Esawy
Impaired diaphragmatic motion
Underventilation
Collapse of small pulmonary sub divisions
Disk atelectasis
Fleischner line formation
Dr Ahmed Esawy
Dr Ahmed Esawy
Plate-like atelectasis Plate-like atelectasis is a common finding on chest x-rays and detected almost every day They are characterized by linear shadows of increased density at the lung bases They are usually horizontal measure 1-3 mm in thickness and are only a few cm long In most cases these findings have no clinical significance and are seen in smokers and elderly They are seen in patients that are in a poor condition and who breathe superficially for instance after abdominal surgery Plate-like atelectasis is frequently seen in patients in the ICU due to poor ventilation Platelike atelectasis is also frequently seen in pulmonary embolism but since it is non-specific it is not a helpful sign in making the diagnosis of pulmonary embolism
Dr Ahmed Esawy
Plate-like atelectasis due to poor inspiration in a patient who had abdominal surgery
Dr Ahmed Esawy
plate-like atelectasis in a patient with pulmonary embolism
Dr Ahmed Esawy
Dr Ahmed Esawy
Bronchial thickening
Dr Ahmed Esawy
Peribronchial cuffing results when fluid-thickened bronchial walls become visible producing rdquodoughnut-likerdquo densities in the lung parenchyma
Dr Ahmed Esawy
THICKENED BRONCHIAL WALLS
Parallel TRAMLINE shadows
Ring shadows on end-on view
They are common finding in
Bronchiectasis
Recurrent asthma
Bronchopulmonary aspergillosis
Pulmonary oedema
Lymphangitis carcinomatosis
Dr Ahmed Esawy
Peri-Bronchial Cuffing Peribronchial cuffing represents extravasated water surrounding the bronchus
Pre-diuresis note the cuffing (large arrow)
Post diuresis
Dr Ahmed Esawy
SENTINEL LINES
Dr Ahmed Esawy
Sentinel lines--an unusual sign of lower lobe contraction
Mucus-filled bronchi
Coarse lines lying peripherally in contact with the pleura and curving upwards
Often left-sided and associated with left lower lobe collapse
They may develop due to kinking of bronchi adjacent to the collapse
Dr Ahmed Esawy
the various densities occurring in the lower zones of the standard postero-anterior chest radiograph one sign has been ignored Coarse linear densities at the bases may be due to adjacent lower lobe contraction usually the superior and inferior branches of the lingular bronchi The densities are probably due to mucus-filled bronchi or alveolar atelectasis distal to the kink resulting from poor bronchial drainage and may indicate more extensive disease The left lower lobe collapse may not be visible on the chest radiograph but the presence of these densities should alert the observer to the more important associated abnormality
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
LINEAR AND BAND SHADOWS
Normal structures such as the blood vessels and fissures form linear shadows within the lung fields
However there are many disease processes which may result in linear shadows
Linear shadows are less than 5 mm wide
Band shadows are greater than 5 mm thick
Dr Ahmed Esawy
Causes for linear shadows
bull 1-Kerleyrsquos lines 2-Plate atelectasis ( Fleischner Lines) etc bull 3-Pulmonary infarcts bull 4-Thickened fissures bull 5-Pulmonary pleural scars bull 6-Bronchial wall thickening bull 7-Sentinel lines bull 8-Anamolous vessels bull 9-Artefacts 10-Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Linear interstitial patterns
Linear interstitial patterns are seen in processes that thicken the axial (bronchovascular) interstitium or the peripheral pulmonary interstitium axial diffuse thickening along the bronchovascular tree seen as parallel opacities radiating from the hila (seen transversely) or peri-bronchial cuffing (seen en-face) peripheral thickening of the peripheral interstitium (either medially or laterally) produces Kerley lines Axial interstitial thickening is difficult to distinguish from airways disease that result in bronchial wall thickening (eg bronchiectasis asthma) and most often seen ininterstitial pulmonary oedema Peripheral interstitial involvement is seen in interstitial pulmonary oedema lymphangitis carcinomatosis and acute viral or atypical bacterial pneumonia Dr Ahmed Esawy
ATELECTASIS
Dr Ahmed Esawy
Impaired diaphragmatic motion
Underventilation
Collapse of small pulmonary sub divisions
Disk atelectasis
Fleischner line formation
Dr Ahmed Esawy
Dr Ahmed Esawy
Plate-like atelectasis Plate-like atelectasis is a common finding on chest x-rays and detected almost every day They are characterized by linear shadows of increased density at the lung bases They are usually horizontal measure 1-3 mm in thickness and are only a few cm long In most cases these findings have no clinical significance and are seen in smokers and elderly They are seen in patients that are in a poor condition and who breathe superficially for instance after abdominal surgery Plate-like atelectasis is frequently seen in patients in the ICU due to poor ventilation Platelike atelectasis is also frequently seen in pulmonary embolism but since it is non-specific it is not a helpful sign in making the diagnosis of pulmonary embolism
Dr Ahmed Esawy
Plate-like atelectasis due to poor inspiration in a patient who had abdominal surgery
Dr Ahmed Esawy
plate-like atelectasis in a patient with pulmonary embolism
Dr Ahmed Esawy
Dr Ahmed Esawy
Bronchial thickening
Dr Ahmed Esawy
Peribronchial cuffing results when fluid-thickened bronchial walls become visible producing rdquodoughnut-likerdquo densities in the lung parenchyma
Dr Ahmed Esawy
THICKENED BRONCHIAL WALLS
Parallel TRAMLINE shadows
Ring shadows on end-on view
They are common finding in
Bronchiectasis
Recurrent asthma
Bronchopulmonary aspergillosis
Pulmonary oedema
Lymphangitis carcinomatosis
Dr Ahmed Esawy
Peri-Bronchial Cuffing Peribronchial cuffing represents extravasated water surrounding the bronchus
Pre-diuresis note the cuffing (large arrow)
Post diuresis
Dr Ahmed Esawy
SENTINEL LINES
Dr Ahmed Esawy
Sentinel lines--an unusual sign of lower lobe contraction
Mucus-filled bronchi
Coarse lines lying peripherally in contact with the pleura and curving upwards
Often left-sided and associated with left lower lobe collapse
They may develop due to kinking of bronchi adjacent to the collapse
Dr Ahmed Esawy
the various densities occurring in the lower zones of the standard postero-anterior chest radiograph one sign has been ignored Coarse linear densities at the bases may be due to adjacent lower lobe contraction usually the superior and inferior branches of the lingular bronchi The densities are probably due to mucus-filled bronchi or alveolar atelectasis distal to the kink resulting from poor bronchial drainage and may indicate more extensive disease The left lower lobe collapse may not be visible on the chest radiograph but the presence of these densities should alert the observer to the more important associated abnormality
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Causes for linear shadows
bull 1-Kerleyrsquos lines 2-Plate atelectasis ( Fleischner Lines) etc bull 3-Pulmonary infarcts bull 4-Thickened fissures bull 5-Pulmonary pleural scars bull 6-Bronchial wall thickening bull 7-Sentinel lines bull 8-Anamolous vessels bull 9-Artefacts 10-Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Linear interstitial patterns
Linear interstitial patterns are seen in processes that thicken the axial (bronchovascular) interstitium or the peripheral pulmonary interstitium axial diffuse thickening along the bronchovascular tree seen as parallel opacities radiating from the hila (seen transversely) or peri-bronchial cuffing (seen en-face) peripheral thickening of the peripheral interstitium (either medially or laterally) produces Kerley lines Axial interstitial thickening is difficult to distinguish from airways disease that result in bronchial wall thickening (eg bronchiectasis asthma) and most often seen ininterstitial pulmonary oedema Peripheral interstitial involvement is seen in interstitial pulmonary oedema lymphangitis carcinomatosis and acute viral or atypical bacterial pneumonia Dr Ahmed Esawy
ATELECTASIS
Dr Ahmed Esawy
Impaired diaphragmatic motion
Underventilation
Collapse of small pulmonary sub divisions
Disk atelectasis
Fleischner line formation
Dr Ahmed Esawy
Dr Ahmed Esawy
Plate-like atelectasis Plate-like atelectasis is a common finding on chest x-rays and detected almost every day They are characterized by linear shadows of increased density at the lung bases They are usually horizontal measure 1-3 mm in thickness and are only a few cm long In most cases these findings have no clinical significance and are seen in smokers and elderly They are seen in patients that are in a poor condition and who breathe superficially for instance after abdominal surgery Plate-like atelectasis is frequently seen in patients in the ICU due to poor ventilation Platelike atelectasis is also frequently seen in pulmonary embolism but since it is non-specific it is not a helpful sign in making the diagnosis of pulmonary embolism
Dr Ahmed Esawy
Plate-like atelectasis due to poor inspiration in a patient who had abdominal surgery
Dr Ahmed Esawy
plate-like atelectasis in a patient with pulmonary embolism
Dr Ahmed Esawy
Dr Ahmed Esawy
Bronchial thickening
Dr Ahmed Esawy
Peribronchial cuffing results when fluid-thickened bronchial walls become visible producing rdquodoughnut-likerdquo densities in the lung parenchyma
Dr Ahmed Esawy
THICKENED BRONCHIAL WALLS
Parallel TRAMLINE shadows
Ring shadows on end-on view
They are common finding in
Bronchiectasis
Recurrent asthma
Bronchopulmonary aspergillosis
Pulmonary oedema
Lymphangitis carcinomatosis
Dr Ahmed Esawy
Peri-Bronchial Cuffing Peribronchial cuffing represents extravasated water surrounding the bronchus
Pre-diuresis note the cuffing (large arrow)
Post diuresis
Dr Ahmed Esawy
SENTINEL LINES
Dr Ahmed Esawy
Sentinel lines--an unusual sign of lower lobe contraction
Mucus-filled bronchi
Coarse lines lying peripherally in contact with the pleura and curving upwards
Often left-sided and associated with left lower lobe collapse
They may develop due to kinking of bronchi adjacent to the collapse
Dr Ahmed Esawy
the various densities occurring in the lower zones of the standard postero-anterior chest radiograph one sign has been ignored Coarse linear densities at the bases may be due to adjacent lower lobe contraction usually the superior and inferior branches of the lingular bronchi The densities are probably due to mucus-filled bronchi or alveolar atelectasis distal to the kink resulting from poor bronchial drainage and may indicate more extensive disease The left lower lobe collapse may not be visible on the chest radiograph but the presence of these densities should alert the observer to the more important associated abnormality
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Linear interstitial patterns
Linear interstitial patterns are seen in processes that thicken the axial (bronchovascular) interstitium or the peripheral pulmonary interstitium axial diffuse thickening along the bronchovascular tree seen as parallel opacities radiating from the hila (seen transversely) or peri-bronchial cuffing (seen en-face) peripheral thickening of the peripheral interstitium (either medially or laterally) produces Kerley lines Axial interstitial thickening is difficult to distinguish from airways disease that result in bronchial wall thickening (eg bronchiectasis asthma) and most often seen ininterstitial pulmonary oedema Peripheral interstitial involvement is seen in interstitial pulmonary oedema lymphangitis carcinomatosis and acute viral or atypical bacterial pneumonia Dr Ahmed Esawy
ATELECTASIS
Dr Ahmed Esawy
Impaired diaphragmatic motion
Underventilation
Collapse of small pulmonary sub divisions
Disk atelectasis
Fleischner line formation
Dr Ahmed Esawy
Dr Ahmed Esawy
Plate-like atelectasis Plate-like atelectasis is a common finding on chest x-rays and detected almost every day They are characterized by linear shadows of increased density at the lung bases They are usually horizontal measure 1-3 mm in thickness and are only a few cm long In most cases these findings have no clinical significance and are seen in smokers and elderly They are seen in patients that are in a poor condition and who breathe superficially for instance after abdominal surgery Plate-like atelectasis is frequently seen in patients in the ICU due to poor ventilation Platelike atelectasis is also frequently seen in pulmonary embolism but since it is non-specific it is not a helpful sign in making the diagnosis of pulmonary embolism
Dr Ahmed Esawy
Plate-like atelectasis due to poor inspiration in a patient who had abdominal surgery
Dr Ahmed Esawy
plate-like atelectasis in a patient with pulmonary embolism
Dr Ahmed Esawy
Dr Ahmed Esawy
Bronchial thickening
Dr Ahmed Esawy
Peribronchial cuffing results when fluid-thickened bronchial walls become visible producing rdquodoughnut-likerdquo densities in the lung parenchyma
Dr Ahmed Esawy
THICKENED BRONCHIAL WALLS
Parallel TRAMLINE shadows
Ring shadows on end-on view
They are common finding in
Bronchiectasis
Recurrent asthma
Bronchopulmonary aspergillosis
Pulmonary oedema
Lymphangitis carcinomatosis
Dr Ahmed Esawy
Peri-Bronchial Cuffing Peribronchial cuffing represents extravasated water surrounding the bronchus
Pre-diuresis note the cuffing (large arrow)
Post diuresis
Dr Ahmed Esawy
SENTINEL LINES
Dr Ahmed Esawy
Sentinel lines--an unusual sign of lower lobe contraction
Mucus-filled bronchi
Coarse lines lying peripherally in contact with the pleura and curving upwards
Often left-sided and associated with left lower lobe collapse
They may develop due to kinking of bronchi adjacent to the collapse
Dr Ahmed Esawy
the various densities occurring in the lower zones of the standard postero-anterior chest radiograph one sign has been ignored Coarse linear densities at the bases may be due to adjacent lower lobe contraction usually the superior and inferior branches of the lingular bronchi The densities are probably due to mucus-filled bronchi or alveolar atelectasis distal to the kink resulting from poor bronchial drainage and may indicate more extensive disease The left lower lobe collapse may not be visible on the chest radiograph but the presence of these densities should alert the observer to the more important associated abnormality
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
ATELECTASIS
Dr Ahmed Esawy
Impaired diaphragmatic motion
Underventilation
Collapse of small pulmonary sub divisions
Disk atelectasis
Fleischner line formation
Dr Ahmed Esawy
Dr Ahmed Esawy
Plate-like atelectasis Plate-like atelectasis is a common finding on chest x-rays and detected almost every day They are characterized by linear shadows of increased density at the lung bases They are usually horizontal measure 1-3 mm in thickness and are only a few cm long In most cases these findings have no clinical significance and are seen in smokers and elderly They are seen in patients that are in a poor condition and who breathe superficially for instance after abdominal surgery Plate-like atelectasis is frequently seen in patients in the ICU due to poor ventilation Platelike atelectasis is also frequently seen in pulmonary embolism but since it is non-specific it is not a helpful sign in making the diagnosis of pulmonary embolism
Dr Ahmed Esawy
Plate-like atelectasis due to poor inspiration in a patient who had abdominal surgery
Dr Ahmed Esawy
plate-like atelectasis in a patient with pulmonary embolism
Dr Ahmed Esawy
Dr Ahmed Esawy
Bronchial thickening
Dr Ahmed Esawy
Peribronchial cuffing results when fluid-thickened bronchial walls become visible producing rdquodoughnut-likerdquo densities in the lung parenchyma
Dr Ahmed Esawy
THICKENED BRONCHIAL WALLS
Parallel TRAMLINE shadows
Ring shadows on end-on view
They are common finding in
Bronchiectasis
Recurrent asthma
Bronchopulmonary aspergillosis
Pulmonary oedema
Lymphangitis carcinomatosis
Dr Ahmed Esawy
Peri-Bronchial Cuffing Peribronchial cuffing represents extravasated water surrounding the bronchus
Pre-diuresis note the cuffing (large arrow)
Post diuresis
Dr Ahmed Esawy
SENTINEL LINES
Dr Ahmed Esawy
Sentinel lines--an unusual sign of lower lobe contraction
Mucus-filled bronchi
Coarse lines lying peripherally in contact with the pleura and curving upwards
Often left-sided and associated with left lower lobe collapse
They may develop due to kinking of bronchi adjacent to the collapse
Dr Ahmed Esawy
the various densities occurring in the lower zones of the standard postero-anterior chest radiograph one sign has been ignored Coarse linear densities at the bases may be due to adjacent lower lobe contraction usually the superior and inferior branches of the lingular bronchi The densities are probably due to mucus-filled bronchi or alveolar atelectasis distal to the kink resulting from poor bronchial drainage and may indicate more extensive disease The left lower lobe collapse may not be visible on the chest radiograph but the presence of these densities should alert the observer to the more important associated abnormality
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Impaired diaphragmatic motion
Underventilation
Collapse of small pulmonary sub divisions
Disk atelectasis
Fleischner line formation
Dr Ahmed Esawy
Dr Ahmed Esawy
Plate-like atelectasis Plate-like atelectasis is a common finding on chest x-rays and detected almost every day They are characterized by linear shadows of increased density at the lung bases They are usually horizontal measure 1-3 mm in thickness and are only a few cm long In most cases these findings have no clinical significance and are seen in smokers and elderly They are seen in patients that are in a poor condition and who breathe superficially for instance after abdominal surgery Plate-like atelectasis is frequently seen in patients in the ICU due to poor ventilation Platelike atelectasis is also frequently seen in pulmonary embolism but since it is non-specific it is not a helpful sign in making the diagnosis of pulmonary embolism
Dr Ahmed Esawy
Plate-like atelectasis due to poor inspiration in a patient who had abdominal surgery
Dr Ahmed Esawy
plate-like atelectasis in a patient with pulmonary embolism
Dr Ahmed Esawy
Dr Ahmed Esawy
Bronchial thickening
Dr Ahmed Esawy
Peribronchial cuffing results when fluid-thickened bronchial walls become visible producing rdquodoughnut-likerdquo densities in the lung parenchyma
Dr Ahmed Esawy
THICKENED BRONCHIAL WALLS
Parallel TRAMLINE shadows
Ring shadows on end-on view
They are common finding in
Bronchiectasis
Recurrent asthma
Bronchopulmonary aspergillosis
Pulmonary oedema
Lymphangitis carcinomatosis
Dr Ahmed Esawy
Peri-Bronchial Cuffing Peribronchial cuffing represents extravasated water surrounding the bronchus
Pre-diuresis note the cuffing (large arrow)
Post diuresis
Dr Ahmed Esawy
SENTINEL LINES
Dr Ahmed Esawy
Sentinel lines--an unusual sign of lower lobe contraction
Mucus-filled bronchi
Coarse lines lying peripherally in contact with the pleura and curving upwards
Often left-sided and associated with left lower lobe collapse
They may develop due to kinking of bronchi adjacent to the collapse
Dr Ahmed Esawy
the various densities occurring in the lower zones of the standard postero-anterior chest radiograph one sign has been ignored Coarse linear densities at the bases may be due to adjacent lower lobe contraction usually the superior and inferior branches of the lingular bronchi The densities are probably due to mucus-filled bronchi or alveolar atelectasis distal to the kink resulting from poor bronchial drainage and may indicate more extensive disease The left lower lobe collapse may not be visible on the chest radiograph but the presence of these densities should alert the observer to the more important associated abnormality
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Plate-like atelectasis Plate-like atelectasis is a common finding on chest x-rays and detected almost every day They are characterized by linear shadows of increased density at the lung bases They are usually horizontal measure 1-3 mm in thickness and are only a few cm long In most cases these findings have no clinical significance and are seen in smokers and elderly They are seen in patients that are in a poor condition and who breathe superficially for instance after abdominal surgery Plate-like atelectasis is frequently seen in patients in the ICU due to poor ventilation Platelike atelectasis is also frequently seen in pulmonary embolism but since it is non-specific it is not a helpful sign in making the diagnosis of pulmonary embolism
Dr Ahmed Esawy
Plate-like atelectasis due to poor inspiration in a patient who had abdominal surgery
Dr Ahmed Esawy
plate-like atelectasis in a patient with pulmonary embolism
Dr Ahmed Esawy
Dr Ahmed Esawy
Bronchial thickening
Dr Ahmed Esawy
Peribronchial cuffing results when fluid-thickened bronchial walls become visible producing rdquodoughnut-likerdquo densities in the lung parenchyma
Dr Ahmed Esawy
THICKENED BRONCHIAL WALLS
Parallel TRAMLINE shadows
Ring shadows on end-on view
They are common finding in
Bronchiectasis
Recurrent asthma
Bronchopulmonary aspergillosis
Pulmonary oedema
Lymphangitis carcinomatosis
Dr Ahmed Esawy
Peri-Bronchial Cuffing Peribronchial cuffing represents extravasated water surrounding the bronchus
Pre-diuresis note the cuffing (large arrow)
Post diuresis
Dr Ahmed Esawy
SENTINEL LINES
Dr Ahmed Esawy
Sentinel lines--an unusual sign of lower lobe contraction
Mucus-filled bronchi
Coarse lines lying peripherally in contact with the pleura and curving upwards
Often left-sided and associated with left lower lobe collapse
They may develop due to kinking of bronchi adjacent to the collapse
Dr Ahmed Esawy
the various densities occurring in the lower zones of the standard postero-anterior chest radiograph one sign has been ignored Coarse linear densities at the bases may be due to adjacent lower lobe contraction usually the superior and inferior branches of the lingular bronchi The densities are probably due to mucus-filled bronchi or alveolar atelectasis distal to the kink resulting from poor bronchial drainage and may indicate more extensive disease The left lower lobe collapse may not be visible on the chest radiograph but the presence of these densities should alert the observer to the more important associated abnormality
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Plate-like atelectasis Plate-like atelectasis is a common finding on chest x-rays and detected almost every day They are characterized by linear shadows of increased density at the lung bases They are usually horizontal measure 1-3 mm in thickness and are only a few cm long In most cases these findings have no clinical significance and are seen in smokers and elderly They are seen in patients that are in a poor condition and who breathe superficially for instance after abdominal surgery Plate-like atelectasis is frequently seen in patients in the ICU due to poor ventilation Platelike atelectasis is also frequently seen in pulmonary embolism but since it is non-specific it is not a helpful sign in making the diagnosis of pulmonary embolism
Dr Ahmed Esawy
Plate-like atelectasis due to poor inspiration in a patient who had abdominal surgery
Dr Ahmed Esawy
plate-like atelectasis in a patient with pulmonary embolism
Dr Ahmed Esawy
Dr Ahmed Esawy
Bronchial thickening
Dr Ahmed Esawy
Peribronchial cuffing results when fluid-thickened bronchial walls become visible producing rdquodoughnut-likerdquo densities in the lung parenchyma
Dr Ahmed Esawy
THICKENED BRONCHIAL WALLS
Parallel TRAMLINE shadows
Ring shadows on end-on view
They are common finding in
Bronchiectasis
Recurrent asthma
Bronchopulmonary aspergillosis
Pulmonary oedema
Lymphangitis carcinomatosis
Dr Ahmed Esawy
Peri-Bronchial Cuffing Peribronchial cuffing represents extravasated water surrounding the bronchus
Pre-diuresis note the cuffing (large arrow)
Post diuresis
Dr Ahmed Esawy
SENTINEL LINES
Dr Ahmed Esawy
Sentinel lines--an unusual sign of lower lobe contraction
Mucus-filled bronchi
Coarse lines lying peripherally in contact with the pleura and curving upwards
Often left-sided and associated with left lower lobe collapse
They may develop due to kinking of bronchi adjacent to the collapse
Dr Ahmed Esawy
the various densities occurring in the lower zones of the standard postero-anterior chest radiograph one sign has been ignored Coarse linear densities at the bases may be due to adjacent lower lobe contraction usually the superior and inferior branches of the lingular bronchi The densities are probably due to mucus-filled bronchi or alveolar atelectasis distal to the kink resulting from poor bronchial drainage and may indicate more extensive disease The left lower lobe collapse may not be visible on the chest radiograph but the presence of these densities should alert the observer to the more important associated abnormality
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Plate-like atelectasis due to poor inspiration in a patient who had abdominal surgery
Dr Ahmed Esawy
plate-like atelectasis in a patient with pulmonary embolism
Dr Ahmed Esawy
Dr Ahmed Esawy
Bronchial thickening
Dr Ahmed Esawy
Peribronchial cuffing results when fluid-thickened bronchial walls become visible producing rdquodoughnut-likerdquo densities in the lung parenchyma
Dr Ahmed Esawy
THICKENED BRONCHIAL WALLS
Parallel TRAMLINE shadows
Ring shadows on end-on view
They are common finding in
Bronchiectasis
Recurrent asthma
Bronchopulmonary aspergillosis
Pulmonary oedema
Lymphangitis carcinomatosis
Dr Ahmed Esawy
Peri-Bronchial Cuffing Peribronchial cuffing represents extravasated water surrounding the bronchus
Pre-diuresis note the cuffing (large arrow)
Post diuresis
Dr Ahmed Esawy
SENTINEL LINES
Dr Ahmed Esawy
Sentinel lines--an unusual sign of lower lobe contraction
Mucus-filled bronchi
Coarse lines lying peripherally in contact with the pleura and curving upwards
Often left-sided and associated with left lower lobe collapse
They may develop due to kinking of bronchi adjacent to the collapse
Dr Ahmed Esawy
the various densities occurring in the lower zones of the standard postero-anterior chest radiograph one sign has been ignored Coarse linear densities at the bases may be due to adjacent lower lobe contraction usually the superior and inferior branches of the lingular bronchi The densities are probably due to mucus-filled bronchi or alveolar atelectasis distal to the kink resulting from poor bronchial drainage and may indicate more extensive disease The left lower lobe collapse may not be visible on the chest radiograph but the presence of these densities should alert the observer to the more important associated abnormality
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
plate-like atelectasis in a patient with pulmonary embolism
Dr Ahmed Esawy
Dr Ahmed Esawy
Bronchial thickening
Dr Ahmed Esawy
Peribronchial cuffing results when fluid-thickened bronchial walls become visible producing rdquodoughnut-likerdquo densities in the lung parenchyma
Dr Ahmed Esawy
THICKENED BRONCHIAL WALLS
Parallel TRAMLINE shadows
Ring shadows on end-on view
They are common finding in
Bronchiectasis
Recurrent asthma
Bronchopulmonary aspergillosis
Pulmonary oedema
Lymphangitis carcinomatosis
Dr Ahmed Esawy
Peri-Bronchial Cuffing Peribronchial cuffing represents extravasated water surrounding the bronchus
Pre-diuresis note the cuffing (large arrow)
Post diuresis
Dr Ahmed Esawy
SENTINEL LINES
Dr Ahmed Esawy
Sentinel lines--an unusual sign of lower lobe contraction
Mucus-filled bronchi
Coarse lines lying peripherally in contact with the pleura and curving upwards
Often left-sided and associated with left lower lobe collapse
They may develop due to kinking of bronchi adjacent to the collapse
Dr Ahmed Esawy
the various densities occurring in the lower zones of the standard postero-anterior chest radiograph one sign has been ignored Coarse linear densities at the bases may be due to adjacent lower lobe contraction usually the superior and inferior branches of the lingular bronchi The densities are probably due to mucus-filled bronchi or alveolar atelectasis distal to the kink resulting from poor bronchial drainage and may indicate more extensive disease The left lower lobe collapse may not be visible on the chest radiograph but the presence of these densities should alert the observer to the more important associated abnormality
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Bronchial thickening
Dr Ahmed Esawy
Peribronchial cuffing results when fluid-thickened bronchial walls become visible producing rdquodoughnut-likerdquo densities in the lung parenchyma
Dr Ahmed Esawy
THICKENED BRONCHIAL WALLS
Parallel TRAMLINE shadows
Ring shadows on end-on view
They are common finding in
Bronchiectasis
Recurrent asthma
Bronchopulmonary aspergillosis
Pulmonary oedema
Lymphangitis carcinomatosis
Dr Ahmed Esawy
Peri-Bronchial Cuffing Peribronchial cuffing represents extravasated water surrounding the bronchus
Pre-diuresis note the cuffing (large arrow)
Post diuresis
Dr Ahmed Esawy
SENTINEL LINES
Dr Ahmed Esawy
Sentinel lines--an unusual sign of lower lobe contraction
Mucus-filled bronchi
Coarse lines lying peripherally in contact with the pleura and curving upwards
Often left-sided and associated with left lower lobe collapse
They may develop due to kinking of bronchi adjacent to the collapse
Dr Ahmed Esawy
the various densities occurring in the lower zones of the standard postero-anterior chest radiograph one sign has been ignored Coarse linear densities at the bases may be due to adjacent lower lobe contraction usually the superior and inferior branches of the lingular bronchi The densities are probably due to mucus-filled bronchi or alveolar atelectasis distal to the kink resulting from poor bronchial drainage and may indicate more extensive disease The left lower lobe collapse may not be visible on the chest radiograph but the presence of these densities should alert the observer to the more important associated abnormality
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Bronchial thickening
Dr Ahmed Esawy
Peribronchial cuffing results when fluid-thickened bronchial walls become visible producing rdquodoughnut-likerdquo densities in the lung parenchyma
Dr Ahmed Esawy
THICKENED BRONCHIAL WALLS
Parallel TRAMLINE shadows
Ring shadows on end-on view
They are common finding in
Bronchiectasis
Recurrent asthma
Bronchopulmonary aspergillosis
Pulmonary oedema
Lymphangitis carcinomatosis
Dr Ahmed Esawy
Peri-Bronchial Cuffing Peribronchial cuffing represents extravasated water surrounding the bronchus
Pre-diuresis note the cuffing (large arrow)
Post diuresis
Dr Ahmed Esawy
SENTINEL LINES
Dr Ahmed Esawy
Sentinel lines--an unusual sign of lower lobe contraction
Mucus-filled bronchi
Coarse lines lying peripherally in contact with the pleura and curving upwards
Often left-sided and associated with left lower lobe collapse
They may develop due to kinking of bronchi adjacent to the collapse
Dr Ahmed Esawy
the various densities occurring in the lower zones of the standard postero-anterior chest radiograph one sign has been ignored Coarse linear densities at the bases may be due to adjacent lower lobe contraction usually the superior and inferior branches of the lingular bronchi The densities are probably due to mucus-filled bronchi or alveolar atelectasis distal to the kink resulting from poor bronchial drainage and may indicate more extensive disease The left lower lobe collapse may not be visible on the chest radiograph but the presence of these densities should alert the observer to the more important associated abnormality
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Peribronchial cuffing results when fluid-thickened bronchial walls become visible producing rdquodoughnut-likerdquo densities in the lung parenchyma
Dr Ahmed Esawy
THICKENED BRONCHIAL WALLS
Parallel TRAMLINE shadows
Ring shadows on end-on view
They are common finding in
Bronchiectasis
Recurrent asthma
Bronchopulmonary aspergillosis
Pulmonary oedema
Lymphangitis carcinomatosis
Dr Ahmed Esawy
Peri-Bronchial Cuffing Peribronchial cuffing represents extravasated water surrounding the bronchus
Pre-diuresis note the cuffing (large arrow)
Post diuresis
Dr Ahmed Esawy
SENTINEL LINES
Dr Ahmed Esawy
Sentinel lines--an unusual sign of lower lobe contraction
Mucus-filled bronchi
Coarse lines lying peripherally in contact with the pleura and curving upwards
Often left-sided and associated with left lower lobe collapse
They may develop due to kinking of bronchi adjacent to the collapse
Dr Ahmed Esawy
the various densities occurring in the lower zones of the standard postero-anterior chest radiograph one sign has been ignored Coarse linear densities at the bases may be due to adjacent lower lobe contraction usually the superior and inferior branches of the lingular bronchi The densities are probably due to mucus-filled bronchi or alveolar atelectasis distal to the kink resulting from poor bronchial drainage and may indicate more extensive disease The left lower lobe collapse may not be visible on the chest radiograph but the presence of these densities should alert the observer to the more important associated abnormality
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
THICKENED BRONCHIAL WALLS
Parallel TRAMLINE shadows
Ring shadows on end-on view
They are common finding in
Bronchiectasis
Recurrent asthma
Bronchopulmonary aspergillosis
Pulmonary oedema
Lymphangitis carcinomatosis
Dr Ahmed Esawy
Peri-Bronchial Cuffing Peribronchial cuffing represents extravasated water surrounding the bronchus
Pre-diuresis note the cuffing (large arrow)
Post diuresis
Dr Ahmed Esawy
SENTINEL LINES
Dr Ahmed Esawy
Sentinel lines--an unusual sign of lower lobe contraction
Mucus-filled bronchi
Coarse lines lying peripherally in contact with the pleura and curving upwards
Often left-sided and associated with left lower lobe collapse
They may develop due to kinking of bronchi adjacent to the collapse
Dr Ahmed Esawy
the various densities occurring in the lower zones of the standard postero-anterior chest radiograph one sign has been ignored Coarse linear densities at the bases may be due to adjacent lower lobe contraction usually the superior and inferior branches of the lingular bronchi The densities are probably due to mucus-filled bronchi or alveolar atelectasis distal to the kink resulting from poor bronchial drainage and may indicate more extensive disease The left lower lobe collapse may not be visible on the chest radiograph but the presence of these densities should alert the observer to the more important associated abnormality
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Peri-Bronchial Cuffing Peribronchial cuffing represents extravasated water surrounding the bronchus
Pre-diuresis note the cuffing (large arrow)
Post diuresis
Dr Ahmed Esawy
SENTINEL LINES
Dr Ahmed Esawy
Sentinel lines--an unusual sign of lower lobe contraction
Mucus-filled bronchi
Coarse lines lying peripherally in contact with the pleura and curving upwards
Often left-sided and associated with left lower lobe collapse
They may develop due to kinking of bronchi adjacent to the collapse
Dr Ahmed Esawy
the various densities occurring in the lower zones of the standard postero-anterior chest radiograph one sign has been ignored Coarse linear densities at the bases may be due to adjacent lower lobe contraction usually the superior and inferior branches of the lingular bronchi The densities are probably due to mucus-filled bronchi or alveolar atelectasis distal to the kink resulting from poor bronchial drainage and may indicate more extensive disease The left lower lobe collapse may not be visible on the chest radiograph but the presence of these densities should alert the observer to the more important associated abnormality
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
SENTINEL LINES
Dr Ahmed Esawy
Sentinel lines--an unusual sign of lower lobe contraction
Mucus-filled bronchi
Coarse lines lying peripherally in contact with the pleura and curving upwards
Often left-sided and associated with left lower lobe collapse
They may develop due to kinking of bronchi adjacent to the collapse
Dr Ahmed Esawy
the various densities occurring in the lower zones of the standard postero-anterior chest radiograph one sign has been ignored Coarse linear densities at the bases may be due to adjacent lower lobe contraction usually the superior and inferior branches of the lingular bronchi The densities are probably due to mucus-filled bronchi or alveolar atelectasis distal to the kink resulting from poor bronchial drainage and may indicate more extensive disease The left lower lobe collapse may not be visible on the chest radiograph but the presence of these densities should alert the observer to the more important associated abnormality
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Sentinel lines--an unusual sign of lower lobe contraction
Mucus-filled bronchi
Coarse lines lying peripherally in contact with the pleura and curving upwards
Often left-sided and associated with left lower lobe collapse
They may develop due to kinking of bronchi adjacent to the collapse
Dr Ahmed Esawy
the various densities occurring in the lower zones of the standard postero-anterior chest radiograph one sign has been ignored Coarse linear densities at the bases may be due to adjacent lower lobe contraction usually the superior and inferior branches of the lingular bronchi The densities are probably due to mucus-filled bronchi or alveolar atelectasis distal to the kink resulting from poor bronchial drainage and may indicate more extensive disease The left lower lobe collapse may not be visible on the chest radiograph but the presence of these densities should alert the observer to the more important associated abnormality
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
the various densities occurring in the lower zones of the standard postero-anterior chest radiograph one sign has been ignored Coarse linear densities at the bases may be due to adjacent lower lobe contraction usually the superior and inferior branches of the lingular bronchi The densities are probably due to mucus-filled bronchi or alveolar atelectasis distal to the kink resulting from poor bronchial drainage and may indicate more extensive disease The left lower lobe collapse may not be visible on the chest radiograph but the presence of these densities should alert the observer to the more important associated abnormality
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
There is several horizontal line densities at left base the traingular shadowe of the contracted Lower lobe is just visible through heart shadowe
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
There is a group of horizontal curved lines at the left base concavity facing upwards
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
(a) There is a linear density at the left base The line is semihorizontal concave upwards The lower lobe is collapsed (b) The line is no longer present The lower lobe has re-aerated
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
(a) Several long horizontal densities are present at the left base 7he upper horizontal line is crossed by a curved oblique line concavity facing the mediastinum (b) The lower lobe is contracted and bronchiectatic The inferior division of the lingular bronchus is displaced inwards and kinked Its distal branches correspond to the horizontal and curved oblique lines of the plain film The lingula is well aerated
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
(a) There is a group of horizontal curved lines at the left base concavity facing upwards (b) The lower lobe is collapsed and fails to fill with contrast medium The lingular bronchi are bronchiectatic but the lobe is only partially contracted The curved lines are the unfilled subdivisions of the lingular bronchi
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Mucous filled bronchi bronchocele with typical gloved-finger branching
patteren
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
KERLEY LINES
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Kerley lines Septal lines in lung
Pulmonary lymphatics are usually not visible
Lymphatics drain the interstitial fluid and foreign particles
They run in the interlobular septa and drain to the hilum
Thickened lymphatics and surrounding connective tissue = Kerley lines
Divided into 3 types
Kerley A lines ndash thickened deep septa
Kerley B lines ndash thickened interlobular septa
Kerley C lines
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Acinus 5 - 6 mm in diameter alveoli alveolar duct resp bronchiole
3 - 5 acini = secondary pulmonary lobule
Each lobule is separated by septa (interlobular
septa)
Thickening of these septa = Kerley B lines
Formation of Kerley B lines
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Kerley B Lines
These are horizontal lines less than 2cm long commonly found in the lower zone periphery These lines are the thickened edematous interlobular septa Causes of Kerley B lines include pulmonary edema lymphangitis carcinomatosa and malignant lymphoma viral and mycoplasmal pneumonia interstital pulmonary fibrosis pneumoconiosis sarcoidosis They can be an evanescent sign on the CXR of a patient in and out of heart failure
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Types Kerley A line Kerley B line Kerley C line
Thin Thin transverse faint Fine
Non branching Non branching Interlacing lines
2 ndash 6 cm long 1 -3 cm long Seen throughout lung
1 ndash 2 mm thick 1- 2 mm thick ldquoSpider webrdquo like appearance
Radiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)
not following course of artery vein or bronchi
Frequently seen than A ampC lines
Lines arranged in step ladder like pattern (05 to 1 cm apart)
ALWAYS perpendicular to pleural surface Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
he patient above is suffering from congestive heart failure resulting in interstitial edema Notice the Kerleys B lines in right periphery (arrows)
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Kerley A lines are approximately cm in length and are most conspicuous in the upper and mid portions of the lung
They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura
Their presence normally indicates a more acute or severe degree of oedema
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Kerley A B and C lines (arrowed) Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
A chest radiograph showed an enlarged cardiac silhouette a dilated azygos vein and peribronchial cuffing in addition to Kerleys A B and C lines These radiologic signs and physical findings suggest cardiogenic pulmonary edema
Kerleys A lines (arrows) are linear opacities extending from the periphery to the hila they are caused by distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base they represent edema of the interlobular septa
Kerleys C lines (black arrowheads) are reticular opacities at the lung base representing Kerleys B lines en face
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Kerley B lines can be
They are present in the base of the lung due to hydrostatic pressure and gravity
Transient Persistent
Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Difference between Kerley B lines and blood vessels
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
KERLEY LINES
Kerleys A lines (arrows)
bull Linear opacities extending from the periphery to the hila
bull Due to distention of anastomotic channels between peripheral and central lymphatics
Kerleys B lines (white arrowheads)
bull Short horizontal lines situated perpendicularly to the pleural surface at the lung base
bull Due to edema of the interlobular septa
Kerleys C lines (black arrowheads) Reticular opacities at the lung base representing superimposed Kerleys B lines
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
KERLEY LINES
B
A
C
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Pulmonary oedema Pneumoconiosis Infections (viral mycoplasma) Lymphangiectasia Mitral valve disease Lymphangitis carcinomatosis Interstitial pulmonary fibrosis Lymphatic obstruction Congenital heart disease Sarcoidosis Alveolar cell carcinoma Lymphangiomyomatosis Pulmonary venous occlusive disease
CAUSES OF KERLY LINES
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Differentiation
Fleischnerrsquos lines Kerley B lines Linear scars
Fewer in number (1 -2) More in number May show fine strands emanating from borders
Irregularly placed Regularly placed (05 to 1 cm gaps)
Associated pleural effusion
Located deep in lung Superficial Permanent
Thicker Thin
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Vascular linear
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Vascular Indistinctness Water is the same density as vessels and so as it leaves vasculature for interstitium the margins become fuzzy
Edema Crisp vessel margins no edema Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Vascular Indistinctness
Crisp margins no edema Edema Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Cephalization The upper lobe vascular caliber is greater than lower vessels
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Cephalization means pulmonary venous hypertension so long as the person is erect when the chest x-ray is obtained
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end (the azygous vein) The azygous lobe is the commonest CXR normal variant seen in up to 04 of individuals This is an embryologic variation which results in an accessory lobe at the right upper lobe The fissure is due to the invagination of the azygous vein and the condition is of no clinical significance
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
CASE 18 HEREDITARY HEMORRHAGIC TELANGIECTASIA OR OSLER WEBER RENDU DISEASE The CXR shows a mass in the right lower zone The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass ) The CT shows marked enhancement of the ldquomassrdquo with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM) Of patients with pAVM 60 have Oslerrsquos disease and 10 of patients with Oslerrsquos disease have pAVM This condition is autosomal dominant Other sites of involvement include skin nose (epistaxis) gastrointestinal (GI) system (bleeding GI and anemia) Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
ANOMALOUS PULMONARY VENOUS DRAINAGE ndashSCIMITAR SIGN The curvilinear shadow in the right lower zone is called a Scimitar sign This is due to aberrant drainage of the right inferior pulmonary vein into the inferior vena cava This is a congenital anomaly and is usually associated with a small ipsilateral hemithorax and a small or hypoplastic pulmonary artery This condition is usually of no clinical significance The CT scan shows the enhancing vein Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patientrsquos right and the left subclavian artery on the left
If it is wide that indicates greater intravascular volume
Look at the example on the following slide
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Intravascular Volume Status
Pre-dialysis Post-dialysis Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
pulmonary infarction
Linear density
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Westermark sign ndash Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels often with a sharp cut off
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
ldquoMeltingrdquo sign of healing Heals with linear scar
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Pleural thickening scar
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
OLD PLEURAL AND PULMONARY SCARS
Scars are unchanged in appearance on serial film
Thin linear shadow often with associated pleural thickening and tenting of the diaphragm
Apical scarring is a common finding with healed tuberculosis sarcoidosis and fungal disease
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Diffuse extensive pleural calcification adjacent to mediastinum heart diaphragm As well as thoracic wall usually parietal
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Coarse parenchyma fibrosis with right interlobar visceral plaque
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Bilateral symmetrical basal and peripheral plaques
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
BL Calcified Pleural Plaques (Asbestosis)
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Lung Scars Scars in the lung like scars on the skin are permanent and usually cannot be removed However the lung is remarkably resilient and able to withstand small scars without any ill effects Granulomas are scars that are caused by previous infection and can develop into calcified scars Normally these lesions are not treated and there is neither treatment nor necessity for their removal Much like a scar on the skin stable scars on the lung are generally not treated Calcified scars are usually caused by previous lung infections such as pneumonia In the Ohio River Valley specifically there is a fungus in the soil known as histoplasmosis that sometimes causes infection but rarely causes any health problems Tuberculosis infections can also cause granulomas Other factors that can cause calcified scars over time include Silicosis (from inhalation of silica dust) Asbestosis (from inhalation of asbestos) Sarcoidosis Cystic fibrosis Prior infections (such as pneumonia tuberculosis infections or fungal infections) In some cases scar tissue can build up and escalate into issues such as interstitial lung disease and pulmonary fibrosis (where swelling and inflammation occur)
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Radiation fibrosis
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Pulmonary fibrosis
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Thickened fissure Linear density
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Normal major fissures Lateral chest radiograph demonstrates the two major fissures Note that both fissures are seen as double lines and that the left fissure (arrows) is behind the right fissure (arrowheads)
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Superolateral major fissures (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows) Note that the left fissure extends higher than the right one (b c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow)
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Vertical fissure line in a child with a ventricular septal defect Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows) (b) Vertical fissure line in a woman with abruptio placentae and transient heart failure Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows)
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Superomedial major fissure (a) Chest radiograph shows a superomedial right major fissure (arrows) The minor fissure is seen as double lines (b) High-resolution CT scan helps confirm the direction of the medial portion of the right major fissure as tangential to the x-ray beam (arrow)
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Intrafissural fat (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow)
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Minor fissure ldquocrossingrdquo a major fissure Lateral radiograph shows a minor fissure (arrowheads) that appears to cross a major fissure (arrows) and extends further posteriorly
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Right middle lobe collapse (middle lobe syndrome) On a lateral radiograph (b) as well as two CT scans (c d) the major fissure (arrows) is anterior to the minor fissure (arrowheads) Incorrect localization of a pulmonary nodule may result from the same mechanism Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Incomplete fissure sign (a) Posteroanterior radiograph shows a curving interface in the lateral part of the left lower lung field (arrows)with lateral opacity and medial lucency (b c) High-resolution CT scans (c obtained at a lower level than b) show bilateral pleural effusionThe left pleural effusion is bounded by the lateral border of the lower lobe (arrow) which may explain the appearance on the radiograph The major fissures are complete thus ldquoincomplete fissure signrdquo may also be seen in cases of complete major fissure Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Usually slightly higher than the right sided horizontal fissure Occcurs in about 4 of the population May incline superiorly laterally
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Azygous fissure is formed by the anomalous development of the azygous vein The vein migrates through the RUL dragging parietal and visceral pleura with it
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Azygous fissure (white arrow) and azygous vein (black arrow)
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
A peak-like shadow along the medial aspect of the right hemidiaphragm is evident in some cases and is referred to as a juxta-phrenic peak This finding is more common in left upper lobe collapse however The formation of the peak is thought to be related to traction on the basal pleura by the inferior pulmonary ligament It has also been ascribed to upward retraction of the inferior accessory fissure or an intrapulmonary septum associated with the pulmonary ligament [9] In severe cases the RUL becomes pancaked against the lung apex or upper mediastinum and can be mistaken for apical pleural thickening Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Right inferior accessory fissure in an 88 year old male who presented to the ED following fall onto his right shoulder Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencil point thickness it can normally attain
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Thickened right interlobar fissure partially calcified diaphragmatic
plaque
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Interlobular Fissure Thickening Edema in the lung along the fissure
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Thickening of fissures left side horizontal fissure
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Septal Lines Thickened interlobular septae
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Pulmonary tuberculosis sequela linear density
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Curvilinear shadows (BullaePneumatocoele
Bronchoceles)
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Bullous Disease of the Lungs
Definition o Thin-walledndashless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura septa or compressed lung tissue middot
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
DD o Pneumatocoele sect Thin-walled (lt 1mm) gas-filled space in the lung developing in association with acute pneumonia such as staph and frequently transient o Cavity sect Gas-containing space in the lung having a wall gt 1 mm thick o Cyst sect Thin-walled air- or fluid-filled with a wall that contains respiratory epithelium cartilage smooth muscle and glands o Bleb sect Intrapleural cystic space
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Type 1 sect Originate in a subpleural location usually in upper part of lung sect Narrow neck sect Produce passive atelectasis of adjacent lung tissue sect Paraseptal emphysema Type 2 sect Superficial in location sect Very broad neck sect Anterior edge of upper and middle lobes and along diaphragm sect Contain blood vessels and strands of partially destroyed lung sect Spontaneous pneumothorax Type 3 sect Lie deep within lung substance sect Like type 2 contain residual strands of lung tissue sect Affect upper and lower lobes with same frequency
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Bullous disease of the lungs-conventional radiograph and CT Frontal and lateral views of the chest demonstrate numerous thin-walledair-containing structures that represent the walls of numerous bullae These lineal densities are characteristic for bullae on conventional radiography The CT scan on the same patient (below) shows the same thin-walled bullae
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic They should not be mistaken for a cavitating lung mass
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Post pneumotic pneumatocoele
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
POST Staphylococcal pneumonia pneumatocele
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
traumatic pneumatoceles
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Bronchocoele also termed mucoid impaction refers to a mucous-filled dilated bronchi surrounded by aerated lung
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Bronchocoele
Allergic bronchopulmonary aspergillosis (ABPA)
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Bronchocele
Subtle increased opacification in the right mid-zone Branching pattern
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Chest radiograph (PA amp lateral view) showing tubular branching opacity in Rt lower lung field
Calcified Bronchocele
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Linear artifact
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
This radiograph demonstrates a curvilinear opacity in the right side with radiolucent lung lateral to that simulating a pneumothorax Ill defined opacification in the right mid and left lower zones can also be seen A repeat study performed few hours later did not show the previously seen curvilinear opacity confirming this to be a skin fold
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Another case of Artifact simulating pneumothorax in a patient following insertion of left internal jugular line One can see a lung margin on the left side suggestive of a pneumothorax
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Another case of axillary skin fold simulating loculated left pneumothorax in a female patient with a known breast carcinoma Extension of the presumed lung edge into the axialla is a clue to its artefactual nature
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
On closer inspection and windowing one can see lung markings in the lung lateral to the presumed lung edge (arrows) caused by oxygen reservoir bag
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
edge of the reservoir bag simulating pneumothorax in an 84 year old unwell patient Presence of gas in the soft tissues caused by necrotising fasciitis in this patient could cause diagnostic uncertainty
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
This chest radiograph demonstrates linear shadows in the upper lobe simulating upper lobe diversion fibrosis On closer inspection you can see linear band shadows bilaterally which extend outside of the chest and represent the patients long hair projected over the lungs Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
