RADIOLOGY - IMAGING OF

THE THORAX
 THE CHEST
METHODS OF EXAMINATION

Radiography
Standard examination :

- PA + lateral projection;

- tube-film distance 1,5 m to minimize divergent distorsion

and magnification;

- full inspiration.

Supine radiographs intensive care units.

DIGITAL RADIOGRAPHY
 THE CHEST
METHODS OF EXAMINATION

Fluoroscopy
dynamic study of the cardiovascular system,
diafragmatic motion.
Disadvantage: high radiation dose.
Bronchography
the study of the bronchial tree by means of the
introduction of opaque material into the bronchi.
Replaced by CT, fiberoptic bronchoscopy, brush biopsy
 THE CHEST
METHODS OF EXAMINATION
Fluoroscopy

1933 2000
 THE CHEST
METHODS OF EXAMINATION
Computed tomography indications for the lung:
- Evaluation and staging of primary pulmonary neoplasms
- Detection of metastasis from non-pulmonary primary
tumors.
- Characterization of solitary pulmonary nodules as benign or
malignant
- High-resolution CT evaluation of interstitial lung
disease, bronchiectasis, emphysema, cystic lung disease.
 THE CHEST
METHODS OF EXAMINATION
Computed tomography
Indications for the mediastinum:
- Causes of mediastinal widening
- Characterization of mediastinal masses cysts, solid,
vascular, fat.
- Staging of tumors that spread to the mediastinum

Other indications:
Pleura plaques, masses, loculated fluid, calcification, chest
wall masses.
 THE CHEST
METHODS OF EXAMINATION-
Computed tomography

1975 1995
 THE CHEST
METHODS OF EXAMINATION
Ultrasonography
fluid can be localized and differentiated
from solid pleural masses;
- lesions in contact with the chest wall
- lesions near the diafragm.
 THE CHEST
METHODS OF EXAMINATION
Magnetic resonance imaging indications:
- congenital and acquired heart conditions
- intracardiac and paracardiac masses.
- pericardial diseases.
- extention of the posterior mediastinal masses, especially
those with intraspinal extension
- brachial plexopathy.
- dissection of the aorta, aneurysm
- diafragm and peridiafragmatic processes.
- chest-wall lesions.
- breast implants and breast masses.
MRI

MAGNET

Coils
 THE CHEST
METHODS OF EXAMINATION
Pulmonary and bronchial angiography:
- thromboembolic disease,
- arterial or venous anomalies.

Scintigraphy

Single Photon Emission Computed Tomography (SPECT )

- Tc 99m iv injection - pulmonary perfusion

- Xe gas is inhaled pulmonary ventilation
 How to analyze the chest X-ray
- Soft tissues
- Bony thorax ribs, clavicles, scapulae, thoracic vertebrae
- Lungs hilum, vessels, apices
- Mediastinum
- Pleura
- Diafragm

Roentgen observations must be correlated with all the

available clinical information
DIGITAL RADIOGRAPHY
 Nodular opacities

Gr.I

MILIARY tuberculosis
Nodular opacities
Nodular opacities
 FELSON sign

Lesion in the mediastinum Lesion in the lung

 Diffuse opacities

ATELECTASIS PNEUMONIA PLEURAL FLUID

PLEURAL FLUID ATELECTASIS
LINEAR OPACITIES
 DIFFUSE LUCENCIES

EMPHYSEMA PNEUMOTHORAX
 CIRCUMSCRIBED LUCENCIES
1
3
1

Chist hidatic
2
3

2 3 4

1.Emphysema - bulla
2. Aeric cyst
3. Cavity- TB
4. Cavity - cancer
 HYDRO - AERIC IMAGE

RUPTURED
ABSCESS HYDATID CYST
 CHEST INFECTIONS
Acute pulmonary infections

1. Lobar pneumonia the bacteria reaches the periphery of

the lung via the airways.Alveolar transudation is followed
by migration of leucocytes into the alveolar fluid.
2. Bronchopneumonia (lobular pneumonia) often observed
in staphyloccocal infection of the lung. The disease
originates in the airways and spreads to peribronchial
alveoli.
3. Interstitial pneumonia usually caused by a virus or a
mycoplasma.
4. Mixed pneumonia is a combination of lobar,
bronchopneumonia and interstitial pneumonia.
 Lobar pneumonia (pneumococcal pneumonia)

- Caused by S.pneumoniae.
- roentgen findings can be observed within 6 to 12 hours after
onset of symptoms.
Chest x-ray:
- triangular opacity, the tip towards the hilum, the base
towards the periphery of the lung.
- all the elements in the diseased lobe may be affected
except the large bronchi air bronchogram.
- Resolution is rapid if there are no complications the
opacity becomes more irregular and patchy, the intensity
decreases.

- Complications delayed resolution, lung abscess, pleural

effusion.
Right upper lobe
1 apical segment
2 posterior segment
3 anterior segment
3x axilar segment
Middle lobe
4 lateral + 5 medial segment
Right lower lobe
6 FOWLER segment
7 medial bazal segment
8 antero- bazal segment
9 lateral bazal segment

10 postero- bazal segment

Left lung: 2b apico-posterior segment

Lingula: - 4b superior segment
- 5b inferior segment
 Bronchopneumonia
Staphyloccocal infection of the lung

- It is the most commonly found in very young or very old

patrients

- the pattern of disease is discontinous or patchy.

Chest x-ray:
-nodular opacities, 1-10mm
-poorly defined
-with the center more opaque compared to the periphery.

- It is particularly difficult to define and diagnose when it

occurs as a complication in case of cardiac failure.
 Staphylococcal pneumonia

Caused by Staphylococcus aureus

- the infection may be primary in the lungs or secondary to a
staphylococcal infection elsewhere in the body.

- Usually occurs in debilitated adults or in the first year of life.

Chest x-ray:
- Consolidation rapidly spreads to involve a whole lobe
bronchi are obscured by exudatethe air brohogram is rarely
seen.
- Abscess formation; coalescense of small abscesses.
- Pleural effusion, empyema, pneumothorax.
- The disease is usually bilateral
 Interstitial pneumonia

- virus or Mycoplasma pneumoniae

Chest x-ray:

- Peribronchial or interstitial type streaky densities

extending from the hilum following the vascular markings.

- Bronchopneumonic type.

- Segmental or lobar types.

- Diffuse type bilateral reticulo-nodular pattern.

Interstitial pneumonia : influenza
Interstitial pneumonia
Interstitial pneumonia
COMPLICATIONS

BRONHOPNEUMONIA

SEGMENTAL PNEUMONIA
 Lung abscess
- lung abscess = an acute pulmonary infectious process breaks
down to form a cavity.
- Primary / secondary.
Chest x-ray
- round opacity, irregular, poorly defined borders.
- when bronchial communication is established the fluid
content of the cavity is replaced by air hydro-aeric
image with orizontal fluid level.
CT useful to define the inner and outer walls, for
complications (rupture into the pleural space).
Differential diagnosis:
- early stage pneumonia;
- cavity tbc, cancer, hydatid cyst, fungal infection.
Oval hydroaeric image
horizontal air fluid level
Thick, well defined wall = old
abscess = fibrosis
pleural effusion

Lung abscess + pleural efusion

 Tuberculosis

- Mycobacterium tuberculosis

- Target population: patients of low economic scale,

alcoholics, elderly, AIDS
Primary TB
Rancke (primary) complex :

1. Ghon focus nodular opacity (1-7cm), irregular

borders, non-homogeneous, low intensity, lower lobe

2. Lymphadenopathy hilar and paratracheal, 95%

3. Lymphangitis linear opacities

 Primary TB

Evolution:

- Healing
- Fibrosis
- Calcification

Complications:

- Cavitation
- Miliary TB
- TB pneumonia
- TB bronchopneumonia
- Pleural effusion
 Secondary TB

- Active disease in adults is reactivation of a primary TB; the

disease tends to be progressive
- Limited to the upper lobes
- No adenopathy
Radiographic features
Early infiltrate low intensity, poorly defined opacities

Cavitation 40%

Fibro-caseous TB

Fibrotic TB linear opacities from the apex to hilum

Fibrothorax, tuberculoma
 Secondary TB
Complications:

1. Miliary TB

2. Bronchogenic spread

3. Pneumonia

4. Bronchial stenosis

5. Bronchiectasis

6. Pneumothorax

7. Pleural effusion often loculated

ASPERGILOMA
 AIDS
Known routes of HIV transmission:
- Blood and blood products
- Sexual activity
- In utero transmission
- During delivery

Clinical:
- Lymphadenopathy
- Incidental infections
- Tumors: lymphoma, Kaposi sarcoma
- Other manifestations: interstitial pneumonia,
spontaneous pneumothorax, septic emboli
 AIDS
Spectrum of chest manifestations:

Nodules Kaposi sarcoma (usually associated with skin

lesions), septic infarcts, fungal infections (Cryptoccocus,
Aspergillus)
Large opacity: consolidation, mass hemorrhage,
pneumonia
Linear or interstitial opacities atypical pneumonia,
Kaposi sarcoma
Lymphadenopathy Mycobacterial infections, Kaposi
sarcoma, lymphoma
Pleural effusion Kaposi sarcoma, fungal infection,
pyogenic empyema