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HRCT
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MEANING
The problem with the terminology o It is often used for anything and everything to do with high resolution. Actual meaning o A scan performed using high- spatial frequency algorithm to accentuate the contrast between tissue of widely differing densities, eg., - air & vessels (lung) - air & bone (temporal & paranasal sinus)
INTRODUCTION
HRCT is the use of thin section CT images (0.625 to 2 mm slice thickness) often with a high-spatial-frequency reconstruction algorithm to detect and characterize disease affecting the pulmonary parenchyma and airways. Superior to chest radiography in terms of improved detection of lung disease, provision for specific diagnosis and identification of reversible disease.
HISTORY
1982 The term HRCT was first used by TODO et. Al
1985 Nakata et.al and Naidich et.al published first report on HRCT Since then has been an important tool in pulmonary medicine
Recent development of MDCT scanner capable of volumetric high resolution scanning has improved the investigation
TECHNICAL ASPECT
Parameters o Slice thickness o Kvp o mAs o Scan time o FoV o Interslice gap (collimation) o Filming.
SLICE THICKNESS
Thin sections 0.5 1.5 mm is essential for optimal spatial resolution Thicker slices are prone for volume averaging and reduces ability to resolve smaller structure Better for delineation of bronchi, wall thickness and diameter
Reconstruction Algorithm
Using a high-resolution algorithm is critical element in performing HRCT. High spatial frequency or sharp algorithm -- bone algorithm is used which reduces image smoothing and increases spatial resolution, making structure appear sharper.
For routine technique Kvp -- 120-140 mAs -- 200- 340 Increased patient and chest wall thickness are associated with increase image noise, may be reduced by increasing mA and Kvp Scan Time : As low as possible (1-2 sec) to minimize motion artifact.
Interslice gap varies from examination to examination, but is usually 10- 20 mm INSPIRATORY LEVEL : Routine HRCT is obtained in suspended full inspiration, which optimizes contrast between normal structures, various abnormalities and normal aerated lung parenchyma; and reduces transient atelectasis, a finding that may mimic or obscure significant abnormalities.
Obtained at 1cm intervals from lung apices to bases. In this manner, HRCT is intended to sample lung anatomy It is assumed that the findings seen at the levels scanned will be representative of what is present throughout the lungs Results in low radiation dose as the individual scans are widely placed
2. Volumetric HRCT
MDCT scanner are capable of rapid scanning and thin slice acquisition. Advantages : 1. viewing of contagious slice for better delineation of lung abnormality
Acquisition time of HRCT with multidetector CT is so short that whole-lung HRCT can be performed in one breath-hold.
Radiation dose
HRCT performed with spaced axial images results in low radiation dose as compared with MD-HRCT.
PA CHEST Radiograph ----- ----- ----0.05 mSv
Combining HRCT scan at 20 mm interval with low mAs scan (40 mAs) would result in radiation comparable to conventional X ray.
HRCT ARTIFACT
Streak Artefacts :
Fine, linear, or netlike opacities
Motion-related artifacts
Pulsation / Star artifacts
Doubling artifacts.
Stair-step artifacts in sag/coro reconstruction. Scanners with rapid scan time (100ms), ECG gating or Spirometry controlled scanning.
PART 2
REVIEW OF ANATOMY
LUNG ANATOMY
Right lung is divided by major and minor fissure into 3 lobes and 10 bronchopulmonary segments
Left lung is divided by major fissure into 2 lobes with a lingular lobe and 8 bronchopulmonary segments
1.1 kg
TRACHEAL ANATOMY
10-12 cm in length, from C6 level to upper border of D5.
Extrathoracic (2-4cm) and Intrathoracic(6-9cm beyond manubrium) In men, tracheal diameter 25-27 mm women 21- 23 mm
The posterior portion of the tracheal wall is a thin fibromuscular membrane----- allows for oesophageal expansion.
BRONCHIAL ANATOMY
Approximately 23 generations of branches from the trachea to the alveoli. Bronchi with a wall thickness of less than 300 um is not visible on CT or HRCT. As a consequence, normal bronchi less than 2 mm in diameter or closer than 2 cm from pleural surfaces equivalent to seventh to ninth order airways are generally below the resolution even of high-resolution CT
BRONCHUS
BLOOD SUPPLY Bronchial Arteries 2 on left side i.e. superior and inferior 1 on right side) Left arises from thoracic aorta Right from either thoracic aorta, sup. lt. bronchial or right 3rd intercostal artery VENOUS DRAINAGE on right- azygous vein on left- left superior intercostal or accessory hemiazygous vein NERVE SUPPLY Pulmonary plexus at hilum (vagus and sympathetic)
PULMONARY ACINUS
It is smaller than secondary lobule
Defined as portion of lung distal a terminal bronchiole and supplied by respiratory bronchiole
It is the largest lung unit in which all airways participate in gas exchange Size is 7 to 8 mm in adults
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Pulmonary veins
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Pulmonary lymphatics
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LUNG INTERSTITUM
Lung interstitium
Peribronchovascular interstitium
Centrilobular interstitium
Subpleural interstitium
Interlobular septa
The peribronchovascular interstitum invests the bronchi and pulmonary artery in the perihilar region. The centrilobular interstitium are associated with small centrilobular bronchioles and arteries
The subpleural interstitium is located beneath the visceral pleura; envelops the lung into fibrous sac and sends connective tissue septa into lung parenchyma.
Interlobular septa constitute the septas arising from the subpleural interstitium.
The normal pulmonary vein branches are seen marginating pulmonary lobules. The centrilobular artery branches are visible as a rounded dot
NORMAL LUNG
ATTENUATION
PART 3
Q.2. Where is it located within the secondary lobule (centrilobular, perilymphatic or random) ? Q.3. Is there an upper versus lower zone or a central versus peripheral predominance ? Q.4. Are there additional findings (pleural fluid, lymphadenopathy, traction bronchiectasis) ?
PARENCHYMAL OPACIFICATION
consolidation
HRCT PATTERN
Ground glass
CYSTIC LESIONS, EMPHYSEMA, AND BRONCHIEACTASIS
Interface sign
Irregular interfaces between the aerated lung parenchyma and bronchi, vessels, or visceral pleural surfaces. Represent thickened interlobular septa, intralobular lines, or irregular scars. Nonspecific. Common in patients with an interstitial abnormality, fibrotic lung disease.
Smooth
Irregular
Nodular
sarcoidosis
PARENCHYMAL BANDS
Non tapering , reticular opacity usually 1 to 3 mm in thickness and from 2 to 5 cm in length. Is often peripheral and generally contracts the pleural surface D/D : 1. Asbestosis 2. Sarcoidosis 3. Silicosis/ coal worker pneumoconiosis 4. Tuberculosis with associated scarring.
HONEYCOMBING
Defined as - small cystic spaces with irregularly thickened walls composed of fibrous tissue. They share wall. Predominate in the peripheral and subpleural lung regions Subpleural honeycomb cysts typically occur in several contiguous layers. D/D- paraseptal emphysema in which subpleural cysts usually occur in a single layer.
Causes
Lower lobe predominance : 1. UIP or interstitial fibrosis 2. collagen disease 3. hypersensitivity pneumonitis 4. Asbestosis 5. NSIP (rare)
Upper lobe predominance : 1. End stage sarcodosis 2. Hypersensitivity Pneumonitis 3. Radiation 4. end stage ARDS
Miliary - <3 mm
Interstitial opacity: Well-defined, homogenous, Soft-tissue density Obscures the edges of vessels or adjacent structure
Appearance
Air space: Ill-defined, inhomogeneous. Less dense than adjacent vessel GGO small nodule is difficult to identify
Interstial nodules
Distribution
Perilymphatic distribution
Nodules in relation to pulmonary lymphatics at # perihilar peribronchovascular interstitium, # interlobular septa, # subpleural regions, and # centrilobular interstitium.
Lymphangitic carcinomatosis
Lymphocytic interstitial pneumonia (LIP) Lymphoproliferative disorders Amyloidosis
Centrilobular nodules
Distributed primarily within the centre of the secondary pulmonary lobule Reflect the presence of either interstitial or airspace abnormalities Dense or ground-glass opacity
Tree-in-bud
Centrilobular nodules m/b further characterized by presence or absence of tree-in-bud. Tree-in-bud -- Impaction of centrilobular bronchus with mucous, pus, or fluid, resulting in dilation of the bronchus, associated with peribronchiolar inflammation . Dilated, impacted bronchi produce Y- or V-shaped structures This finding is almost always seen with pulmonary infections.
Box 1. Centrilobular nodules with or without tree-in-bud opacity: diagnostic considerations With tree-in-bud opacity Without tree-in-bud opacity
Bacterial pneumonia Typical and atypical mycobacteria infections Bronchiolitis Diffuse panbronchiolitis Aspiration Allergic bronchopulmonary aspergillosis Cystic fibrosis Endobronchial-neoplasms (particularly Bronchioloalveolar carcinoma)
All causes of centrilobular nodules with tree-in-bud opacity Hypersensitivity pneumonitis Respiratory bronchiolitis Cryptogenic organizing pneumonia Pneumoconioses Langerhans cell histiocytosis Pulmonary edema Vasculitis Pulmonary hypertension
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Random nodules
Random nodules No definable distribution Random nodules, in contrast to perilymphatic nodules, usually do not show a patchy distribution in the lung parenchyma; rather, random nodules are usually distributed uniformly throughout the lung parenchyma in a bilaterally symmetric distribution.
Random nodules: Miliary tuberculosis. Axial HRCT image shows multiple nodules scattered uniformly throughout the lung parenchyma.
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Random nodules: diagnostic considerations 1. 2. 3. 4. 5. 6. Haematogenous metastases Miliary tuberculosis Miliary fungal infection Disseminated viral infection Silicosis or coal-workers pneumoconiosis Langerhans cell histiocytosis
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Parenchymal Opacification
Ground-glass opacity
Consolidation Lung calcification & high attenuation opacities.
IMPORTANCE OF GGO
Can represent - microscopic interstitial disease (alveolar interstitium) - microscopic alveolar space disease - combination of both Mostly indicates the presence of an ongoing, active, potentially treatable process (in the absence of fibrosis) NB :: Ground Glass opacity should be diagnosed only on scans obtained with thin sections : with thicker sections volume averaging is more - leading to spurious GGO, regardless of the nature of abnormality
GGO with few cystic lesion and reticular in HIV + ve patient -- PCP
CONSOLIDATION
Consolidation is defined as increased attenuation, which results in obscuration of the underlying vasculature, usually producing air bronchograms. The presence of consolidation implies that the air within affected alveoli has been replaced by another substance, such as blood, pus, edema, or cells.
When consolidation is evident on a chest radiograph, HRCT does not usually provide additional diagnostically useful information.
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CONSOLIDATION
Organizing pneumonia
Diffuse & dense lung calcification Metastatic calcification, Disseminated pulmonary ossification, or Alveolar microlithiasis
High attenuation opacity Talcosis asso with fibrotic mass, inhalation of metals (tin/barium) Small focal areas of increased attenuation injection and embolized radiodense materials such as mercury or acrylic cement Diffuse, increased lung attn in absence of calcification amiodarone lung toxicity or embolization of iodinated oil after chemoembolization
Lung Cysts,
Emphysema, and Bronchiectasis
Lung cysts
Thin walled (less than 3mm) , well defined and circumscribed air containing lesions They are lined by cellular epithelium, usually fibrous or epithelial in nature. Common cause are : 1. Lymphangiomyomatosis 2. Langerhans Histiocytosis 3. Lymphoid interstial pneumonia They need to be differentiated from emphysematous bullae, blebs and pneumatocele.
) Axial HRCT image through the upper lobes shows multiple bilateral uniform, thin-walled cysts.
Axial HRCT image through the upper lobes shows multiple bilateral bizarreshaped cysts (arrows) and small centrilobular nodules (arrowheads) in a smoker with Langerhans cell histiocytosis.
BRONCHIEACTASIS
Bronchiectasis is defined as localized, irreversible dilation of the bronchial tree.
HRCT findings of the bronchiectasis include # Bronchial dilatation # Lack of bronchial tapering # Visualization of peripheral airways.
BRONCHIAL DILATATION # The broncho-arterial ratio (internal diameter of the bronchus /pulmonary artery) exceeds 1. # In cross section it appears as Signet Ring appearance LACK OF BRONCHIAL TAPERING # The earliest sign of cylindrical bronchiectasis # One indication is lack of change in the size of an airway over 2 cm after branching.
VISUALIZATION OF PERIPHERAL AIRWAYS # Visualization of an airway within 1 cm of the costal pleura is abnormal and indicates potential bronchiectasis
Coned axial HRCT image shows bronchial dilation with lack of tapering (arrows). Bronchial morphology is consistent with varicose bronchiectasis.
Extensive, bilateral mucoid impaction Mosaic perfusion caused by large and small airway obstruction. Small centrilobular nodules are visible in the right lower lobe
Types 1. CYLINDRICAL BRONCHIECTASIS # mildest form of this disease, # thick-walled bronchi that extend into the lung periphery and fail to show normal tapering
2. VARICOSE BRONCHIECTASIS # beaded appearance of bronchial walls - dilated bronchi with areas of relative narrowing # string of pearls. # Traction bronchiectasis often appears varicose.
3. CYSTIC BRONCHIECTASIS : # Group or cluster of air-filled cysts, # cysts can also be fluid filled, giving the appearance of a cluster of grapes.
4.TRACTION BRONCHIECTASIS : # Defined as dilatation of intralobular bronchioles because of surrounding fibrosis # due to fibrotic lung diseases
Differential diagnosis
1. Infective causes : specially childhood pneumonia, pertusis, measles, tuberculosis
EMPHYSEMA
Permanent, abnormal enlargement of air spaces distal to the terminal bronchiole and accompanied by the destruction of the walls of the involved air spaces.
PANLOBULAR EMPHYSEMA
Affects the entire secondary pulmonary lobule and is more pronounced in the lower zones Characterized by complete destruction of the entire pulmonary lobule. Results in an overall decrease in lung attenuation and a reduction in size of pulmonary vessels
does not represent a specific histological abnormality Emphysema characterized by large bullae Often associated with centrilobular and paraseptal emphysema
Bullae
A sharply demarcated area of emphysema 1 cm in diameter
Pneumatocele
defined as a thin-walled, gas-filled space within the lung, usually occurring in asso. with acute pneumonia or hydrocarbon aspiration, is often transient. believed to arise from lung necrosis and bronchiolar obstruction.
Mimics a lung cyst or bulla on HRCT and cannot be distinguished on the basis of HRCT findings.
Clinical & microbiological correlation.
CAVITARY NODULE
thicker and more irregular walls than lung cysts
In diffuse lung diseases - LCH, TB, fungal infections, and sarcoidosis. Also seen in rheumatoid lung disease, septic embolism, pneumonia, metastatic tumor, tracheobronchial papillomatosis, and Wegener granulomatosis
fungal pneumonia
It is seen as inhomogeneous attenuation of lung parenchyma with focal region of lucency which show smaller size of vessles
May be due to vascular obstruction, abnormal ventilation or airway disease/
Mosaic attenuation due to small airway disease # Air trapping and bronchial dilatation commonly seen. # Areas of increased attenuation have relatively large vessels, while areas of decreased attenuation have small vessels. # Causes include: Bronchiectasis, cystic fibrosis and bronchiolitis obliterans.
Mosaic attenuation due to vascular disease # common in patients with acute or chronic pulmonary embolism (CPE), and # decreased vessel size in less opaque regions is often visible
MOSIAC PATTERN
NONDEPENDENT LUNG
EXPIRATION
AIR TRAPPING
AIRWAYS DISEASE
VASCULAR
GROUND GLASS
Air trapping on expiratory imaging in the absence of inspiratory scan findings in a patient with bronchiolitis obliterans.
(A) Axial inspiratory image through the lower lobes shows no clear evidence of inhomogeneous lung opacity. (B) Axial expiratory image shows abnormal low attenuation (arrows) caused by air trapping, representing failure of the expected increase in lung attenuation that should normally occur with expiratory imaging.
Axial HRCT image in a patient with hypersensitivity pneumonitis shows a combination of ground-glass opacity, normal lung, and mosaic perfusion (arrow) on the same inspiratory image.
Additional findings
Pleural effusion is seen in: Pulmonary edema Lymphangitic spread of carcinoma - often unilateral Tuberculosis Lymphangiomyomatosis (LAM) Asbestosis
#'Eggshell calcification' in lymph nodes occurs in ---Silicosis and coal-worker's pneumoconiosis and is sometimes seen in sarcoidosis, post irradiation Hodgkin disease, blastomycosis and scleroderma .
Conclusion
With the advent & availability of better techniques & more efficient CT machines, it has become more convenient for a Radiologist to give a proper diagnosis When attempting to reach a diagnosis or differential diagnosis of lung disease using HRCT, the overall distribution of pulmonary abnormalities should be considered along with their morphology, HRCT appearance, and distribution relative to lobular structures. A thorough knowledge of the basic anatomy is of utmost importance.