CHEST IMAGING deataied lecture on Radiological investigations of the chest

Detailed imaging of chest

1. CHEST IMAGING – PART 3 DR. KIKOMEKO SHARIF DEPARTMENT OF RADIOLOGY HABIB MEDICAL SCHOOL, IUIU.

2. CHEST TRAUMA Direct trauma to the chest Penetrating or Non penetrating Effects of trauma elsewhere in the body Fat embolism following limb # Pulmonary complications following abdominal surgery Open or closed

3. Penetrating injuries Shooting, stabbing, shapnels and surgery Non penetrating Falls, blows, blasts and automobile accidents.

4. IMAGING MODALITIES Plain radiography Ultrasound scan Pleura, diaphragam and subphrenic areas Computed tomography

5. Chest injuries: Open injuries Examples are stab wounds Important complications tension pneumothorax , rupture of vital viscera, haemorrhage This diagnosis can usually be made clinically although a chest X-ray is important to exclude smaller pneumothorax and other complications. Surgical emphysema is common .

6. Chest injuries: Open injuries Internal bleeding may occur into the pleura, the pericardial sac or mediastinum . Blood in the pleural cavity looks like an effusion, bleeding into the pericardium will show by increasing size of the heart which may become globular in shape although these are late signs. Bleeding into the mediastinum will cause widening of the mediastinum . A normal mediastinum will appear wider if the film is taken supine: If a film cannot be taken erect or semi-erect look for progressive increase in width on repeat films.

7. Closed chest injuries The commonest abnormality seen are rib fractures and their complications More severe injuries lead to damage to major structures such as trachea, aorta, vena cava. Spinal fractures may be associated with severe chest trauma.

8. Chest trauma: rib fractures: R ib fractures – these are not significant in themselves but associated injuries are more important. They are often seen on the PA view but may do oblique films with important fractures. Fractures difficult to see if not displaced: examine whole length of each rib: posterior, lateral or anterior. A clue is often an associated small pleural reaction. Fractures of the upper 3 ribs are often associated with major intrathoracic injuries Fractures of the lower 3 ribs may be associated with upper abdominal injury, e.g. ruptured spleen

9. Chest trauma:Complication of rib fracture Include: flail chest; pneumothorax ; haemothorax ; surgical emphysema; pulmonary contusion. Air in the soft tissues (surgical emphysema) may spread widely along the chest wall into the neck. If surgical emphysema is very marked, it may obscure a pneumothorax , especially if small. Haemothorax may be small or moderate in size. The appearances are identical to a pleural effusion. Pulmonary contusion looks like consolidation. It may also occur without obvious rib fracture.

10. Chest trauma: other chest fractures Fracture sternum. Hidden by the spine on a PA view and will be visible only on lateral view. Usually there is associated soft tissue swelling. Dorsal spine – look for a paraspinal mass due to haematoma. Clavicle, scapula. Posterior dislocation of the sterno-clavicular joint is associated with injury to the trachea, oesophagus, or great vessels.

11. Chest trauma figure 1 Describe this CX R. what views are done to show fractures of various bony structure of the thorax? What is a closed and open chest injury? What are the CXR findings in closed and open head injuries? Are all rib fractures a risk to the pt? which type pose a risk? What do we mean by is a stove in chest, flail chest? What other chest Viscera may be damaged in trauma and how does this appear on a CXR? what dangers are associate with posterior dislocation of the sternal clavicular joint?

12. Chest trauma: figure 2 Describe the CXR. What is lung contusion and its CXR appearances? How do fractures of the thoracic spine present at radiography?What is cardiac tamponade, what causes it and how does the pt. present? Why is tamponade risky? How can one diagnose a ruptured aorta? What is aortic dissection and how does it present clinically? What is a ruptured diaphragm? How does it present on a CXR?What are other imaging modalities in chest trauma and their indications?

13. Chest trauma: rupture hemidiaphragm Inability to trace the normal hemidiaphragm contour Intrathoracic herniation of hollow viscus with or without focal constriction at the site of tear If large, mass effect may cause contralateral mediastinal shift Visualisation of NGT above the hemidiaphragm on the left side

14. Chest trauma: figure 3 Describe the CXR. How does diaphragmatic rupture appear on CXR? What are the other pitfalls in detection of diaphragmatic rupture by CXR? What may be other findings on CXR for a pt. with diaphragmatic hernia?What imaging studies help to confirm diaphragmatic rupture? What is the differential diagnosis of unilateral diaphragmatic elevation? What are the other types of diaphragmatic hernia and how do they occur?

15. Chest trauma: other chest injuires Pneumothorax – occurs following rib fracture and following stab wounds. If there is surgical emphysema suspect also a pneumothorax.  Haemopneumothorax – blood + air in the pleural cavity. Looks like a hydropneumothorax. Usually due to open trauma.   Pulmonary contusion – localised areas of alveolar shadowing which clear in a few days. Lung haematoma – usually appears following resolution of contusion. Rounder and better -defined areas of shadowing than contusion. Clears after a few weeks.

16. Chest trauma: pneumomediastinum Air in the momediastinum secondary to rupture of the oesophagus, trachea or bronchus. This is seen as vertical lucencies in the mediastinum , air may outline the mediastinal pleura, especially on the left side It is often associated with subcutaneous air in the neck and there may be an associated pneumothorax . It may be seen following rupture of the oesophagus due to other causes, for example oesophagoscopy or prolonged vomiting.

17. pneumomedistinum Describe the CXR. Under which conditions may one get Pneumomediastinum? What are other associated findings in pneumomediastinum? What risk does this condition pose to the pt? What is Mallory-Weis syndrome?

18. Chest trauma: rupture of major airway and aortic rupture Ruptured major airway – severe pneumomediastinum; pneumothorax   Aortic rupture - The majority of patients die before chest X-ray can be taken. Plain film signs are due to mediastinal and pleural bleeding. These are: - Widened mediastinum - Abnormal or obscured aortic contour - Tracheal displacement to the R - Depression of the left main bronchus - There may be an associated left haemothorax

19. Non- traumatic causes of surgical and mediastinal emphysema There may be a lung tear due to a sudden rise in intra-alveolar pressure, often with airway narrowing. This causes air to dissect through the interstitium to the hilum and then to the mediastinum. Causes may be: - Spontaneous – following coughing/strenuous exercise - Asthma - Childbirth - Artificial ventilation - Foreign body aspiration in a child.

20. Spontaneous surgical emphysema in a child Describe the changes in this pt with chronic cough. What would be the findings on physical examination of this patient? What are other causes of surgical emphysema apart from trauma?

21. Radiology of Cardiovascular System Imaging methods normal appearances abnormities diseases

22. Methods X-ray Plain radiography Fluoroscopy - Angiocardiography & DSA CT & CTA MRI & MRA Echocardiography (US) Nuclear medicine

23. X-ray---- PA view ----high KV, 2M

24. X-ray---- Lat view left lateral

25. Echocardiography It is the ultrasound of the heart Major imaging examination Heart and great vessels are imaged Modality of choice in evaluation of valvular heart disease Assess left ventricle - size, wall thickness and function Useful in cardiomyopathy , pericardial effusion and cardiac masses/tumors

26. Technique The patient lies on a bed or examination table, and the echo technician places a transducer over the chest wall The transducer is moved back and forth across the chest wall, collecting several “ views ” of the heart A gel is applied to the chest wall to aid in sliding the transducer back and forth The test takes 30 – 60 minutes to complete

27. Echocardiography Echocardiograms are sometimes used in conjunction with stress test An echo test is made at rest Patient is asked to exercise Then echo is done again to look for changes in the function of the heart muscle when exercise is performed Deterioration in muscle function during exercise can indicate coronary artery disease

28. Echocardiography A Doppler microphone can be used during echocardiography to measure the velocity of blood flow in the heart This information can be useful in assessing heart valve function Transesophageal echocardiogram is done to see areas which are difficult to see and also for guidance during surgery

29. Echocardiography

30. Echocardiography

31. Computed Tomography and Coronary Angiogram

32. Computed Tomography Can complete data acquisition in 1/10 or 1/20 of a second Uses : Detection of blockage of coronary arteries Assessment of morphological and functional wall abnormalities associated with myocardial infarction Presence of ventricular aneurysm Patency of bypass grafts Pericarditis , pericardial effusion

33. The two MDCT views above show that the left coronary artery (red arrows) and its side branches are normal This 3D MDCT view is looking down on top of the left ventricle It shows a normal coronary artery (black arrow

34. CT ANGIOGRAM Patient with equivocal stress test results and atypical chest pain Curved reconstructions of the left anterior descending coronary artery and a dynamic 3D surface reconstruction demonstrate a long, densely calcified atherosclerotic plaque [arrows] resulting in significant narrowing of the artery

35. The CT Scan also reveal any filling defect in the chambers Weakness of the cardiac wall Abnormality of the valves

36. Magnetic Resonance Imaging

37. Magnetic Resonance Imaging Used to identify abnormalities in the Heart muscles- weakness , aneurysm, thickening Valves Coronary arteries Great vessels for any abnormality Presence of tumors, thrombus

38. Magnetic Resonance Imaging Due to the development of new imaging techniques, MRI has the capability to identify areas of the heart muscle that are not receiving adequate blood supply from the coronary arteries Aided by use of non-iodine-based enhancing agent (Gadolinium-DTPA), it can also clearly identify areas of the muscle that have become damaged as a result of infarction (heart attack)

39. RIGHT CORONARY ARTERY LEFT CORONARY ARTERY

40. MRI-based coronary angiography (3-dimensional balanced turbo field echo) in the left anterior oblique view, demonstrating significant stenosis (arrow) of the right coronary artery confirmed by conventional coronary angiogram

41. Magnetic Resonance Imaging

42. Nuclear Cardiography

43. Nuclear Cardiography

44. Technique A nuclear exercise stress test is a diagnostic test used to evaluate blood flow to the heart During the test, a small amount of radioactive tracer is injected into a vein A special camera, called a gamma camera, detects the radiation released by the tracer to produce computer images of the heart Combined with exercise, the test can help determine if there is adequate blood flow to the heart during activity versus at rest

45. Technique Then, a second dose of radioactive tracer is injected into the IV Heart rate, EKG and blood pressure are monitored throughout the test If the patient is unable to achieve target heart rate, a medication may be given to simulate exercise About 30 minutes after exercising, the patient is asked to again lie very still under the camera with both arms over the head for about 15-20 minutes The camera records images that show blood flow through the heart during exercise These images are compared to the first set

46. Technique For patients unable to exercise on a treadmill a medication called adenosine ( Adenoscan ) is given Adenosine does not increase the heart rate Adenosine dilates blood vessels leading into the heart, increasing blood flow, therefore simulating exercise

47. Nuclear Cardiography

48. Conventional Angiography

49. Technique Direct catheterization of the coronary arteries is done and contrast injected It is imaged by fluoroscopy Any occlusion of the arteries will be revealed Any flow abnormality will be revealed Diagnostic as well as therapeutic angiograms are done in which the blockage is relieved as soon as it is discovered

50. Technique Patient is made to lie under the fluoroscopy machine Catheter is pushed through the femoral artery to reach the ascending aorta just above the aortic sinus Contrast is injected into the coronary arteries and cine images are taken in arterial and venous phase

51. Angiography Most Frequently Performed To Assess Coronary Artery Disease

52. Conventional Angiography

53. Conventional Angiography

54. Conventional Angiography

55. Choosing the Most Appropriate Modality Based on Suspected Cause Congenital Anomalies First modality is Chest Radiograph Most appropriate is echocardiography Angiogram may show the level of defect Valvular Heart Disease – Most appropriate is echocardiography MRA may be done to evaluate the blood flow Angiogram also shows the valvular abnormality

56. Choosing the Most Appropriate Modality Based on Suspected Cause Hypertension and Coronary Artery Disease Echocardiography MRI CT Angiogram Nuclear Medicine Tests Conventional Angiogram Cardiomyopathies – Echocardiography MRI and CT Scan

57. Choosing the Most Appropriate Modality Based on Suspected Cause Tumors Echocardiography MRI CT Scan Angiogram Aneurysms CT Angiograms MRA Echocardiography Conventional Angiograms

58. Observing the chest plain film The size, shape, and position of the heart The state of the lungs and pulmonary vessels Aorta and cardiac calcifications

59. Normal appearance right ventricle, atrium : front left ventricle, atrium : behind Location of the heart ： 2 / 3 on the left side of midline ， 1/ 3 on the right side apex of heart point to left bottom ， oblique axis

60. Normal appearance ---- PA View Composition ： Right border of heart ： aorta （ old ）、 superior vena cava （ youth ） right atrium Left border of heart ： aortic bulb ： aortic arch pulmonary artery segment （ cardiac waist ）： main pulmonary artery left ventricle ： Upper 1/2 Lower 1/2 midline 70 20

61. Aorta arch below the clavicle, 2.0±1.0cm aorta arch wider and higher –eldly, high BP no aorta knob -- right aorta arch – variation aorticopulmonary window – small indentation of the lung into the mediastinum, between the arch and left PA

62. PA view Left atrium PV RPA

63. 66 /231 Normal appearance ---- Lat. view Composition: Anterior border of heart Ascending aorta The infundibular of the right ventricle, pulmonary trunk Anterior border of right ventricle Posterior border of heart Left atrium Left ventricle The normal R. atrium is not border-forming in this projection

64. Normal appearance ---- Lat. view Retrocardiac esophageal space Retrosternal space the anterior heart border touch the lower 1/3 of the distance between the diaphagm and the suprasternal notch RV CT CT X-ray

65. Normal appearance ---- Lat. view normal L. atrium don’t displace the esophagus Barium-filled esophagus

66. Size of the heart and great vessels a b C/T ratio = a+b / T = ≤ 0.5 T Normal ： C / T ≤0.5 Slightly enlarged ： 0.51- 0.55 Moderately enlarged ： 0.56- 0.60 Massive ly enlarge d ：＞ 0.60

67. Sometimes, CTR is more than 50% But Heart is Normal Extracardiac causes of cardiac enlargement Portable AP films Obesity Pregnancy Ascites Straight back syndrome Pectus excavatum

68. Obstruction to outflow of the ventricles Ventricular hypertrophy Must look at cardiac contours Sometimes, CTR is less than 50% But Heart is Abnormal

69. Influencing factor of the normal heart shadow Body type ： oblique , transverse , vertical Age ： grows ， globular — oblique — horizontal Respiration ： inspiration ： dropping heart, normal heart shadow expiration ： heart shadow horizontal Patient position ： erect position ： heart shadow elongated lying position ： heart shadow enlargement

70. Influencing factor of normal heart shadow --- body type horizontal heart oblique heart dropping heart classification ： horizontal heart oblique heart dropping heart C/T R ＞ 0.5 ≈0.5 < 0.5 included angle of cardiac longitudinal ＜ 45 ≈45 ＞ 45 axis and horizontal Heart longest axis

71. normal heart shadow ＝ 45 ° oblique heart horizontal heart dropping heart ＝ 38 ° ＝ 52 °

72. Influencing factor of normal heart shadow -- respiration inspiration expiration

73. Influencing factor of normal heart shadow -- position erect position supine position

74. Basic X-ray features Heart dislocation/ abn situs Heart enlargement Abnormal pulmonary blood flow Changes of aorta Pericardial anomalies

75. Basic X-ray features Heart dislocation dextrocardia Mirror i mage d extrocardias

76. Enlargement of the heart chambers Left ventricular enlargement Right ventricular enlargement Left atrium enlargement Right atrium enlargement General cardiac enlargement Basic X-ray features Heart enlargement

77. Left ventricular enlargement X-ray appearance ; cardiac apex extending to left and down left ventricle segment extended,rounded,expand to left the aorta is prominent Lat ： retrocardiac space become narrowed or disappeared, esophageal space disappeaered Common disease ： high blood pressure aortic incompetence 、 stenosis mitral incompetence congenital heart disease ： PDA

78. Left ventricular enlargement

79. Right ventricular enlargement X-ray appearance ： MPA prominent Lat ： contact between the front surface of heart and the sternum (a nterior chest wall ) >1/3 (narrow of the retrosternal space) Common disease ： Mitral valve stenosis Chronic pulmonary airway disease Pulmonary stenosis Pulmonary hypertension Fallot ’ s tetralogy ASD , VSD

80. Right ventricular enlargement

81. Left atrium enlargement X-ray ： enlarged LA bulges to back & right PA – right border ： double density of left atrial enlargement PA – left border ： Indentation where the left atrium, when it enlarges, will appear on the left side of the heart Lat & RAO ： middle of esophagus compressed and displaced posteriorly LAO ： Elevation of left mainstem bronchus Common disease ： mitral lesion (rheumatic) left ventricular failure ( cardiomyopathies ) congenital heart diseases ： PDA VSD

82. Left atrium enlargement

83. Right atrium enlargement X-ray appearance ： PA ： inferior segment of right border of heart extending to right , bulge, high bulge point LAO ： the right atrial curvature at least half as long as the anterior border of heart ， bulge Common disease ： right heart failure ASD tricuspid disease pulmonary vein ectopy drainage atrial myxoma

84. Right atrium enlargement

85. General cardiac enlargement X-ray appearance ： PA ： The cardiac shadow is increased to both sides, the transverse diameter increased Lat and RAO ： narrowing of both retrosternal space and retrocardiac space, the oesophagus is displaced backward LAO ： the trachea bifurcation is splayed , the trachea is displaced backward Common disease ： Pericardial effusion Myocarditis Total cardiac failure Total cardiac failure, hyperthyroidism

86. general cardiac enlargement -- Pericardial effusion

87. Five States of the Pulmonary Vasculature Normal Pulmonary venous hypertension Pulmonary arterial hypertension Increased flow/plethora Decreased flow/ oligemia

88. What We’re Going to Evaluate Right Descending Pulmonary Artery Distribution of flow in the lungs Upper versus lower lobes Central versus peripheral

89. Venous Hypertension RDPA usually > 17 mm Upper lobe vessels equal to or larger than size of lower lobe vessels = Cephalization

90. Rapid cutoff in size of peripheral vessels relative to size of central vessels Central vessels appear too large for size of peripheral vessels which come from them = Pruning Pulmonary Arterial Hypertension

91. Increased Flow/Plethora RDPA usually > 17 mm All of blood vessels everywhere in lung are bigger than normal

92. Increased Flow Normal

93. Increased Flow Distribution of flow is maintained as in normal Lower lobe vessels bigger than upper lobe Gradual tapering from central to peripheral

94. PAH Increased Flow

95. Unrecognizable most of the time Small hila Fewer than normal blood vessels Decreased Flow

96. Changes of aortaic shape and density elongation, widening ,calcification PA ： Aorta distortion: the ascending and descending aorta displacement exceeding the heart boundary , intruding the lung field The demarcation between the ascending aorta and right atrium descend Aorta elongation: aortic knob is high , above the clavicula sometimes Lat ： Ascending and descending aorta bend forward, backward respectively ，

97. Aorta distortion and elongation

98. Aorta calcification

99. Coronary artery calcification

100. Dissection of aorta Symptom ： Severe chest-back pain sudden ly, with tearing sensation , radiating to the neck and abdomen Pathology ： Hemorrhage in the media separate media from adventitia, and form pseudocoele inside the aortal wall Medical emergency Clue for diagnosis intimal tear point intimal flap pseudocoele

101. Dissection of aorta True lumen

102. Dissection of aorta

103. Aneurysm ascending aorta > 5 cm Descending aorta > 4 cm   abdominal aorta >3 cm Normal size of abdominal aorta >50 years of age: About 2 cm

104. Abdominal aortic aneurysm perianeurysmal fibrosis (10%)

105. Aneurysm

106. Abdominal aortic aneurysm

107. CTA

108. 111 /231 Aneurysm of aorta （ syphilitic ）