Chest Radiology Plain Film and CT- Beyond the Basics John W. Renner, M.S., M.D. Clinical Professor of Radiology UCSD Medical Center Brendan Kidder, M.S. IV UCSD School of Medicine

Chest Radiology Goals Review the basics of Chest Imaging Examine the modalities of the Chest “Plain Film” and Computed Tomography Review basic disease entities and their imaging evaluation Allow Hospitalists to better understand “How to talk to a radiologist in a hospital setting if you must!”

Chest Radiology Normal Radiographic Anatomy Normal frontal and lateral views Cross-sectional anatomy Symmetry and asymmetry Interfaces, lines and junction stripes Chest compartments Densities

Normal Chest

Pre-Vascular Space

Anterior Junction Line

Right Paratracheal Stripe

Carina

Basal Segmental Anatomy

Main Pulmonary Artery

Aortic Valve

Inferior Pulmonary Veins

Left Coronary Artery

Right Coronary Artery

Secondary pulmonary lobule Webb, R : Radiology 2006

Chest Radiology Patterns of Disease Honeycombing Cystic lesions Nodules Ground-glass opacities Mosaic pattern Tree-in-bud Interlobular septal thickening

Honeycombing Chest X-Ray .com

Centrilobular Emphysema Webb, R. Radiology 2006

Centrilobular Emphysema

Centrilobular Emphysema Webb, R. Radiology 2006

Centrilobular Nodules Webb, R. Radiology 2006

Sarcoidosis Chest X-Ray. com

Sarcoidosis Webb, R. Radiology 2006

Hypersensitivity Pneumonitis Webb, R. : Radiology 2006

Ground-Glass Opacities Chest X-Ray. com

Pulmonary Edema

Bronchopneumonia

Mosaic Perfusion Chest X-Ray. com

Mosaic Perfusion

Mosaic Perfusion

Transplant Lung

Transplant Lung

Tree-in-Bud

Tree-in-Bud Webb, R. : Radiology 2006

Interlobular Septal Thickening Webb, R. Radiology 2006

Interlobular Septal Thickening Webb, R. Radiology 2006

Lymphangitic Carcinomatosis Webb, R. Radiology 2006

Lymphangitic Carcinomatosis

Bronchiectasis Chest X-Ray. com

Air Trapping Chest X-Ray. com

Head Cheese Sign Webb, R. : Radiology 2006

Crazy Paving Pattern

Idiopathic Pulmonary Hemosiderosis

Idiopathic Pulmonary Hemosiderosis

Idiopathic Pulmonary Hemosiderosis

Aspergilomas

Bronchogenic Cyst

Interstitial Pulmonary Fibrosis

Interstitial Pulmonary Fibrosis

Interstitial Pulmonary Fibrosis

Neurofibromatosis

Neurofibromatosis

Neurofibromatosis

Chest Radiography Congenital Pulmonary Abnormalities Tracheal bronchus Pulmonary arteriovenous malformation Partial anomalous pulmonary venous return Bronchopulmonary sequestration Congenital lobar emphysema and cysts

Right Upper Lobe Bronchus

Tracheal Bronchus

Hypogenetic Lung

Pulmonary Sequestration

Pulmonary Sequestration

Thrombosed Aneurysm

Pulmonary Sequestration

Pulmonary Artery Sling

Pulmonary Artery Sling

Hilar Lymphadenopathy

Pneumocystis Pneumonia

Pneumocystis Pneumonia

Pneumocystis Pneumonia

Pulmonary Tuberculosis

Chest Radiology Critical Care Radiography Pulmonary Embolism Chest radiograph Normal vs. abnormal Westermark’s sign Enlargement of the central pulmonary arteries Hampton’s hump-pulmonary infarction Atelectasis, consolidation and elevation of the ispilateral hemidiaphragm Pleural effusion

Chest Radiography Critical Care Radiography Pulmonary Thromboembolism-Catheter Angiogram Pulmonary angiography-former “gold standard” Invasive with known morbidity-mortality High specificity—approaching 100% Right heart catheterization-useful data Negative exam excludes the diagnosis Allows for treatment— Thrombolytics IVC filter placement

Chest Radiology Critical Care Radiography Pulmonary Thromboembolism-CTA High sensitivity (>90%), specificity (>95%) CTA limited in sub-segmental arteries Evaluation of upstream findings-right heart strain CT findings Intra-luminal filling defect or Vessel cutoff Mosaic perfusion

Chest Radiology Critical Care Radiography Pulmonary Thromboembolism-CTA CT Pulmonary Angiogram Requires MDCT, helical scan Requires iodinated contrast—high concentration of iodine, non-ionic or iso-osmolar contrast agents Requires apnea during scan Requires normal renal function Relatively high radiation dose!

Massive Thromboembolism

Massive Thromboembolism

Massive Thromboembolism

Pulmonary Thromboembolism

Chest Radiology Chronic Thromboembolism Organizing thromboemboli Adherent clots to vessel wall Lack of recanalization of a vessel Webs, bands Abrupt caliber change Pulmonary arterial hypertension Mosaic perfusion

Type A Aortic Dissection

Primary Pulmonary Hypertension

Chest Radiology Pulmonary Arterial Hypertension Dilation of central pulmonary arteries Rapid tapering of peripheral pulmonary arteries Dilation of right interlobar pulmonary artery to > 18 mm on PA chest view Dilation of left pulmonary artery to > 18 mm on lateral chest view Dilation of RA, RV

Primary Pulmonary Arterial Hypertension

Primary Pulmonary Artery Hypertension

Tricuspid Regurgitation

Chest Radiology Idiopathic Interstitial Pneumonias Idiopathic Pulmonary Fibrosis-IPF Non-specific Interstitial Pneumonia-NSIP Cryptogenic Organizing Pneumonia-COP Respiratory Bronchiolitis-associated Interstitial Lung Disease-RB-ILD Desquamative Interstitial Pneumonia Lymphoid Interstitial Pneumonia-LIP Acute Interstitial Pneumonia-AIP

Idiopathic Pulmonary Fibrosis

Idiopathic Pulmonary Fibrosis

Non-specific Interstitial Pneumonia

IPF vs. NSIP

Cryptogenic Organizing Pneumonia

Respiratory Bronchiolitis-ILD

Desquamative Interstitial Pneumonia

Lymphoid Interstitial Pneumonia

Organizing Pneumonia

ILS plus GGO

Chest Radiology Critical Care Radiography CXR may be done on a daily basis Evaluate “life-support” lines, tubes catheters, devices, monitoring equipment Evaluate changes in cardiopulmonary status Determine why a patient has undergone “clinical deterioration”— Hypoxia Hypotension Sepsis

Chest Radiology Critical Care Radiography Pulmonary Edema Hydrostatic Increased capillary permeability Diffuse alveolar damage –(DAD) Differential diagnosis Atelectasis Pneumonia Aspiration Pulmonary embolism and hemorrhage

Chest Radiology Critical Care Radiography Hydrostatic Pulmonary Edema Pulmonary venous hypertension and vascular redistribution Interstitial pulmonary edema Alveolar pulmonary edema Cardiomegaly Pleural effusion Vascular pedicle

Chest Radiology Critical Care Radiography Pulmonary Edema Interstitial pulmonary edema Kerley A, B and C lines Interlobular septal thickening Subpleural edema along fissures,pleura Peribronchial cuffing Perihilar haze Interstitial veiling Ground-glass opacities

Interstitial Pulmonary Edema

Chest Radiology Critical Care Radiography Alveolar Edema Air-space consolidation Acinar or air-space ill-defined nodules Peri-hilar or “batwing” distribution Peripheral sparing Rapid clearance with theraphy Occasionally a clinical lag in onset and clearance

Chest Radiology Critical Care Radiography Increased Permeability Edema or ARDS and DAD Alveolar-capillary leak, normal left atrial pressure Multiple etiologies Occurs in stages Latent period Air-space consolidation Homogeneous confluence and air bronchogram Decreased lung volumes and pulmonary compliance compliance Slow clearance Organizing chronic changes--fibrosis

Chest Radiology Critical Care Radiography Barotrauma Mechanical ventilation and increased airway resistance, high ventilatory pressures, CPAP and others Extra-alveolar air Pulmonary interstitial emphysema Pneumomediastinum Pneumothorax Subcutaneous emphysema

Chest Radiology Cardiac Cardiac CT Calcium scoring Coronary artery angiography-CTA Congenital Heart Disease Anatomical applications Triple rule-out

LAD Stenosis

CT Coronary Angiography

LAD Stenosis

Calcium LAD

3D Workstation

CTA Coronary Artery

Right Coronary Artery

LAD-Soft Plaque

Multiplanar Reconstruction

Anomalous Left Coronary Artery

Consensus A negative test may be consistent with a low risk of a cardiovascular event in the next two to five years A high calcium score may be consistent with a moderate to high risk of a cardiovascular event within the next two to five years

Chest Radiology Airways Disease Trachea Bronchiectasis-cylindrical, varicose, cystic Cystic Fibrosis ABPA and asthma Chronic bronchitis Bronchiolitis

Chest Radiology Emphysema Centrilobular emphysema Panlobular emphysema Paraseptal emphysema Bullous emphysema Saber-sheath trachea

Chest Radiology Pneumonia Lobar pneumonia Peripheral opacity to homogenous consolidation Bronchopneumonia Airway mucosa to alveoli Interstitial pneumonia Reticular opacities to confluent infection Lung abscess Cavitation

Chest Radiology Tuberculosis Primary tuberculosis Post-primary tuberculosis HIV-associated tuberculosis

Chest Radiology Lung Cancer Early Detection National Lung Cancer Screening Trial Chest x-ray vs. low-dose CT International Early Lung Cancer Action Project—I-ELCAP Low-dose screening CT 92% survival rate, stage I NEJM 355:1763-1771, Oct. 26, 2006

Chest Radiography Cardiac Cardiac MRI Myocardial function Myocardial viability Valvular heart disease Systolic heart failure Diastolic heart failure Myocarditis Pericardial diseases

Chest Radiology Thank you John W. Renner, M.S., M.D. Clinical Professor of Radiology Department of Radiology UCSD Medical Center San Diego, California