1. Imaging pattern of respiratory disease
Liu Lin Xiang 刘林祥
Radiology school ,
21:11

2. Imaging pattern Lung disease Obstructive change of bronchiel
Consolidation
Fibrosis
Calcification
Nodule and mass
Cavity and
Interstitial changes
Obstructive change of bronchiel
emphysema
Atelectasis
Pleural abnormalities
Pleural effusion
pneumothorax
Pleural thickening
21:11

3. Chronic diffuse obstructive emphysema
21:11

4. Chronic diffuse obstructive emphysema
Increased translucency of both lungs
Lung marking scattered, thined
normal domed diagphragms are flattened
Retrosternal space is increased on the lateral film
Heart tends to be elongated, narrow and central in position
21:11

5. Obstructive emphysema
21:11

6. CT findings of emphysema
Centrilobular emphysema
Panlobular emphysema
Paraseptal emphysema
21:11

7. Centrilobular emphysema
Result from cigarette smoking
Mainly involves the upper lung zones
Predominantly affects the central portion of acini (centriacinar emphysema)
Multiple, small areas of emphysema scattered throughout the lung
More severe, areas of destruction confluent
21:11

8. Panlobular emphysema
Involves all the components of the acinus uniformly, entire lobule
On HRCT, widespread areas of abnormally low attenuation expressing the uniform destruction of the pulmonary lobule
Pulmonary vessels appear fewer and smaller than normal
Severe in the lower lobes
Mild and moderately severe emphysema can be subtle and difficult to detect radiologically
21:11

9. Paraseptal emphysema
Often marginated by interlobular septa and is more striking in a subpleural location
HRCT, areas of low attenuation visible in the subpleural areas, along the peripheral or mediastinal pleura, mainly in the upper lobe, and along the fissures
Often have very thin but visible walls corresponding to interlobular septa thickened by associated fibrosis
CT may early detect the apical subpleural emphysematous spaces in spontaneous pneumothorax
Subpleural bullae are frequently associated
21:11

10. Paraseptal emphysema
paraseptal emphysematous spaces along the peripheral and mediastinal pleura and the major fissure
21:11

11. Emphysema Normal Centrilobular Panacinar
21:11

12. Emphysema
21:11

13. Obstructive emphysema
21:11

14. Obstructive emphysema
21:11

15. Segmental obstructive emphysema
21:11

16. Obstructive atelectasis
Involve one or more lobes or segments
Air within the collapsed or atelectatic lung parenchyma can be entirely resorbed and partially replaced by fluid or fibrosis
Appears radiologically as an opacification
Mostly bronchiel obstruction
Also called lobar collapse
Loss of lung volume with reduced inflation of a segment or a lobe
21:11

17. Lobar atelectasis Opacity of the lobe, loss of volume of the lobe
Direct signs of loss of volume: displacement of fissures, pulmonary blood vessels and major bronchi, and shift of other structures to compensate for the loss of volume
Tumor mass in parahilar produce a bulge in the contour of the collapsed lobe (golden S sign)
Compensatory overinflation of the adjacent lobe results in spreading out of the vessels within that lobe
Mediastinal shift accompanying lobar atelectasis
Displacement of the anterior mediastinal fat, and trachea
Hemidiaphragm elevation is another sign of compensatory shift
Inward displacement of the chest wall causing narrowing of the spaces between the affected ribs, seen in severe atelectatic lobe
21:11

18. Normal condition of the right lung
21:11

19. Right upper lobe atelectasis
Right hilum be elevated
Minor fissures are displaced upwards and rotated towards the mediastinum
Collapsed lobe packs against mediastinum and apex
Compensatory overinflation of the right lower lobe, especially superior segment
21:11

20. Right upper lobe atelectasis
21:11

21. Right upper lobe atelectasis
21:11

22. Right upper lobe atelectasis
21:11

23. Right upper lobe atelectasis
Right hilum be elevated
minor fissures are displaced upwards
Collapsed lobe packs against mediastinum and apex
Compensatory overinflation of the right lower lobe
21:11

24. Right upper lobe atelectasis
21:11

25. Right middle lobe atelectasis
The collapsed lobe is easily and reliably recognized on the lateral chest radiograph
The major and minor fissures move towards one another and the collapsed lobe resembles a curved, elongated wedge
The right hilum is not displaced
The right hemidiaphragm and mediastinum are in a normal position
21:11

26. Right middle lobe atelectasis
21:11

27. Right middle lobe atelectasis
21:11

28. Right middle lobe atelectasis
21:11

29. Right lower lobe atelectasis
The atelectatic lobe is seen as a triangular retrocardiac opacity limited laterally by the displaced major fissure
Right hilum is displaced downwards
The vascular pedicle visible in the normal location for the hilum corresponds to the anterior trunk of the right pulmonary artery
21:11

30. Combined right lower and middle lobe colapse
Obstruction to the intermediate bronchus
Major and minor fissures are both displaced downward and backward creating an opacity that obliterates the dome of the right hemidiaphragm
Right hilum, mainstem bronchus and upper lobar bronchus are displaced downward
Anterior mediastinal fat is markedly shifted to the right side
21:11

31. Right lower lobe atelectasis
21:11

32. Right lower lobe atelectasis
21:11

33. Right lower lobe atelectasis
21:11

34. Right lower lobe atelectasis
21:11

35. Normal condition of the left lung
21:11

36. Left upper lobe atelectasis
Hilum is displaced upwards and the major fissure forwards
Lobe retains much of its original contact with the anterior chest wall
Displacement of the anterior mediastinum fat and displacement of the trachea towards the left are commonly present
Left hemidiaphragm is moderately elevated
21:11

37. Left upper lobe atelectasis
21:11

38. Left upper lobe atelectasis
21:11

39. Left upper lobe atelectasis
21:11

40. Left upper lobe atelectasis
21:11

41. Left upper lobe atelectasis
21:11

42. Left lower lobe atelectasis
Major fissures are displaced downward and backward creating an opacity that obliterates the dome of the right hemidiaphragm
left hilum are displaced downward behide the shadow the heart
Mediastinum is markedly shifted to left side
21:11

43. Left lower lobe atelectasis
21:11

44. Left lower lobe atelectasis
21:11

45. Left lower lobe atelectasis
21:11

46. Consolidation
Replacement of alveolar air by fluid, cells, tissue, or other material
Homogeneous increase in lung attenuation with obscuration of underlying pulmonary vessels
Air bronchogram may be seen
21:11

47. Exudate
21:11

48. Consolidation
21:11

49. Consolidation
21:11

50. Proliferation
21:11

51. 21:11

52. Fibrosis
21:11

53. Fibrosis
21:11

54. Calcification
Pattern of calcification in a solitary pulmonary nodule can help differentiate benign from malignant nodules
Four benign patterns of calcification: central, diffuse solid, laminated, and "popcornlike."
The first three patterns are typically seen with prior infections, particularly histoplasmosis or tuberculosis.
Popcornlike calcification is characteristic of chondroid calcification in a hamartoma. When present, are reliable indicators of a benign cause
Unfortunately, 38%–63% of benign nodules are not calcified, and the reported prevalence of calcification in hamartomas at CT varies from 5% to 50%
21:11

55. Popcornlike calcification
21:11

56. Calcification of hilar nodes
21:11

57. Popcornlike calcification
21:11

58. Solitary pulmonary nodule
A well-circumscribed round or oval-shaped lesion measuring less than 3 cm in diameter
Common finding on routine screening chest radiograph in adults
vast majority of such incidentally detected lesions are benign
Most common radiological manifestation in patients with asymptomatic lung cancer
Almost always benign in patients under 30.
but should be followed for at least 2 years.
At the age of 40 and beyond, the likelihood of malignancy is increased
Most prove resectable, early diagnosis remains essential
21:11

59. Solitary pulmonary nodule
CT is almost always obtained in the diagnostic work-up of SPN
Radiological factors most often considered useful in determining nature of a SPN:
lesion size
Nodule margins and contours can be classified as smooth, lobulated, irregular, or spiculated
growth rate
presence of calcification
21:11

60. Solitary pulmonary nodule
Large majority of nodules >2cm are malignant while only 50% of nodules <2cm are malignant
Malignant nodules appear ill-defined and/or irregular in shape
A spiculated appearance on HRCT strongly suggests malignancy
Benign nodules are often well-defined, round and smooth in contour
However, solitary pulmonary metastases may have the same appearance
21:11

61. Solitary pulmonary nodule
Air bronchograms within a nodule are more common in malignancies than in benign nodules and more suggestive of adenocarcinomas or bronchioalveolar cell carcinoma
Cavitation is more common in malignant nodules than benign nodules
But focal benign pulmonary lesions such lung abscess can also cavitate
Satellite nodules in association with an SPN suggest granulomatous disease
Skip metastases around a bronchogenic carcinoma cannot be ruled out
21:11

62. Solitary pulmonary nodule
Calcification within SPN is a reliable sign of benignancy
Benign calcification include diffuse, those with a central nidus, laminated or popcorn
While stippled or eccentric calcification may be present in as many as 10% of malignant lung neoplasms
CT is more sensitive in the detection of calcification
Measuring CT number can allow the detection of calcifications invisible on CT scans in some patients with benign nodules
Pixels denser than 200 HU usually indicate the presence of calcifications
21:11

63. Solitary pulmonary nodule
By detecting the presence of fat, CT may be helpful in diagnosing pulmonary hamartoma, or other benign lesions such as lipoid pneumonia
Certain lesions in the lung may display the nonspecific features of an SPN on chest radiography, while CT may identify specific diagnostic features
21:11

64. SPN
21:11

65. SPN: contour
21:11

66. SPN: contour
21:11

67. SPN: contour
21:11

68. SPN: contour
21:11

69. SPN: contour
21:11

70. SPN: contour
21:11

71. SPN: density
21:11

72. SPN: density
21:11

73. SPN: density
21:11

74. SPN: density
21:11

75. SPN: density
21:11

76. SPN: density
21:11

77. SPN: density
21:11

78. SPN: Vascular convergence
21:11

79. SPN: Vascular compression
21:11

80. SPN: Pleural retraction
21:11

81. SPN: Pleural concave
21:11

82. SPN: Pleural thickening
21:11

83. Peribronchovascular interstinal thickening
21:11

84. Interlobular septal thickening
21:11

85. Dependent opacity
21:11

86. Subpleural lines
21:11

87. SPN: satelite lesion
21:11

88. SPN
21:11

89. Cavity non- wall cavity:
Thin-wall cavity: thickness of cavity wall is less than 3 mm, Tuberculosis
Thick-wall cavity: thickness of cavity wall is more than 3 mm, Tuberculosis, abscess, cancerous
21:11

90. Cavitation Occurs in both benign and malignant nodules
Benign cavitary nodules generally have smooth, thin walls, whereas malignant nodules typically have thick, irregular walls
Most nodules with a wall thickness greater than 16 mm are malignant, whereas those with a wall thickness less than 4 mm are usually benign
21:11

91. Non-wall cavity
21:11

92. Tuberculous cavity
21:11

93. Thin-walled cavity
21:11

94. Tuberculous cavity
21:11

95. Abscese cavity
21:11

96. Cancerous cavity
21:11

97. Cancerous cavity
21:11

98. Bullae Emphysematous spaces larger than 1 cm
Generally seen in centrilobular emphysema and/or paraseptal emphysema
presence of emphysema associated with large bullae is referred to as bullous emphysema
Patients with isolated bullae are usually without signs or symptoms
Occasionally large bullae produce dyspnoea that may necessitate bullectomy
On the chest radiograph, large bullae are seen as avascular transradiant areas usually separated from the remaining lung parenchyma by a thin curvilinear wall of a very variable extent
cause marked relaxation collapse of the adjacent lung
even extend across into the opposite hemithorax, particularly by way of the anterior junctional area
CT is the best available technique for assessing the number, size and location of bullae, which is essential in cases considered for bullectomy
avascular, low attenuation areas that are larger than 1 cm and that can have a thin but perceptible wall
21:11

99. Confluence of emphysematous spaces causes multiple bullae
21:11

100. Bullae
21:11

101. Pleural effusion
Develops when the rate of formation of pleural fluid exceeds its absorption
Formed principally by the parietal pleura and absorbed by the lymphatics
There is normally less than 5 ml of fluid within the pleural space
Several mechanisms contribute to the formation of a pleural effusion
Raised pulmonary venous pressure with resultant increased microvascular hydrostatic pressure
Increased microvascular permeability as in inflammatory lung disease
Reduced pleural space pressure (for example, in lobar collapse), which results in leakage of intravascular fluid into the pleural space
Decreased plasma oncotic pressure as in hypoproteinaemia
Impaired lymphatic drainage
Transdiaphragmatic passage of peritoneal fluid
May be a transudate or an exudate and these can be distinguished by biochemical analysis of the fluid content
21:11

102. Pleural effusion
Radiological signs of a pleural effusion depend on the amount and distribution and whether fluid is freely mobile or loculated
Free fluid tends to collect in dependent areas, initially in the subpulmonary region beneath the lower lobes
As the volume increases, it spills into the posterior and then lateral costophrenic angles
Blunting of the lateral costophrenic angle on an erect frontal chest radiograph occurs when 25~525 ml is present. However, as little as 10 ml can be detected with a lateral decubitus view
With an increasing volume of pleural fluid the hemidiaphragm outline is obscured and there is homogeneous opacification of the lower hemithorax associated with a meniscus shape of the fluid at its upper, lateral margin
21:11

103. Pleural effusion
In supine, pleural fluid collects posteriorly, producing reduced transradiancy of the ipsilateral hemithorax but vascular markings are preserved, enabling differentiation from consolidation
Supine chest radiographs are relatively insensitive for pleural fluid detection
Larger volumes of fluid may produce a peripheral opacity between the lung and chest wall, particularly towards the apex of the lung and there may be thickening of the minor fissures and widening of the paraspinal soft tissues
A massive effusion causes dense opacification of the hemithorax with displacement of the mediastinum to the contralateral side and flattening or inversion of the ipsilateral hemidiaphragm
Collapse of the underlying lung such as occurs with an endobronchial malignancy or extensive pleural thickening should be considered if the mediastinum remains central
21:11

104. Pleural effusion
The differential diagnosis of a completely opaque hemithorax includes a massive pleural effusion, lung collapse or consolidation, massive tumor, pneumonectomy or lung agenesis
Unusual radiographic appearances may be produced if fluid lies within the pleural fissures, is loculated or is subpulmonary
Fluid may collect adjacent to the mediastinum, especially on the left, producing a triangular retrocardiac opacity, simulating left lower lobe collapse which is differentiated from true collapse by the normally positioned lower lobe bronchus
Right-sided pleural effusions may displace the azygoesophageal line to the left producing a retrocardiac opacity
Fluid in the azygoesophageal recess may simulate subcarinal lymphadenopathy
21:11

105. Pleural effusion
21:11

106. Pleural effusion
21:11

107. Loculated pleural effusion
Pleural fluid has become loculated or encysted between layers of visceral pleural within the fissures or between partially fused visceral and parietal layers adjacent to the chest wall, diaphragm or mediastinum
The chest radiographic appearance depends on the site of the loculus, the amount of fluid and the radiographic projection
Seen en face it usually appears as an oval opacity, its margin partially well defined and partially ill defined
Viewed tangentially it is sharply defined on its convex pulmonary aspect
These appearances are similar to other pleural and chest wall masses
Fluid may collect within the loose connective tissue of the lung beneath the visceral pleura producing the so-called lamellar pleural effusion which is common in heart failure
There is a vertical band of soft tissue density between the lung and chest wall extending above the costophrenic angle which does not change in appearance with postural changes. The fluid is not a true pleural effusion as it lies outside the pleural space
21:11

108. Interlobar pleural effusion
Collection of pleural fluid between lobes
Radiographic appearance depends on the shape and orientation of the fissure, the volume of fluid, its position within the fissure and the radiographic projection
particularly common in heart failure
Fluid in the minor fissure produces an opacity with a lentiform shape and sharply defined margins on the lateral radiograph
oval or round shape on the frontal view, mimicking a pulmonary mass
Fluid in the major fissure is less common. It is best identified on the lateral projection where it produces a triangular opacity along the line of the fissure, extending inferiorly to the anterior surface of the diaphragm. On the frontal view, there is hazy opacification of the lower hemithorax, more transradiant medially
On CT interlobar pleural fluid appears as a well-defined opacity of fluid attenuation between the fissures
21:11

109. Subpulmonary pleural effusion
is a collection of pleural fluid beneath the lung. Although pleural fluid usually collects initially at this site when the patient is erect, it is unusual for fluid to remain localized under the lung when more than ml is present. Occasionally, however, large volumes of pleural fluid accumulate in the subpulmonary area without fluid collecting in the rest of the pleural space. The cause is unknown; theories such as distorsion of pleural pressures due to abnormality of the lower lobe have not been substantiated. The fluid is not loculated by pleural adhesions and is freely mobile when the patient's posture is changed. Subpulmonary effusions may be bilateral but are more commonly unilateral and right-sided and due to transudates rather than exudates. They are most frequently seen in cardiac failure.
On the frontal chest radiograph there is apparent elevation of the hemidiaphragm as the superior margin of the fluid collection is well defined, mimicking the diaphragmatic contour. The correct diagnosis is suggested by the contour of the collection which peaks more laterally than a raised hemidiaphragm; on expiration, this appearance is more pronounced. The adjacent costophrenic angle may be clear but it is often slightly blunted. On the left side, the distance between the gas-filled stomach bubble and lung is usually greater than 2 cm. Bilateral subpulmonary effusions are particularly easily missed. On the lateral radiograph the superior margin of the fluid collection tends to be relatively horizontal, particularly posteriorly, mimicking a flattened hemidiaphragm. Occasionally fluid can be seen extending into the oblique fissure.
21:11

110. Loculated pleural effusion
21:11

111. Loculated pleural effusion
21:11

112. Interlobar pleural effusion
21:11

113. Interlobar pleural effusion
21:11

114. Subpulmonary pleural effusion
21:11

115. Pneumothorax
is the abnormal presence of air within the pleural space, which occurs when the parietal or visceral pleura, or both, are breached spontaneously, or following iatrogenic or noniatrogenic trauma or pathological processes.
Spontaneous pneumothorax most often occurs in otherwise healthy, slender young men, most commonly as a result of rupture of apical bullae or blebs. One third to one half of people who experience spontaneous pneumothorax have a recurrence.
21:11

116. Pneumothorax
21:11

117. 21:11

118. Pleural thickening
May follow organization of a variety of inflammatory processes involving the pleura
Include infective pleural effusions, empyema, hemothorax, occupational exposure to asbestos or talc, rheumatoid lung disease, radiation therapy and drugs
May also occur as a result of infiltration of the pleura by various malignant tumors, especially mesothelioma and metastatic adenocarcinoma
May be uni- or bilateral, diffuse or localized and may be calcified
21:11

119. Pleural thickening
On the chest radiograph the changes predominantly affect the dependent areas with blunting of the costophrenic angle
Extensive pleural thickening produces volume loss and a veil-like reduction in transradiancy of the hemithorax
There is a soft tissue density medial to and paralleling the chest wall with a well-defined inner margin
There may be extension into the fissures which appear thickened
21:11

120. Pleural thickening
CT is much more sensitive in detecting pleural thickening which is seen as a layer of soft tissue density between the chest wall and lungs
Thickening of as little as 12 mm can be detected with HRCT
best assessed immediately internal to the ribs where there is normally no detectable soft tissue
Between the ribs the normal pleura and innermost intercostal muscle produce a thin line which should not be mistaken for pleural thickening
In the paravertebral region, any thickening of the pleural line is abnormal
In many diseases causing pleural thickening the layer of extrapleural fat between parietal pleura and chest wall is increased, allowing a subtle degree of thickening to be detected, especially with HRCT
21:11

121. Pleural thickening
The distribution and shape of pleural thickening as determined by CT are useful for differentiating between benign and malignant causes of pleural thickening
The most useful signs in predicting the presence of malignancy are circumferential thickening, nodularity, thickening of greater than 1 cm and involvement of the mediastinal pleura
Localized pleural thickening often occurs at the lung apices with increasing age, forming an apical cap
This may be uni- or bilateral and is usually of homogeneous, soft tissue density, usually less than 5 mm thick, with a well-defined inferior margin
21:11

122. Pleural thickening
21:11

123. Pleural thickening
21:11