The terms are fuzzy and interchangeable hard to believe. In Figure , the left lung is consolidated and collapsed. Look at Figures A and B and decide which lobe has collapsed. The accompanying CT scan shows collapse of the right upper lobe, and the arrow points to an endobronchial tumor obstructing the right upper lobe bronchus. There is a triangular density over the heart. Changes on the frontal radiograph are often subtle. The minor fissure is elevated. The right upper lobe is partially collapsed.
There is a silhouette sign of the right diaphragm, and the heart has moved to the right, indicating right lower lobe collapse. The right middle lobe remains aerated. We see the undersurface of the minor fissure and the right heart border because the right middle lobe is aerated. It is common for an endobronchial lesion tumor, foreign body, mucus to obstruct them together.
In Figure A, the upper arrow is at the level of the upper lobe, and the lower arrow is at the level of the lingula. These two lobes often collapse together. Figure shows dense consolidation at the right base. Crowding of pulmonary vessels or bronchi and movement of parenchymal landmarks e.
If the lung is consolidated, the air bronchogram sign might show us the bronchi. The collapsed lung is difficult to see behind the heart. There is a silhouette sign of the left diaphragm.
The nodule moved medially because there is now air in the pleural space pneumothorax arrow. Yes, I did the biopsy. There are several less specific signs, such as shift of adjacent structures and change in lung density. Hilar shift is a reliable indirect sign of atelectasis. Figures are based on normal chest x-rays studied by Dr. By the way, which diaphragm is usually higher?
Similarly, mediastinal structures may shift. With upper lobe collapse, the trachea shifts toward the lesion see Figure The airless, atelectatic lung is more radiopaque, and adjacent lobes may hyperinflate to fill the void.
Various physiologic mechanisms keep the lung expanded. When one or more fails, the lung tends to lose volume. There are five basic mechanisms that cause volume loss: 1 resorption of air as a result of obstruction of a bronchus; 2 relaxation of the lung as a result of air or fluid in the pleural space; 3 scarring, causing lung contraction; 4 decreased surfactant reducing lung distensibility adhesive atelectasis ; and 5 hypoventilation as a result of central nervous system depression or pain.
Obstruction may be central i. In adults younger than 40 years old, it is usually due to a mucous plug, a foreign body, or a low-grade endobronchial tumor adenoma, carcinoid. In adults older than age 40, bronchogenic carcinoma is a frequent cause of postobstructive collapse.
Collapse must be due to peripheral mucous plugging or hypoventilation. The central lucency C is the collapsed right lung. The minor tissue is elevated arrows. Diminished surfactant promotes volume loss. It most often involves the lung base. Atelectasis also can occur at the segmental level or in random small areas of the lung parenchyma. This usually presents as a linear band of dense lung, often referred to as plate or bandlike atelectasis.
Figure shows bandlike atelectasis at the lung base caused by hypoventilation. This is a chance for you to pull together what you have learned in the last several chapters. Which lobes are collapsed? Direct signs? Indirect signs? Silhouette sign—where? We now look at other patterns of diffuse and focal lung disease. The lung reacts to disease in a limited number of ways.
The interstitium can thicken or thin, and the alveoli can fill with fluid or extra air. These changes may be focal or diffuse. They may be acute or chronic. We concentrate only on the most common combinations. These four basic variables help us analyze the chest x-ray and form a differential diagnosis.
Review Figures A and B. If the interstitium thickens, it can be seen more peripherally on the x-ray or CT scan. If the interstitial thickening is generalized, the pattern is linear reticular Figure A. If the thickening is discrete, it forms multiple nodules Figure B. If the alveoli fill with fluid, the fluid-filled area becomes radiodense, and the interstitium is enveloped in the dense white lung and is not visible Figure C.
If the markings are hazy ill defined and not distorted i. If the lung markings are sharp well defined and distorted i. Neither is cheating. It is synthesizing information to arrive at the best possible answer for the patient. In Figure B, the CT scan shows distorted and sharp interstitium and aerated lung. Figures A and B show an x-ray and CT scan with honeycombing.
Most alveolar disease airspace consolidation , whether focal, multifocal, or diffuse, is acute. With alveolar disease, the airspaces are filled with fluid e. The alveolar pattern may be relatively homogeneous a lobe or segment or patchy and scattered throughout the lung. There is also focal consolidation of the right lower lobe without an air bronchogram or silhouette sign.
The most frequent cause of acute focal alveolar consolidation is also infection. Subacute alveolar consolidation is often granulomatous infection tuberculosis, fungal. History is helpful but less reliable.
Figure A shows focal left upper lobe alveolar consolidation and diffuse interstitial thickening in a patient with silicosis. Figure B shows the two patterns nicely. Note the interstitium is sharp and distorted. In patients older than age 40, cancer becomes a major concern. When the patient is erect, the fluid settles to the bottom, and the air rises to the top.
Which was taken with a horizontal x-ray beam? In Fig. The top of the water column is wider than the bottom. One is looking down at two edges not quite superimposed. The glass is just too big. From geekswithblogs. Figure shows an air-fluid level arrow in a cavitary right upper lobe pneumonia. Compare with Figure , where there is no fluid in the cavities. Granulomas frequently calcify. Figure A shows a nodule in the left mid lung. Figure B shows the same granuloma on CT. Healed tuberculosis and histoplasmosis are the most frequent causes of lung granulomas.
The adjacent hilar lymph nodes often calcify Figure B. If the lung is hyperinflated, it becomes hyperlucent because a fixed amount of tissue is spread over a larger volume.
If the interstitium is destroyed e. Bullae or sparse markings replace normal branching vessels Figure A. The AP diameter is increased i. In Figure C, note the cystic spaces and distortion caused by the thin walled bulla.
However, this approach provides a way of organizing your descriptions to form a differential diagnosis. II Radiographic signs of alveolar filling disease or airspace consolidation: 1. The patient has what generalized lung disease? On Figure C, how does CT confirm your suspicions about his x-ray findings and his personal habits?
Use all the information on the film! Mediastinal diseases can be difficult to detect on chest x-ray because most diseases are of soft tissue density and are surrounded by other soft tissue structures. Mediastinal lesions may cause local or diffuse widening; displace, compress, or invade adjacent structures; or cause a silhouette sign with adjacent structures.
The lateral view is often helpful for localization. Which is likely due to tumor? Which is likely due to hemorrhage? This helps to locate the mass. Note tracheal displacement and marked narrowing arrows. There are several methods of dividing the mediastinum. None is perfect because structures and diseases often cross these artificial divisions. In Figure , an imaginary line separates the anterior I and middle mediastinum II. On the lateral x-ray, the upper portion is the area of the retrosternal clear space.
It fills the retrosternal clear space. Compare with Figure B. Big White is discussed in Chapter Generally, it is difficult to differentiate one anterior mediastinal mass from another on the chest x-ray. CT is often helpful in delineating boundaries. In Figure B, CT shows a homogeneous anterior mediastinal thymic mass with sharp margins, just anterior to the ascending aorta. The trachea is not compressed. Middle mediastinal adenopathy is most often due to sarcoidosis in young patients and lung cancer in older patients.
Figures A and B show an air-containing mass behind the heart. Figure C is a lateral view of a barium swallow esophagram showing the large hiatal hernia stomach above diaphragm. The descending aorta usually sits anterolateral to the anterior margin of the vertebral bodies. As it elongates with age, it usually overlaps the spine on the lateral. Note the calcified atherosclerotic intima of the aortic arch upper arrow. The tortuous descending aorta is lateral to the heart lower arrow. Figure B shows the tortuous descending aorta arrow overlapping the spine.
A feeding tube shows the normal course of the esophagus—a middle mediastinal structure. More simply, the posterior mediastinum is the paravertebral area. The vertebral body V is intact, but a soft tissue mass M protrudes through the neural foramen into the posterior mediastinum. The descending aorta x is normal. Clinical Pearl: Most posterior mediastinal masses are from the nerves or their coverings e. Multiple myeloma and metastatic spine diseases are more common in older patients.
In Figure B, the CT scan shows fluid blood surrounding the aortic arch. Figure C is a multiplanar reconstruction of the aorta, showing a post-traumatic pseudoaneurysm arrow. They taper as they course peripherally. Normal hilar nodes are not visible on the chest x-ray. In Figure , there is bilateral hilar adenopathy. The hila are lumpy because of the enlarged nodes. The chest x-ray is reasonably sensitive in detecting mediastinal lesions. Additional imaging usually is required to characterize the abnormality.
There are many different examinations to choose from. It is often helpful to check with the radiologist. You may even get different answers from different radiologists.
II For each named structure, give the mediastinal compartment: 1. The right hilum Figures B and C are axial and coronal images through the mediastinum and hilum. Note large nodes N. This patient has lymphoma. The extrapleural space, a potential space, lies between the rib cage and the adherent parietal pleura. Each produces characteristic radiographic signs of disease, with the usual overlapping of signs.
This is called the costophrenic sulcus or angle. The lateral costophrenic sulcus is also fairly deep. The bullet, almost spent, just penetrated his chest wall and dropped harmlessly into the pleural space. In Figure B lateral film , the bullet is clearly in the costophrenic angle.
In Figure C supine film , several days later, the bullet has shifted in the pleural space. In Figure A, the lateral costophrenic sulcus is normal. Additional fluid tracks up the pleural space, forming a meniscus, as shown in Figure C. Figures A, B, and C are all the same patient. If there is a discrepancy between them, believe the lateral. Figure and Figure are of the same patient. Compare each set of PA and lateral examinations. The true diaphragm lies in normal position, but is obscured by a parallel layer of free fluid.
In the upright position, free fluid often collects between the lung base and the top of the diaphragm. In radiology, however, gravity can be a friend. What view would be most helpful in proving that Figure A has a subpulmonic effusion?
The free fluid has redistributed to the dependent side of the left pleural cavity, between the lung and chest wall. Figure C, a CT scan, shows a gravitydependent pleural effusion layered posteriorly E. On the left, the stomach bubble is normally separated from the lung base by only the thin diaphragm. Figure shows the normal distance between the stomach and the lung arrow.
In Figure , the apex of each diaphragm is in the mid clavicular line. What are the signs of pleural effusion on the right? There is also fluid in a major fissure arrow. How would you confirm suspicions on the PA image? The erect PA requires greater than mL; the erect lateral, 75 mL; the decubitus, greater than 5 mL; the supine, more than several hundred milliliters.
Now you know. Does the name Pavlov ring a bell? See Figure A, an example of loculated pleural fluid. There is a second smaller loculation as well. Compare this with the free effusion of Figure C. It may look like a lung mass. Remember, the beam must be parallel to the fissure to see it.
The two loculated collections in the major fissure B and C are completely sharp only in the lateral projection. On the frontal image, portions of the major fissure pseudotumors are indistinct. Figure B shows the pleural air against the edge of the consolidated upper lobe arrow. There are no lung markings in the air-filled pleural space.
There is also air in the subcutaneous tissues arrowhead. In Figure A, we see what two signs of pneumothorax? Note the subpulmonic air. Figure B shows air anterior to the lung on a CT scan of a supine patient.
In Figure , we see the pleural line and air in the pleural space, signs of pneumothorax. The ribs on that side may be further apart. Learn the clinical signs so that you can diagnose and treat it without an x-ray.
Signs include rapid onset of respiratory failure, decreased breath sounds, deviated trachea, and jugular venous distention. There is fluid in the lower pleural space, air in the upper pleural space, and an air-fluid level. The air bubble in the stomach is elevated, indicating diaphragmatic elevation because the lung has been removed.
Lesions that arise in structures within or bordering the extrapleural space e. If none is visible, it may be difficult to separate the two. The convex margin facing the lung is sharp, and the borders are tapered obtuse angle with chest wall. The lesion looks similar to encapsulated fluid see Figure A. The rib fractures arrowheads in Figure indicate the extrapleural origin. What are the three patterns seen with free pleural effusions seen on an erect film?
II 1 peripheral hyperlucency intrapleural air 2 visceral pleural line or edge III Figures A and B are supine x-rays of a young woman who was in an auto accident. Every beginner should be able to recognize the cardiovascular structures, cardiomegaly, and left heart failure. If you can, you will be ahead of most of your peers.
Two medical students spotted a bear while walking in the woods. Student 1 took out sneakers from his backpack and put them on. On the left side, there are four bulges moguls to you skiers. They are: 1. The right ventricle does not form a lateral border on the frontal view.
Label the cardiovascular structures on the lateral Figure B. Review the following: A. Measure the horizontal width of the heart and divide it by the widest internal diameter of the thorax. The normal cardiothoracic ratio is less than 0. Oversimplified, but useful. For a given patient, an increase of greater than 1 cm in cardiac diameter from a prior film is a more reliable index of cardiac enlargement than the cardiothoracic ratio.
In general, a radiologist with a ruler is a radiologist in trouble, but these measurements work fairly well on erect, inspiratory PA radiographs. The upper left heart border bulges laterally arrow on Figure A and posteriorly arrow on Figure B. Compare with Figures A and B.
On the lateral view, the left heart border moves inferoposteriorly. The aorta is so tortuous that even the aortic arch is visible. In the frontal projection, the normal right heart protrudes slightly to the right of the spine, and an enlarged heart protrudes further to the right soft science, at best. In the lateral projection, the right heart enlarges anteriorly and superiorly. The normal right heart contacts the lower one third of the sternum, whereas the enlarged right heart contacts the lower one half.
In a supine patient, what happens to blood flow? This is called cephalization or vascular redistribution. Cephalization, not heart size, is the key to diagnosing elevated left heart pressure. Compare Figure A and Figure B until cephalization is absolutely clear.
A shunt e. The patient in Figure B is in left heart failure. There is enlargement of the upper lobe vessels cephalization. This is mild left heart failure because the vessel margins remain distinct i. Which patient has prominent upper lobe vessels as a result of an atrial septal defect?
Figure A shows mild left heart failure. The upper and lower lobe vessels are equal, and there is no edema. Fluid thickens the interlobular septa, causing short lines perpendicular to the pleural surface. Figure C is a close-up of Kerley B lines arrows in a different patient. With alveolar edema, the pulmonary vessels may not be visible. In addition: A. Kerley also described A and C lines.
He was obviously a splitter, rather than a lumper. We will not worry about A and C lines. Figure is a CT scan of Kerley B lines arrows. With interstitial edema, crackling rales are audible.
With alveolar edema, rales are audible. Is there cephalization? Is there edema? Is there a pleural effusion? There are no significant signs of left heart failure. Figure , a CT scan of a different patient, shows a pericardial effusion P , bilateral pleural effusions, and left lower lobe consolidation atelectasis. Echocardiography, CT, and MRI accurately depict pericardial effusions, but echocardiology is most cost-effective.
Clinical Pearl: Marked generalized enlargement of the cardiac silhouette, with no or mild signs of left heart failure, is most likely due to pericardial effusion. Cardiomyopathy and multivalvular heart disease may have a similar radiographic presentation. These should be evaluated on every x-ray before your standard search. You are done. There is no review quiz. Take a break! When you come back, challenge yourself to the dozen great quiz cases in the last section. The CD on the back cover is worth a look.
Principles are as important as facts. If you master the principles, you can make up the facts. You learn better when you know your goals. Follow your cases. Like sex, learning is better if you are actively involved. When you read, talk back to the author.
Be skeptical. Reinforcement is essential for acquiring knowledge. See a case, look it up; read an article, find a case or ask a question. Reward is important for learning. Show off what you know. Brag a little. Speak up in class. Different people learn best by different methods. Figure out your own best method and cater to it, whether it be reading, listening, observing, or doing, or a combination of these.
They are as rare as great students. Quick retrieval of once-acquired information is crucial. The home computer is ideal but other good retrieval methods are available. Create your own personal modification and keep improving it. Divide your study time into prime time, work time, and sleepy time. Biorhythms vary widely among students, so develop your own study schedule. Felson, B. Read the history. Then, and only then, answer all questions before you turn to the answers on the next page.
Many patients have several abnormalities that you can combine to arrive at a diagnosis. Metal nipple markers have been placed to distinguish nipples, which sometimes show on x-rays, from real pulmonary nodules. Is the lung abnormal? Are there any changes to suggest pleural effusion? What type of surgery did the patient have?
Diagnosis: Can you combine the history and x-ray findings to suggest a diagnosis? Yes, below the right nipple marker, where the ribs cross, there is a pulmonary nodule. The costophrenic angles are sharp. The stomach bubble sign is absent. Diaphragms are normally shaped. The right shoulder has been amputated.
A systematic approach helps avoid embarrassing misses. Quickly grasp the radiology fundamentals you need to know—including basic science, image interpretation, and terminology—with the popular "programmed learning" approach, which promotes fast learning and reference. Benefit the from more robust interactive offerings in an e-book format. On the first rotation in chest imaging, radiology residents are asked to learn significant amounts of information at a fast and unrelenting pace. However, most current books are densely written and contain far more material than residents need to know.
Moreover, the number, variety, and quality of images is often limited. This book covers such topics as volume loss, pneumonia, pulmonary edema, inhalation diseases, and pulmonary, mediastinal, and pleural tumor imaging. In addition, it contains tips on approaching and interpreting chest radiographs and CT based on decades of practical experience and teaching residents at the work station. With liberal use of illustrations in the text and an online bank of many more high-quality images, this book gives readers a comprehensive library of chest imaging scans and serves as an ideal guide for radiology residents.
This edition includes nearly new images obtained with state-of-the-art technology and a new chapter on cardiac imaging. A new patterns of lung disease section provides a one-stop guide to recognizing and understanding findings seen on thin-section CT.
This edition also includes the new classification of idiopathic interstitial pneumonias, current techniques for evaluating solitary pulmonary nodules, an algorithm for managing incidental nodules seen on chest CT, the new World Health Organization classification of lung tumors, and numerous new cases in the self-assessment chapter.
James Reed, walks you through a logical, sequential thought process for the differential diagnoses of 23 radiologic patterns of common chest diseases, using superbly illustrated patient cases. Heavily illustrated with chest radiographs and additional CT, HRCT, and MR correlative images; plus bulleted summary boxes of comprehensive diagnoses lists and interpretation points. An ideal resource for mastering this lower-cost modality before considering more complicated and costly procedures.
Illustrated case studies and quizzes feature new and improved questions that address the challenges seen in practice today.
Page Count. Discern the nuances between modalities by comparing CT and MR images as well as traditional radiographs.
View detailed clinical images covering all the image types you'll see on the boards including digital quality radiographs and an introduction of PET imaging, plus more advanced imaging such as CT and MRI than ever before. Test your skills and simulate the exam experience with updated content aligned with the new MCQ-format Board exam for easy preparation and review. Benefit the from more robust interactive offerings in an e-book format? Expert Consult eBook version included with purchase.
0コメント