Radiology II
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🫁 Lung
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more infos below
- Bone abnormalities? (scoliosis, rib fx)?
- Thorax size? (↑ - emphysema)
- chest wall mass? (obtuse angle - Bernou sign)
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- bone deformities
- Kypo-scolisosis / scoliosis 📷
- pectus excavatum 📷
- Rib deformities / fractures 📷
- emphysema (↑size) 📷
- chest diameter↑
- Diaphragm: flattening
- Ribs
- Horizontal disposition
- widened intercostal spaces
- → usually 7-8 ant. ribs seen → >8 in emphysema
- heart: vertical (falls down)
- hyperlucencies w/ visible vessel (might not be that obvious)
- Chest wall tumors 📷
⇒ (might overlay pathology)
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if in the middle → CT might be needed to differentiate intra-pulmo vs. chest wall (see later)
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- ↑opacity?
- heart
- vessels
- LN
- tumor
- shifted?
- atelectasis
- pleural effusion, pneu
- adhesions (pleural)
- dynamic alterations?
- complete?
- incomplete?
- inspiratory bronchial stenosis → towards stenosis
- expiratory bronchial stenosis → towards opposite side
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more infos below
- elevation?
- flat? (emphysema)
- costophrenic angle?
- mobility? (Hinge signs = costophrenic symphysis)
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- Elevation of hemidiaphram?
- >1,5(-2)cm height compared to contralat.→ pathologic 📷
- Etiology: Pleural effusion (→US!), phrenic n. paralysis, hepatomegaly
- ↓ mobility?
- check with fluroscopy or 2xrays (inspir. + expir.)
- adhesions? (peridiaphgramatic inflammation→fibrosis)
→ HINGE SIGN (costrophrenic symphysis) 📷
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pic 1: inspiration pic 2: expiration
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- Localization
- chestwall: Bernou sign = obtuse angle 📷 (betw. border of lung and mass)
- pulmonary: acute angle 📷
- Silhouette sign 📷→ contour blurred when 2 object in contact (if Ø→ superimposed)
- diffuse
- How many lesions? (number)
- Whats the form of the lesion? Size? homogenous/inomogenous
- border / contour?
- relation with sourrunding
- Intensity compared to heart
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- Localisation: Pulmonary region in PA, lobes, segments, fissures (PA and LL)
- Number: How many lesions?
- Shape: Systematized or non-systematized
- Size: Dimensions of the lesion
- Contour/Outline: Sharp, sharp and linear (fissure), ill-defined, regular/irregular (infiltrating, lobulated)
- Structure: Homogeneous or inhomogeneous
- Nature: Fatty, soft tissue, bony (calcium)
- Intensity: Greater than, less than, or equal to the heart
- Relation with Surrounding Structures: Relationship with adjacent structures
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- localized?
- vessel vs. Ø vessel?
- vessels → emphysema
- Øvessel → enclosed air cavity (sharp outline - wall)
- diffuse?
- vessel vs Øvessel + uni vs. bilat
- vessels
- bilat → emphysema 📷, ac. asthma
- unilat → stenosis main bronchus
- assoc. signs
- ↑size: thorax + pulmonary volume
- Air trapping: ↓Insp.+exp. difference
- pulmonary arteries abnormalities
- Øvessels
- lateral → pneumothorax (see below)
- intra-pulmonary → large cavity/air cyst
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“
- Localization: circumscribed / diffuse
- Number: for circumscribed lesions
- Dimensions: for circumscribed
- Outline: for circumscribed (thin/thick wall)
- Structure: with/without vessels
- Relation with the surrounding structures
- Dynamic: size decreased/increased at inspiration/expiration maneuvers”
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air-fluid level ⇒ always horizontal
- Mixed cyst
- Partially evacuated abcess 📷
- if completely evacuated ⇒ air cavity
- if Ø evacuated → cant be seen!
- walls?
- thick irregular → recent abscess
- thin + calcification → chronic abscess
- Partially evacuated hydatic cyst (+waterlily sign → wavy 📷)
- if completely evacuate ⇒ air + small opacity
- if Ø evacuated → homogenous opacity
- Infected air cyst
- Hydropneumothorax 📷 📷
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Remember:
Straight surface = Abscess Wavy surface = Ruptured hydatid cyst
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- Prominence of pulmonary vessel?
- large vessels?
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→ see pleural syndrome
pneumo, effusion?
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thickened bronchial wall
⇒ w/ shift towards (inspiratory valve) ⇒obstructive atelectasis (when complete)
⇒ or hyperinflation w/ shift away (expir. valve)
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in lung tumor:
complete = obstructive atelectasis
incomplete inspiratory valve = hypoventilation + pneumonia
incomplete expiratory valve = hyperlucency
thickening of bronchial walls: 📷 peribronchial “cuffing” (in asthma & chronic bronchitis)
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DIRECT SIGNS:
- ↓volume: pulmo+thoracic
- Øair bronchogram
- if lobar / systemized:
- retraction of fissures (inverted S) 📷
- triangle-shape
INDIRECT SIGNS:
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- Diffuse / non-systemized + non-confluent
- low intensity
- DDx features interstial syndrome vs. bronchopneumonia:
- sharp border (??)
- slow evolution
→ see also “interstital pneumonia”
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Xray, US, CT
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- lateral hyperlucency
- Ø Pulmonary pattern (Øvessels)
- medial = adjacent lung (visc. pleura edge visible)
- lat = parietal pleura
- Lung collapse (atelectasis) towards hilum
- diaphram compression + incr. intercostal space
- Etiology:
- Trauma
- Spontaneous (i.e. emphysema)
- Ømediastinal shift
- if Mediastinal shift ⇒ 🚑 Tension-Pneumothorax!
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F - clinical
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- Cardiac
- Tumor
- Infection (exudates)
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⇒ can be FREE OR LOCULATED (i.e. in the fissures)
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SMALL: 📷
⇒ Diaphragm
- blurred outline
- loss of costro-phrenic angle
- mobility testing (→ DDx: CP-symphisis)
- ↓motility of diaphragm
- effusion moves with diaphragm
MEDIUM: 📷
⇒ ascends on lat thorax
- concave + blurred upper outline
- mobile opacity ( with position )
- Øair-bronchogram
LARGE: 📷
⇒ Apex reached
- Mediastinal shift away
- ↑Volume
⇒ if Ø shift → consider assoc. atelectasis
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👉🏽
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= effusion + pneumothorax
Mixed image (Pneu + Effusion) ⇒ Basis + lat changes
- Inf: Opaque
- Sup: Radiolucent (Pneu signs)
- AIR FLUID LEVEL (unlike pleural effusion)
- free vs. loculated!
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freq. iatrogenic (or post-traumatic)
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FROM INSIDE OR OUTSIDE
- Lung parenchyma
- intercostal + intermammary vessels
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same as pleural effusion
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👉🏽
pleural calcifications: 📷
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- Inflammatory non-suppurative pneumonia
- Inflammatory suppurative pneumonia
- Primary: abscess, pulmonary gangrene, diffuse pulmonary suppuration
- Secondary: complication of pneumonia, bronchiectasis, pulmonary cysts
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👉🏽
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- Peribronchial + perivascular thickening (interstital edema)
- reticular infrahilar band (opaque)
- micro/macronodular opacities
👉🏽
📷 (infrahilar bands; nodules; prominent hili = thickening can be seen)
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Classics benign vs. malignant features
(malignant → + rib lysis, pleural effusion, LN)
Benign | Malignant | |
Border | sharp | irregular |
Structure | homogenous, solitary, round | heterogenous |
calcifications | hamartoma | (”scar cancer”) |
sourrundings | Ø | - rib lysis
- pleural effusion
- LN (hilum)
- pulmo mets |
growth | slow | faster (2x 3-6m) |
Complications | central necrosis
|
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- Adenoma 📷
- Fibroma
- Hamartoma
- Lipoma
- Chondroma
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- Central / Hilar
- exobronchial (outside of bronchi)
- endobronchial (involving bronchi)
- complete = obstructive atelectasis 📷
- incomplete
- expiratory valve → hyperlucency
- inspiratory valve → hypoventilation + pneumonia
- Peripheral
- Malignant outline! (irregular outline, spicules, “tail”) ⇒ see illustration in lecture
- Bronchialveolar 📷
- diffuse
- patchy or might be confluent
⇒ compare above
→ bronchoscopy!
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CLASSIC
- cough, dyspnea, hemoptysis
- pleuritic pain
- B- symptoms
- extension signs: recurr. laryngeal, phrenic n, dysphagia, SVC syndrome, pleural+pericardial effusion
- paraneoplastic syndrome
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- Benign masses
- mets
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INVADE sourrundings
- chest wall
- mediastinum
METS:
- Head
- Liver + adrenals
- bone
- Lung
- common mets
- lymphangitis carcinomatosis 📷
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- Breast cancer
- Bone cancer
- Thyroid cancer
- Seminoma and prostate cancer
- Uterine cancer
- Digestive tract cancer
- Renal cancer
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🫀 Mediastinum
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- SUP mediastinum ⇒ Sup. vena cava syndrome
- MIDDLE mediast ⇒ bronchi + recurr. laryngeal n. compression
- INF mediast. ⇒ Inf. vena cava syndrome
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- Xray (PA, LL) → identification
- CT +con→ characterization, extension, LN, (bone involvement)
- MRI +con → Spinal / nervous system
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👉🏽
- Enlarged mass in ant. mediastinum (enhancing) [red arrows]
- Mass effect → trachea (Dislocation/compression) [white arrow]
- retrosternal goiter vs. tumor?
- homogenous → retrosternal goiter
- inhomogenous cervical LN? invasive? → tumor
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scinti 📷
more details later
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anterior middle 📷 (anterior to asc. aorta on AP view)
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any XRAY LESION needs CT workup (consider all differentials)
DDx: Thymus pathologies (Hyperplasia, Thymoma, Carcinoma) + Teratoma
- Hyperplasia 📷
- Cyst 📷
- Thymoma 📷
- Carcinoma 📷
- Teratoma 📷
→ global enlarged → normal shape/outline
→ fluid density → wall calcification
→ benign features, → homogenous contrast uptake → +/- calcifications
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→ inhomogenous → WELL DEFINED OR INVASIVE/mets → inhomogenous contrast uptake
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→ fat + calcifications → cystic (uni or poly)
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normal findings:
⛵ thymic sail sign 📷 = normal in children
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Middle mediastinum 📷
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- Infectious
- Malignancy
- Primary: Lymphoma (HL+NHL)
- Secondary LN mets
- Granulomatous
- Sarcoidosis
- Silicosis (egg shell)
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👉🏽
Stage | LN group | extralymphatic region |
1 | 1 ———> OR: | 1 |
2 | 2 ———>OR: 1+
(same side diaphragm) | 1
|
3 | 2
(both sides diaphragm) | +/- (spleen) |
4 | +/- | multiple organs |
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Posterior mediastinum (paravertebral) 📷
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- Periph nerves → Neurofibroma + Schwannoma (Neurinoma)
- Sympathetic → Neuroblastoma
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👉🏽
Xray - Neurinoma 📷
- opacity (paravertebral)
- Øsilhouette sign (behind heart)
- round/oval
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Pathology of other structures in post. mediastinum
→ esophagus, thoracic aorta, spine
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🫀 Heart
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MRI → myocard + septum; CT → other structural problems
Soft tissue evaluation!
- MYOCARD
- MI
- hypertrophy (+wall function)
- tumor invasion (also pericardal tumor)
- SEPTUM
- defects? 📷
- Other imaging exams: echo, xray, scinti, angio, catheter
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→ see below
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LEFT → Backwards (retrocardial)
Right → Forwards (retrosternal)
⇒ touches >1/3 of retrosternal clearspace (inner ant. chest wall) 📷
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- Aortic knob: >35mm distance to lateral. air border of trachea 📷 📷
- ↑Pressure/Flow
- Aortical wall abnormalities
- Main Pulmonary artery (might not be seen)
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→ Normal: 0-15mm medial from tangent line (aortic knob→LV) 📷 📷
→ If extends beyond (convexity?) ⇒ Pulmonary artery HT (↑Pressure/flow)
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Venous → pulmonary capillary p >(10-)12
Arteral → PAP systolic >25 OR PAP median >15
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- Oligemia ⇒ ↓blood into lungs (obstrucion (PA stenosis), ↓V (hypovolemia +R-L shunt)
- Hyperemia
- Venous PHT
- Arterial PHT
- venous PHT (LV congestion)
- Obstruction
- embolism
- Primary PHT
⇒↑blood into lung (PA regurg, ↑V( hypervolemia, L-R shunt)
⇒ LV congestion (mitral stenosis, LV failure)
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Lung: hyperlucent (olgemia + arterial PHT) vs. congested (venous PHT)
Lung | Hili | Vessels | Felix rim (Fleischer signs) | |
Oligemia 📷 | Hyperlucent periph. (Westernmark) | small + frail | small (+ not filled) | enlarged PA 📷 |
Hyperemia 📷 | Hyperlucent (relative) | Arterial hili | dilated + redistribution (cephalization) | Ø |
mild venous PHT (12-18mmhg) 📷 | Venous hilum | visible pattern + redistribution
(cephalization) 📷 | Ø | |
moderate venous PHT
(18-25) 📷 | 1. interstital edema
→ Kerley A+ B, blurred hilum (cuffing) , vascular opacities
2. pleural effusion (free/loculated)
📷 | “ | “ | |
severe venous PHT (>25) 📷 | (acute) alveolar edema
→ air-space filling syndrome
→ central Bat/butterfly wing | “ | “ | |
arterial PHT 📷 | Hyperlucent
(periph collapse) = Westermarck sign) |
Large + „Amputated” = embolus
(Goodwin/Knuckle sign)
| ↓periph. vessels
Pulmonary artery >15mm from tangent | enlarged PA (ri. desc. pulmonary artery) 📷 |
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Pulmonary Arterial Congestion | Pulmonary Venous Congestion |
Active congestion | Passive congestion |
Pulmonary arterial hypertension | Pulmonary venous hypertension |
Constricted arterial vessels | Prominence and thickening of upper lobe vessels |
Dilated hilar trunks | Prominence of lower lobed vessels |
Pulmonary vasculature on CXR findings | Hazy hilar vessels present |
Seen in ASD, VSD, PDA | Seen in left sided obstruction such as mitral or aortic valve defects regurgitation and stenosis |
Roentgen features of Kerley A, B, C lines | |
Kerley B Lines= pulmonary venous pressure is at 17- 20 mmHg | |
Pulmonary edema= > 25 mmHg |
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👉🏽
- apex lifted boot shaped (”coeur en sabot”)
- prominent pulmonary artery (aPHT)
- retrosternal space filling (LL)
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also check LL view → ant or post ?
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⇒ Echo for all valvular pathologies
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👉🏽
- LA enlargment
- covex/straight appendix
- double-density sign
- elevation left main bronchus + ↑carina angle
- Venous pulmonary hypertension
- upper zone venous enlaregment
- pulmonary edema
- Progresses: arterial pulmonary HT, RV hypetrophy, trikuspid regurg
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👉🏽
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Mitral stenosis + regurgitation = ↑LA, venous PHT (or further)
Difference = LV enlargement ‼️ (also present in Aortic regurg + stenosis)
- LA enlargement (see above)
- Venous pulmonary hypertension
- upper zone vein enlargemen
- acute:edema
- LV enlargement
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👉🏽
- LV enlargement (hypertrophy → later dilation)
- post-stenotic dilation
- later: pulmonary venous cong
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Aortic regurgitation esp. effects the aortic knob + the asc. aorta while stenosis (usually) only leads to post-stenotic dilation of the asc. aorta.
Both are assoc. with an enlarged LV (like mitral regurg)
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👉🏽
- global enlargement (w/ clear margins)
- “lying on diaphragm” - shape change
- +/- signs of HF (clinic + radio)
- congestion (vPHT→ aPHT)
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🧣 Head & Neck
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eyeball, nerve, vessels, muscles, LACRIMAL GLAND
- Optic nerve
- Optic vein
- Eye muscles
- Lacrimal gland (look for classic malignant signs)
- eye ball (shape/outline, position, symmetry, walls, post. fat)
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#1 US (with doppler, 2D, elaso) → thyroid + LN (see pathologic LN)
→ nodules? → #2 scinti (”cold” vs. “hot” nodule) 📷
→ malignant? → #3 CT/MRI (con) 📷
⇒ extension? ⇒ LN?
👉🏽
Algorithm - Thyroid nodule: 📷
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- Morphology?
- Size?
- Symmetry?
- Homogenous? (cysts/nodules?)
- Extension?
- Blood vessels? (common cartoid + IJV) 📷
- cervical LN?
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🌶️ Blood vessels
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- int. thrombus / embolus /spasm
- aneurysm + dissection
- hemodynamic changes → ↑clotting
- ext. compression
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Leriche synd:
👉🏽
- Aorto-femoral obstruction → bilat.
- RICH COLLATERALS!
- Clinic:
- first sign = impotence
- Pain buttocks + lumbar → DDx lumbar disk
→ stenosis / occlusion
Burger D. (thrombangitis oblit.)
- Small terminal vessel → small caliber
- POOR COLLATERALS
- Clinic: young male, smoker
→ “spiral-like” + multiple thrombi
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👉🏽
- Hampton’s hump (focal subpleural density - evtl. triangular) & Knuckle sign (sharp cuttoff pulmonary artery) 📷
- Westermark signs (hyperlucent periph. vasc. → regional oligemia) 📷
- Indirect due to ↑ back pressure
- Pleural effusion 📷
- Elevated hemidiaphragm
- Signs of PH → Fleischner sign: Prominent PA + ↑diameter, cut-off
- ↑RV diameter
- angio → filling defect 📷
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🧠 Neuro
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- bone/calcifications
- fresh blood (first 7d)
- contrast
- foreign bodies
- (light gray: tentorium, venous sinuses)
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- hemorrhage (subacute)
- cerebral → 20d
- meningeal (subarachnoid) → 5d
- Other isodense structure → tumors + pus
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- chronic hemorrhage
- edema
- central necrosis (”behaves like fluid”)
- ischemia
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- Dead brain tisse
- ischemic lacuna + brain atrophy
- central necrosis: cystic tumor or met
- arachnoid cyst 📷
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↓Signal in both seq. (T1+T2)
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Diffusion weighted (DW) MRI
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- hyperdensity within blood vessel (hyperdense artery+vizualisation)
- Vasogenic edema (later cytotoxic edema): loss of grey & white differentiation → hypodense area
- CT + T1 → hypodense/-intense
- T2 → hyperintense
- edema & mass effect → loss of sulci +- ventricle compression
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Always respecting vascular territory!!
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- sharply demarked area
- black (similar to CSF → T2 hyperintense)
- +- contrast enhancing rim
- Hemorrhagic stroke (see “Trauma”)
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- approx. round well delineated lesion often at parasagittal convexity or falx
- hyper-isodense
- homogenous enhancing (compared to brain parenchyma)
- calcifications*
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- dural tail
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- mass effect
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- Hypodense Halo (edema)
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- 🫁 lung cancer
- 🍈 breast cancer
- 👻 malignant melanoma
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#1 in:
- Trauma
- bone tumor suspected
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- fracture line (dark)
- opcities in sinuses? (indirect sign of fx)
- Soft tissue changes?
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👉🏽
Acute: hyperdense = white (fresh blood)
days - 1 month = Subacute: Isodense
> 1 m. Chronic: hypodense = dark (w/ time loses its density d/t breakdown of hemoglobin)
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👉🏽
between skin & skull: 📷
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- between dura & skull
- arterial bleeding (middle meningeal a.)
- bi-convex (lemon shaped) (contained within sutures)
- Mass effect (midline shift + compression of ventricles)
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dural attachments/reflections:
- if contains air → mastoid / sinus fracture
- swirl sign if active extravasation of blood 📷⇒ immediate surgery!
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- between dura & arachnoid mater
- venous bleeding (cortical bridging veins)
- concave/crescent shape (concavity towards parenchyma) (not bound by sutures)
- midlineshift + compression of ventricles (might lead to brain herniation)
- crosses sutures
- Ø cross dural reflections (stops there)
- +/- underlying intra-parenchymal + interventricular bleeding
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- within subarachnoid space (between arachnoid & pia mater)
- aterial bleeding
- blood within cisterns, sulci, ventricles
- hyperdense falx cerebri
- Etiology: aneurysm, trauma (subarachnoid a. damage or extension)
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ANGIO (CT / MRI)
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Intraparenchymal Hemorrhage/Hemorrhagic Stroke
- hyperdense accumulation within parenchyma (fresh blood)
- hypodense halo (perilesional vasogenic edema)
- not respecting vascular territory
- mass effect → midline shift + ventricle compr. + brainstem herniation
- compression of sulci/not visible anymore (edema)
- +/- intra-ventricular (ventricular flooding due to BBB disruption)
- resorption or lacuna (intense black “CSF-like”)
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MRI: Hypo or Hyper depending on T1/T2 + age of bleeding
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Feature | CT | MRI |
Contour of the disk | ++++ | +++ |
Hydration of the disk | + | ++++ |
Contour of the dural sac | ++ | +++ |
Contents of the dural sac | - | ++++ |
Nerve roots | +++ | +++ |
Bones | ++++ | ++ |
Para-vertebral regions | +++ | +++ |
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👉🏽
- post. displacement of IVD
- protrusion into spinal canal
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- multiple lesion spread over entire column
- compression fractures
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- loss of height in the middle dimension (vertebral body)
- → height alteration of intravertebral space
- disrupted continuity of ant. line along vertebral bodies (missalignment)
- post. surface intact
- anterior wedging of the vertebral body
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- Xray (bone lesion?)
- CT (bone lesion? fresh blood? compression: dura/spinal cord/ root?)
- MRI ( spinal cord? (compression/section/contusion) dural sac? disk? meninges? extradural hematoma?)
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🚑 Emergencies
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- US → FAST
- Xray → slight doubts → CT
- EXAMINATION OF CHOICE IS ALWAYS CT
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4-9
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Trachea + Vessels
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abdominal organs
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Flail chest or flail thoracic segment occurs when 3 or more contiguous ribs are fractured in 2 or more places. The fractured segment will sink into the chest with inspiration and expand out of the chest wall with expiration opposite to the normal chest wall movement.
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in lecture it say 2 or more ribs (??)
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- Pneumothorax
- Hydropneumothorax
- Hemothorax
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2-3d ; severe up to 14
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- Pneumothorax (non-traumatic)
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- Cardiogenic
- Hydrostatic (renal, hyperhydration)
- ARDS (↑capillary permeability)
- inflammation (chemical/allergic)
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- Airspace-filling syndrome (see above)
- Central “bat wing” 📷
- Non-systemized (across fisures)
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- Signs of atelectasis (consolidation, ↓lung volume, segment collapse)
- If expiratory valve (ball valve) →hyperinflation
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- Infectious spread → Pleura + Neck
- Esophagus perforation
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- Fatty stranding + edema: ↑density
- fluid collections
- w/ air inclusion → air fluid levels
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Xray → see pneumomediastinum
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- Maxillary (Le fort 1-3)
- Mandibular
- Nasal bone
- Infraorbital
- Zygomatic (malar)
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→ see above
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- intra-axial ⇒ intrapranchymal ⇒ blunt traumatic = cortical contusion
- extra-ax ⇒ outside of parenchyma (Epidural, subdural, subarachnoid+ventricular)
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Intra-axial hemorrhage aka in CORTICAL CONTUSION
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frontal + temporal
→ “glide” over rough surface of skull base
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depressed fx
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- Hemorrhage → necrosis phase (white)
- Resorption + Organization phase (iso)
- Defect stage (containing CSF - black)
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- Aneurysmal subarachnoid hemorrhage (see above)
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→ Chance fx 📷
