DIAGNOSTIC IMAGING METHODS

HISTORY
1895-Wilhem Roentegen
Produced the 1st X ray film image of his wifes hands
X RAY
Form of radiant energy similar to visible light
Has very short wavelength
Penetrates many substances that are opaque to light
Produced by bombarding a tungsten target with an electron beam with an x-ray tube.
FILM RADIOGRAPHY
Utilize a screen film system within a film cassette ( x-ray detector)

COMPUTED RADIOGRAPHY (CR)

Filmless system
No processing
Produces A DIGITAL RADIOGRAPHIC IMAGES

DIGITAL RADIOGRAPHY
Filmless system
Substitutes a fixed electronic detector on charge-coupled device for the film screen cassette or
phosphor imaging plate.

CONVENTIONAL TOMOGRAPHY
Provides radiographic images of slices of the patient
Done by simultaneously moving both x-ray tube and x-ray detector around a pivot point center
to the patient
Improved detail

FLUOROSCOPY
Real time radiographic visualization of moving anatomic structures
Useful in evaluating motion such as gastrointestinal peristalsis, movement of diaphragm during
respiration and cardiac action

PRINCIPLES OF INTERPRETATION

5 basic radio densities

Air density
Fat density
Soft tissue density
Bone density
Metal/contrast agent density
Air attenuates very little of the x ray beam-most are transmitted-> black on radiograph
Bone, metal, contrast agent attenuates a large proportion of x ray beam-> white on radiograph.
Fat and soft tissue intermediate amt. of x ray beam-> shades of gray on radiograph
Anatomic structures are seen when outlined by tissues.
Contrast agents- suspensions of iodine or barium
Disease states may obscure normally visualize structures by silhouetting their outline.

CROSS SECTIONAL IMAGING TECHNIQUES

CT, MR, AND ULTRASOUND
Produced 2 dimensional image
Resulting image is made up of pixels which represent a voxel of patient tissue
COMPUTED TOMOGRAPHY
Displays each splice separately
No superimposed blurred structures seen.
Hounsfield unit (H) scale
o Air:1,000H
o Lung tissue :-400 to -600 H
o Fat:- 60 to -100 H
o Water: value of 0 H
o Soft tissue:+40 - +80 H
o Bone:+400 to + 1000 H
Most CT units allow slice thickness between 0.5 to .10mm
Advantages of CT compared to MRI:
o Rapid scan acquisition
o Superior bone detail and demonstration of calcification.
TYPES OF CT SCAN:
Conventional CT (non helical)
- Obtain image data one slice at a time- one slice per breath hold.
- Requires at least 2-3x the total scanning time of helical CT.
Helical CT (spiral)
- Improved speed of image acquisition.
- Improved visualization of small lesions.
- Scans entire abdomen, pelvis in 2-3 breaths.
Multidetector helical CT
- Latest technical advance in CT imaging
- Obtains multiple slices per tube rotation
5-8x faster than single slice helical CT.
DA: radiation dose, 3-5x higher than single slice CT.
Contrast administration in CT
- Intervenous iodine based contrast agents are administered in CT to:
o Enhance density differences between lesions surrounding the parenchyma.
o To demonstrate vascular anatomy and vessel patency.

PRINCIPLES OF CT INTERPRETATION

Images are oriented so that the observer is looking at the patient below.
Patients right side is oriented on the left side of the image.
Optimal bone detail is viewed at bone windows
Lungs are viewed at lung windows
Window width of 2,000 H, window level of 400-600H
Soft tissues
Window width of 400 -500 H, window level of 20-40H.
MAGNETIC RESONANCE IMAGING (MRI)
Produces images by means of magnetic fields and radio waves
Analyzes multiple tissue characteristics :
Hydrogen
T1 and T2 relaxation times of tissue
Blood flow within tissue
Provides the best tissue contrast.
Most tissues can be differentiated by differences in their T1 and T2 relaxation times.
Blood flow has a complex effect on MR signal that may decrease or increase signal intensity
within blood vessel.
Because the MR signal is very weak, prolonged imaging time is often required for optimal
changes.
ADVANTAGES OF MRI
Outstanding soft tissue contrast resolution
Provides images in any anatomic plate
Absence of ionizing radiation

DISADVANTAGES OF MRI
Limited in its ability to demonstrate dense bone
detail or calcifications
Involves long imaging of many pulse sequences
Possesses limited spatial resolution compared with
CT

CONTRAST ADMINISTRATION IN MRI:

Gadolinium chelates
- A heavy metal ion with paramagnetic effect that shortens T1 and T2 relaxation times of
hydrogen nuclei within its local magnetic field.
- Essential in providing high quality MR angiographic studies by enhancing the signal
differences between blood vessel and surrounding tissues.
- If very high tissue concentrations, such as the renal collecting system, T2 shortening
causes a significantly loss of signal intensity best seen on T2WIs.

SAFTETY CONSIDERATIONS:

MR is contraindicated in patients who have electrically, magnetically or mechanically activated

implants.
Cardiac pacemakers, insulin pumps, cochlear implants, neurostimulators, bonegrowth stimulators, and implantable drug infusion pumps.
Intracardiac pacing wires or Swan-Ganz catheters
Ferromagnetic implants such as cerebral aneurysm clips, vascular clips, and skin
staples.
Bullets, shrapnel, and metallic fragments may move and cause additional injury
or become projectiles in the magnetic field.
Metal workers and patients with heinous story of penetrating eye injuries
should be screened with radiographs of the orbit to detect intraocular metallic
foreign bodies that may dislodge, tear the retina and cause blindness.
SAFE FOR MRI
No ferromagnetic vascular clips and staples and orthopedic devices.
Prosthetic heart valves with metal components and stainless steel greenfield
filters
Pregnant patients can be scanned, provided the study is medically indicated.

Principles of Interpretation:
Soft tissue contrast is obtained through imaging sequences that accentuate differences in T1
and T2 tissue relaxation times.
Water is the major source of the MR signal in tissues other than fat.
Mineral rich structures, such as bone and calculi, and collagenous tissue such as ligaments,
tendons, fibrocartilage and tissue fibrosis are low in water contents and lack mobile protons to
produce an MR signal.
Low in signal intensity on all MR sequence
Free Water
Long T1 (low signal) and long T2 (high signal)
Found mainly as extracellular fluid, also as intracellular free water
Organs with extracellular fluid (free water)
Kidneys (Urine); ovaries and thyroid (fluid-filled follicles); spleen and penis (stagnant
blood); and prostate, testes and seminal vesicles (fluid and tubules)
Edema (increase in extracellular fluid) - prolongs T1 and T2 relaxation times.
Most neoplastic tissues have increase in extracellular fluid as well as an increase in the
proportion of intracellular free water bright signal intensity on T2WIs.

 Proteinaceous fluids
Addition of protein and free water shortens T1 relaxation time bright.
T2 relaxation is also shortened, but the T1 shortening effect is dominant even on T2WIsremain bright on T2WIs.
Synovial fluid, complicated cysts, abscesses, many pathologic fluid collections, and
necrotic areas within tumors.
Soft tissues
Soft tissues that have a predominance of intracellular bound water have shorter t1 and
t2 times than do tissues with large amounts of extracellular water.
Include the liver, pancreas, adrenal glands and muscle- intermediate signal
intensities on both t1wis and t2wis
Intracellular protein synthesis shortens t1 more.
Muscle (less active protein synthesis) is lower in signal intensity on t1wis
than are organs with more active protein synthesis
Benign tumors with a predominance of normal cells, such as focal nodular
hyperplasia in the liver, tend to remain isointense with their surrounding normal
parenchyma on all imaging sequences.
Hyaline cartilage has a predominance of extracellular water but extensively
bound to mucopolysaccharide matrix
Signal resembles cellular soft tissues intermediate on most imaging
sequences.
Fat
Protons in fat are bound to hydrophobic intermediate sized molecules and exchange
energy efficiently within their chemical environment.
T1 relaxation time is short resulting in a bright signal.
T2 is shorter than t2 of water lower signal intensity for fat, relative to water.
On images with lesser degrees of t2 weighting, t1 effect predominates and fat
appears isointense or slightly hyper intense compared with water.
Specialized fat saturation imaging sequences may be used to reduce the signal
intensity of fat and enhance the visibility of edema and pathologic processes within
fat.
STIR sequences suppress signals from all tissues with short t1 times, including fat.

Flowing blood
The MR signal of slow moving blood, such as in the spleen, venous plexuses and cavernous
hemangiomas is dominated by the large amount of extracellular water present.
Low signal on t1WIs and high signal on t2WIs

Ultrasonography
Utilizes pulse echo technique
Transducer converts electrical energy to a brief pulse of high frequency sound energy
transmitted into patient- transducer becomes a received detecting echoes of sound energy
reflected from tissue composite image is produced.
Produces nearly real time images of moving patient tissue.
Enables assessment of respiratory and cardiac movement vascular pulsations, peristalsis
and moving fetus.
Images may be produced in any anatomic plane by adjusting the orientation and angulation of
the transducer and the position of the patient.
Standard orthogonal planes: axial, sagittal and coronal.
Visualization of structures by US is limited by bone and gas contaminating structures (e.g. bowel
and lung)
Sound energy is nearly completely absorbed at interfaces between soft tissue and bone
causing an acoustic shadow limiting visualization of structures deep to the bone surface.
Soft tissue gas interfaces cause nearly complete reflection of the sound beam,
preventing visualization of deeper structures.

Doppler US:

Adjunct to real time gray scale imaging.

Detects reflection of the sound wave from a moving object RBC in flowing blood.
Can detect presence of blood flow and its direction and velocity.
Color Doppler
Gray scale + color coded Doppler information in a single image.
Stationary tissue shades of gray.
Blood flow and moving tissue colored.
Blood flow relatively toward the transducer face shades of red.
Blood flow relatively away from the transducer face shades of blue.
Lighter shades of color imply higher glow velocities

US Artifacts
Must be recognized to avoid diagnostic errors.
Acoustic shadowing
Produced by nearly complete absorption or reflection of the beam, obscuring deeper
tissue structures.
Produced by gallstones, urinary tract stones, bone, metallic objects, and gas bubbles.
Acoustic enhancement
Increased intensity of echoes deep to structures that transmit sound exceptionally well.
Such as cysts, fluid filled bladder and gallbladder.
Presence of acoustic enhancement aids in the identification of cystic masses.
Comet tall artifact is seen as pattern of tapering bright echoes trailing from small bright
reflectors
Such as air bubbles and cholesterol crystals.

PRINCIPLES OF ULTRASOUND INTERPRETATION

Fluid containing structures (cysts, dilated calyces and ureters, bladder and gallbladder
Well defined walls, absence of internal echoes, and distal acoustic enhancement
Solid tissue
Speckled pattern of tissue texture and definable blood vessels.
Fat: usually highly echogenic.
Solid organs (liver, pancreas, and kidney): lower degrees of echogenic.
Terminologies
Hypo echoic: lesions of lower echogenicity than surrounding parenchyma
Hyperopic: lesions of greater echogenicity than surrounding parenchyma
Anechoic: complete absence of echoes
E.g. simple cysts

TERMINOLOGY

AIR
FAT
WATER/FLUIDS

SOFT TISSUE
BONE/METAL

RADIOGRAPH
DENSITY
Radiolucent
black
Radio
opaque/radio
dense white

radiolucent
Moderately
radiolucent
Moderately radio
opaque
Moderately
radiopaque
Very radio
opaque

ULTRASOUND
ECHOLGENICITY
Anechoic black
Hypoechoic darker
than parenchyma
Hyperechoic
whiter than
parenchyma
Isoechoic same as
parenchyma
Not visualized
Hyperecholic

CT SCAN
DENSITY
Hypodense
darker
Hyperdense
whiter
Isodense
same as
parenchyma
Black
Hypodense

T1
Hypointense

T2
Hyperintense

Anechoic

hyperdense

Hypointense

Varying echogenicity

Varying
hyperdenseity
Very
hyperdense

hypointense

Lower
intensity
than water
hyperintense

Intermediate
intensity
Hypointense

Intermediate
intensity
Hypointense

Not visualized

MRI
INTENSITY
Hypointense darker
Hyperintense whiter
Isointense same as
parenchyma

PULMONARY RADIOLOGY

IMAGING MODALITIES:
Conventional Chest Radiography:
Posteroanterior (PA) and lateral chest radiographs are the mainstays of thoracic imaging
Initial imaging study in all patients with thoracic disease.
Proper radiographic technique on frontal radiographs involves assessment of four basic
features:
Penetration faint visualization of the intevertebal disc spaces of the thoracic spine:
discrete branching vessels can be identified through the cardiac shadow and the
diaphragms.
Rotation note the relationship between the medial cortical margins of the clavicular
heads and the spinous processes of the thoracic vertebrae.
Inspiration apex of the right hemidiaphragm is visible below the tenth posterior rib.

 Motion cardiac margin, diaphragm and pulmonary vessels should be sharply

marginated in a completely still patient.

Portable Radiograph:
Obtained when patients cannot be safely mobilized.
There is magnification of intra thoracic structures.
Normal gravitational effect evens out the blood flow between upper and lower zones in supine
patients.
Widened upper mediastinum.
Special techniques:
Lateral decubitus
Used to detect small effusions and characterize free-flowing effusions on the decubitus
side, or to detect a small pneumothorax on the contralateral side.
Expiratory radiograph
Detection of a small pneumothorax.
Apical lordotic view
Improves visualization of the lung apices
Chest fluoroscopy
Assess chest dynamics on patients with suspected diaphragmatic paralysis.
CT and HRCT
Long windows: window width of 1000 to 2000 H and window levels of about 500 to 600 H
Routine settings for CT display of mediastinal structures are WW = 400 and WL = 40 and for the
lungs are WW = 1500 and WL = 700
Advantages of CT scan:
Superior contrast resolution
Cross-sectional display format

Indication for thoracic CT

Indication
example
Evaluation of an abnormality identified on
conventional radiographs
Staging of lung cancer
Assessment of extent of the primary tumor and
the relationship of the tumor to the pleura, chest
wall
Detection of occult pulmonary metastases
Extrathoracic
Detection of mediastinal nodes
Lymphoma metastases infections
Distinction of empyema from lung abscess
Contrast-enhanced CT can usually distinguish a
peripheral lung abscess from loculated empyema

Detection of central pulmonary embolism

Detection and evaluation of aortic disease:
aneurysm, dissection, intramural hematoma,
aortitis, trauma

Anglo-CT with high inje

Detection and localization of extent, including
aortic branch involvement

HRCT technique involves incremental thinly collimated scans (1.0 to 1.5mm) obtained at evenly
spaced intervals through the thorax for the evaluation of diffuse bronchial or parenchymal lung
disease.

Indication of Thoracic HRCT

Indications
Examples
Solitary pulmonary nodule
Breath-hold volumetric exam with thin
collimation for accurate density determination
without respiratory misregistration
Detection of lung disease in a patient with
Emphysema
pulmonary symptoms or abnormal pulmonary
Extrinsic allergic alveolitis
function studies and a normal or equivocal chest
Small airways disease
film
Immunocompromised patient
Evaluation of diffusely abnormal chest film
A baseline for evaluation of patients with chronic Cystic fibrosis
diffuse infiltrative lung disease for follow-up
Sarcoidosis
changes with therapy
Interstitial lung disease
Histiocytosis x
Adult respiratory distress syndrome
To determine approach (type and location) of
Bronchoscopy versus VATS or needle biopsy
biopsy
Image acquisition time is limited to minimize the effects of respiratory and cardiac motion.

MRI
Morphologic studies usually require only spin echo T1W and T2W sequences in the axial plane.
Advantages of MRI:
Superior contrast resolution between tumor and fat
Ability to characterize tissues based on T1 and T2 relaxation times
Ability to scan in direct sagittal and coronal planes
Lack of need for intravenous iodinated contrast
Disadvantages of MRI
Limited spatial resolution

 Inability to detect calcium

Difficulties in imaging the pulmonary parenchyma
More time-consuming and expensive than CT

Indications for MR of the Thorax

Evaluation of aortic disease in stable patients: dissection, ancurysm, intramural hematoma, aortitis
Assessment of superior sulcus tumors
Evaluation of mediastinal, vascular and chest wall invasion of lung cancer
Staging of lung cancer patients unable to receive intravenous iodinated contrast
Evaluation of posterior mediastinal masses

Ultrasound
Used for the detection, characterization and sampling of pleural, peripheral parenchymal and
mediastinal lesions
Can also confirm phrenic nerve paralysis without the use of ionizing radiation
Detects subpulmonic and subphrenic fluid collections

NORMAL LUNG ANATOMY

Tracheobronchial Tree
Trachea
Hollow cylinder composed of a series of c-shaped cartilaginous rings
Seen as a vertically oriented cylindric lucency extending from the cricoid cartilage
superiorly to the main bronchi inferiorly on chest radiographs.
Bronchial system
Exhibits a branching pattern of asymmetric dichotomy
Main bronchi arise from the trachea at the carina
Right bronchus forms a more obtuse angle with the long axis of the trachea and is
considerably shorter than the left main bronchus
Bronchi on the end can be seen as a ring shadow on the chest radiographs
Tracheal and main, lobar and segmental bronchial anatomy are easily seen on CT
Pulmonary arteries
Arises from the right ventricle
Left pulmonary artery is a direct continuation of the main pulmonary artery
Right artery divides into the truncus anterior and interlobar arteries

Bronchial arteries
Primary nutrient vessels of the lung
Usually arise from the proximal descending thoracic aorta at the level of the carina

Pulmonary veins
Arise within the interlobular septa from the alveolar and visceral pleural capillaries
Lobar and segmental anatomy
Interlobar fissures
Invaginations of the visceral pleura
Completely or incompletely separate the lobes from one another
There are two interlobar fissures on the right and one on the left
Right minor fissure separates the middle from the upper lobe

Projects as a thin undulating line on frontal radiographs and as a thin

curvilinear line with a convex superior margin on lateral radiograph
Right and left major fissure separates the lower lobe from the upper lobe
superiorly and from the middle lobe inferiorly
Not usually visualized on frontal radiographs because of the oblique
course relative to the x-ray beam
The upper lobe bronchus and its artery arising from the truncus anterior branch into three
segmental branches: anterior apical and posterior.
The middle lobe bronchus arises from the intermediate bronchus and divides into medial and
lateral segment branches, with its blood supplied by a branch of the right interlobar pulmonary
artery.
The lower lobe (RLL) is supplied by the RLL bronchus and pulmonary artery. It is subdivided into
a superior segment and four basal segments: anterior, lateral, posterior and medial.
Left upper lobe is subdivided into four segments: anterior, apicoposterior, and the superior and
inferior lingular segments.
The superior and inferior lingular arteries are proximal branches of the left inter-lobar
pulmonary artery analogous to the middle lobes blood supply.
Arterial supply to the anterior and apicoposterior segments parallels the bronchi and is via
branches of the upper division of the left main pulmonary artery.
The left lower lobe has a superior segment and three basal segments: anteromedial, lateral and
posterior.

Pulmonary lymphatics
Visceral pleural lymphtics
Reside in the vascular layer of the visceral pleura
Form a network over the surface of the lung that roughly parallels the margins of the
secondary pulmonary lobules
Penetrate the lung to course centrally within interlobular septa, along with the
pulmonary veins toward the hilum
Parenchymal lymphatics
Originate in proximity to the alveolar septa (juxta-alveolar lymphatics)
Course centrally with the Broncho arterial bundle
Perivenous and bronchoarterial lymphatics
Communicate via obliquely oriented lymphatics located within the central regions of the
lung.
The perivenous lymphatics and their surrounding connective tissue when distended by
fluid account for the radiographic appearance of kerley a lines.

Pulmonary interstitium
Provides support for the airways and pulmonary vessels
Begins within the hilium and extends peripherally to the visceral pleura
Axial interstitium
Extends from the mediastinum and envelopes the bronchovascular bundles
edema within is recognized radio graphically as per bronchial cuffing.
Centrilobular interstitium
These are axial fiber system continues distally along with the arterioles, capillaries, and
bronchioles to provide support for the air exchanging portions of the lung.
Peripheral interstitium
Where the pulmonary veins and lymphatics lie within
subpleural interstitium (and interlobular septa)
Parts of the peripheral inerstitium which divides secondary pulmonary lobules
Radio graphically, edema of the peripheral and supleural interstitium accounts for kerley
b lines (or interlobular lines on HRCT) and thickened fissures on chest radiographs.
Intralobular interstitium
Bridges the gap between the centrilobular and peripheral compartments.
Pathologic involvement may account for some cases of so called ground glass opacity on
chest radiographs and HRCT scans.
Respiratory bronchioles contain a few alveoli along their walls and give rise to the gasexchanging units of the lung:
Alveolar ducts
Alveolar sacs
Type 1 pneumocyte
Flattened squamous cells
Incapable of mitosis or repair
Type2 pneumocyte
Cuboidal cells
Course of new type 1 pneumocytes and provide a mechanism for repair
following alveolar damage
Source of alveolar surfactant

Posterioranterior chest radiograph

Soft tissues
Consist of the skin, subcutaneous fat and muscles
Visualization of normal fat in the supraclavicular fossae and the companion shadows of
skin and subcutaneous fat paralleling the clavicles helps exclude mass, adenopathy or
edema in his region.
The inferolateral edge of the pectoralis major muscle is normally seen curving towards
the axilla
Breast shadows should be evaluated routinely to detect evidence of prior mastectomy
or distorting mass.
Bones
Thoracic spine, ribs and costal cartilages, clavicles, and scapulae are routinely visible on
frontal chest radiographs.
The bodies of the thoracic vertebrae should be vertically aligned, with endplates,
pedicles, and spinous processes visualized.
Coastal cartilage calcification is seen in a majority of adults, increase in prevalence with
advancing age. Men typically show calcification at the upper and lower margins (vaginal
sign). While the majority of women develop central cartilaginous calcification (penile
sign).
Lungs
Opacity of the lungs as visualized radiographically is attributable solely to th4 presence
of the pulmonary vasculature and enveloping interstitial structures.
Arteries are solid cylinders branching along the airways and both gradually diminish in
caliber as they divide.
Pulmonary veins can often be traced horizontally to the left atrium, whereas the arteries
caqn be followed to their hilar origin, which lies more cephalad than the left atrium.
The effects of gravity explain the basal predominance of vasculature in an upright
patient, as well as isodistribution of vessels in the supine patient.
Lung mediastinal interfaces
Superior vena cava
Straight or slightly concave interface with the right upper lobe extending from
the level of the clavicle to the superior margin of the right atrium.
Lateral margin of the right atrium
Projects just to the lateral margin of the thoracic spine on a normal PA
radiograph.
Smooth convex inter with the medial segment of the middle lobe.
Pectus excavatum- displaces the cardiac shadow leftward and may not
demonstrate this interface.
Right lateral border of the inferior vena cava
Concave lateral interface at the level of the right hemidiaphragm
Best visualized on lateral radiographs

 Aortic knob
Small convex indentation on the left lung
Aortopulmonary window
Inferior to the aortic arch
Usually straight or concave toward the lung.
Left lateral border of the main pulmonary artery
Inferior to the aortopulmonary window
This structure may be convex, straight, or concave toward the lung.
Enlargement is seen in diopathic condition in young women, poststenotic
dilatation in valvular pulmonic stenosis, conditions where there is increased
flow or pressure in the pulmonary arterial system.
Left atrial appendage
Forms a concave interface immediately below the main pulmonary artery.
Lateral border of the left ventricle
Comprises most of the left heart border as a gentle convex margin with the
lingua.
Diaphragm
Major inspiratory muscle comprised of muscular origins along the costal margins and
insertions into the membranousdome
Right hemidiaphragm
Overlies the liver
Apex typically lies at the level of the sixth anterior rib on frontal radiographs
exposed in deep inspiration, approximately one half interspace above the apex
of the left hemidiaphragm.
Left hemidiaphragm
Overlies the stomach and spleen
Lateral chest radiograph
Summation of the right hemi thorax over the left.
Knowledge of normal lateral radiographic anatomy can greatly aid in detection and localization
of parenchymal and cardiomediastinal processes.
Parenchymal lung disease:
Pulmonary opacity abnormal increase in lung density
Pulmonary lucency abnormal decrease in lung density

Pulmonary opacity
Airspace disease:
Develop when air normally present within the terminal spaces are replaced by material of soft
tissue density such as blood transudate, exudates or neoplastic cells.
Radiographic characteristics of airspace disease:
Lobar or segmental distribution
Poorly marginated
Airspace nodules
Tendency to coalesce
Bats wing or butterfly distribution
Rapidly changing over time
CT findings of airspace disease:
Lobar or segmental distribution
Poorly marginated that tend to coalesce
Airspace nodules
Air bronchogram
Differential diagnosis:
Pneumonia
Pulmonary edema
Hemorrhage
Neoplasm
Alveolar proteinosis
Interstitial disease:
Produced by processes that thicken the interstitial compartments of the lung with water bleed
tumor, cells, fibrous tissue or any combination of these
Patterns of interstitial disease are divided into:
Reticular network of curvilinear opacities
Fine reticular or ground glass pattern
1 to 2 mm of intervening lucent spaces
Seen in interstitial pulmonary edema and interstitial pneumonitis
Medium reticulation or honeycombing
3 to 10 mm
Seen in pulmonary interstitial fibrosis
Coarse reticular pattern
<1 cm
Seen langerhanscell histiocytosis of the lung, sarcoidosis and idiopathic
pulmonary fibrosis.
Reticulonodular

May be produced by overlap of reticular shadows or presence of both

nodular and reticular opacities.
Silicosis, sarcoldosis and lymphangitic carcinomatosis give rise to true
reticulonodular pattern.

Nodular homogenous, well defined, small rounded lesions within the

pulmonary interstitium.
Military < 2 mm
Micro nodules 2 to 7 mm
Nodules 7 to 30 mm
Masses 30 mm
Military or mironodular pattern are seen in granulomatous processes
(military or histoplasmosis) hematogenous pulmonary metastasis
(thyroid and renal cell
And pneumoconiosis (silicosis)
Nodules and masses are seen in metastatic disease to the lung
Linear processes that thickens the axial (Broncho vascular) or peripheral
interstitium of the lung. Produce parallel linear opacities radiating from the hila
when visualized in length or peribronchial cuffing when visualized end on.
Kerley A lines - < 1 mm thick lines obliquely oriented and course through
the lung toward the hila 2 to 6 cm long.
Corresponds connective tissue within the lung
Kerley B lines peripheral lines that course perpendicular to and
contact the pleural space 1 to 2 cm long.
Represent thickened peripheral subpleural interlobular septa.

Atelectasis:
Incomplete expansion of the lungs
4 mechanisms of atelectasis:
Obstructive/resorptive atelectasis
Most common form
Secondary to complete endobronchial obstruction of lobar bronchus with
resorption of gas distally
Common causes are bronchogenic carcinoma foreign bodies mucous plugs and
malpositioned endotracheal tube.
Passive/relaxation atelectasis
Result from mass effect of an air or fluid collection within the pleural space on
the adjacent lung.
Causes are pneumothorax and pleural effusion.
Compressive atelectasis

Form of passive atelectasis in which intrapulmonary mass compresses adjacent

lung parenchyma.
Causes include bullae, abscess and tumors.

Cicatricial atelectasis
Produced by processes resulting in parenchymal fibrosis and reduce alveolar
volume.
Most often seen in chronic upper lobe fibrotic tuberculosis.
Adhesive atelectasis
Occurs in association with surfactant deficiency disease.
Radiograph show diminution in lung volume.
Pulmonary lucency
Abnormal lucency of the lung may be localized or diffuse
Diffuse lung lucency
Unilateral hyperlucency
Result in decrease in blood flow to the lung.
Hypoplasia of the right or left pulmonary artery.
Lobar resection or atelectasis
Pulmonary arterial obstruction
Swyer james syndrome
Emphysema most common with severe disease
Bilateral hyperlucent lung:
May be simulated by an over penetrated film or by a thin patient
Result of diminished pulmonary blood flow
Congenital pulmonary stenosis
Pulmonary emphysema
Asthma
Focal radiolucent lesions
Includes cavities, cysts, bullae, blebs and pneumatoceles
Cavities
Form when a pulmonary mass undergoes necrosis and communicates
with an airway
The wall of a cavity is usually irregular or lobulated
Wall is greater than 1 mm thick
Lung abscess and necrotic neoplasm are the most common cavitary
pulmonary lesions

Bulla

Gas collection within the pulmonary parenchyma

>1 cm in diameter and has a thin wall <1 mm thick
Represents a focal area of parenchymal destruction (emphysema) and
may contain fibrous strands, residual blood vessels or alveolar septa

Air cyst
Well-circumscribed intrapulmonary gas collection
Smooth thin wall >1 mm thick
Bleb
Collection of gas <1 cm in size within the lawyers of the visceral pleura
Usually found in the apical portion
Not seen on plain radiographs but may be visualized on chest CT
Rupture can lead to spontaneous pneumothorax
Pneumatoceles
Thin-walled, gas-containing structures
Represent distended airspaces distal to a check-value obstruction of a
bronchus or bronchiole
Most commonly secondary to staphylococcal pneumonia

Pneumonia:
Microorganisms enter the lung via three potential routes:
Tracheobronchial tree
Pulmonary vasculature
Direct spread from infection in the mediastinum, chest wall or upper abdomen.

1.

Lobar pneumonia:
Typical of pneumococcal pulmonary infection.
The inflammatory exudate begins within the distal airspaces.
Airways are usually spared, air bronchograms are common and significant volume loss is
unusual.

2.

Bronchopneumonia:
Most common patterns
Most typical staphylococcal pneumonia
Early stages of inflammation is centered primarily in and around lobular bronchi
As the inflammation progresses, exudative fluid extends peripherally along the bronchus to
involve the entire pulmonary lobule.

 Radio graphically, multifocal opacities that are roughly lobular in configuration produce a
patchwork quilt appearance.
Exudate within the bronchi accounts for the absence of air bronchograms in bronchopneumonia
3. Interstitial pneumonia
Seen in viral and mycoplasma infection
There is inflammatory thickening of bronchial and bronchiolar walls and the pulmonary
interstitium
Radiographic findings pattern of airways thickening and reticulonodular opacities
Segmental and sub segmental atelectasis from small airways obstruction is common.

Pulmonary tuberculosis:
Mycobacterium tuberculosis is an aerobic acid fast bacillus
Two principal forms of tuberculous pulmonary disease are recognized clinically and
radiographically
Primary tuberculosis (TB)
Reactivation or post-primary disease
Involves cell-mediated immunity (delayed hypersensitivity)
Primary PTB:
Has classically been a disease of childhood
Ranke complex: calcified parenchymal focus (the ghon lesion) and nodal calcification.
Nonspecific focal pneumonitis seen as small ill-defined areas of segmental or lobar
opacification.
Unllateral/ollateral hilar or mediastinal lymph node enlargement.
Post-primary PTB:
Tends to occur in the apical and posterior segments of the upper lobes and the superior
segments of the lower lobes as ill-defined patchy and nodular opacities.
Cavitation: may lead to transbronchial spread of organisms and result in a multifocal
bronchopneumonia.
Rasmussen aneurysm erosion of a cavitary focus into a branch of the pulmonary artery can
produce an aneurysm and cause hemoptysis.
Parenchymal healing is associated with fibrosis, bronchiectasis and volume loss (cicatrizing
atelectasis) in the upper lobes.
Military TB:
May complicate either primary or reactivation disease.
Results from hematogenous dissemination of tubercle bacilli and produces diffuse
bilateral 2 to 3 mm pulmonary nodules.

Asthma:
An airway disorder characterized by the rapid onset of bronchial narrowing with
spontaneous resolution or improvement as a result of therapy.
Radiographic findings include:
Hyperinflation
Bronchial wall inflammation and thickening (peribronchial cuffing and tram tracking)
In some patients the hila are prominent from transient pulmonary arterial hypertension.

Emphysema:
Defined as an abnormal permanent enlargement of the airspaces distal to the terminal
bronchioles accompanied by destruction of alveolar walls and without obvious fibrosis.
Frontal and lateral chest radiographs are the initial radiographic examinations obtained in
patients with suspected emphysema.
Hyperinflation most important plain radiographic finding.
1. Centrilobular emphysema
Most common affects the upper lobes to a greater extent than the lower lobes
Airspaces distention in the central portion of the lobule sparing of the more distal portions of
the lobule.
2. Panlobular emphysema
Affects lower lobes more than the upper lobes.
Uniform distention of the airspaces throughout the substance of the lobule from the central
respiratory bronchioles to the peripheral alveolar sacs and alveoli.
3. Paraseptal emphysema
Most often seen in the immediate subpleural regions of the upper lobes.
Selective distention of peripheral airspaces adjacent to the interlobular septa with sparing of the
centrilobular region.
May coalesce to form apical bullae.
4. Paracicatricial or irregular emphysema
Destruction of lung tissue associated with fibrosis; has no consistent relationship to a given
portion of the lobule.
Often seen in association with old granulomatous inflammation.
Bronchogenic carcinoma:
Majority of patients are cigarette smokers who are over 40 yrs of age.
Men are more affected.

 Solitary pulmonary nodule or mass and a hilar mass with or without bronchial obstructionare
the most common radiographic findings.
Obstruction of the bronchial lumen can result into resorptive atelectasis or obstructive
pneumonitis
Pancoast tumor (superior sulcus) peripheral neoplasm arising in the lung apex indented
superior by the subclavian artery.
Majority are squamous cell carcinomas or adenocaricinomas.
Apical thickness of >5 mm asymmetry of the apical opacities of >5 mm or evidence of rib
destruction should prompt further evaluation with helical CT or MR.
Subtypes of bronchogenic carcinoma:
adenocarcinoma
Most common type of lung cancer (35% of bronchogenic carcinoma)
Usually located in the lung periphery; of cases found in central portions.
Arise from the bronchiolar or alveolar epithelium.
They have irregular or speculated appearance where they invade adjacent lung
5 year survival rate of 17%
Squamous cell carcinoma
2nd most common subtype of bronchogenic carcinoma (25%)
Arises centrally within a lobar or segmental bronchus.
Usually present as hilar mass with or without obstructive pneumonitis or atelectasis
5 year survival rate 15%
Small cell carcinoma
25% of bronchogenic carcinomas and arise centrally within the main or lobar bronchi.
Most malignant neoplasm arising from neuroendocrine (kultchitsky) cells.
Produces a hilar or mediastinal mass with extrinsic bronchial compression.
5 year survival rate 5%
Large cell carcinoma
15% of bronchogenic carcinomas
Present as a large peripheral mass usually peripherally located
5 year survival rate of 11%
TMN classification of lung cancer
Primary tumor (T)
Tx
T0
T1

T2

Malignant cells in sputum without identifiable

tumor.
No evidence of primary tumor.
Tumor <3.0 cm in diameter surrounded by lung
or visceral pleura arising distal to a main
bronchus.
Tumor >3.0 cm in diameter any tumor invading
the visceral pleura any tumor with atelectasis or
obstructive pneumonitis of less than an entire

lung; tumor must be >2 cm from the tracheal

carina.
Any tumor with localized chest wall
diaphragmatic mediastinal pleural or pericardial
invasion the tumor may be, 2 cm from the carina
but cannot involve the carina.
Any tumor that invades the mediastinum or vital
mediastinal structures including the heart, great
vessels trachea carina or vertebral body; separate
tumor nodules in the same lobe; presence of a
malignant pleural effusion.

T3

T4

Nodal metastases (N)

N0
N1

N2
N3
Distant metastases (M)
M0
M1

No evidence of nodal metastases

Metastasis to ipsilateral peribronchial or hilar
nodes including involvement by contiguous
spread of tumor.
Metastasis to ipsilateral mediastinal or subcarinal
nodes.
Metastasis to contralateral mediastinal or hilar
nodes or scalene or supraclavicular nodes.
No evidence of distant metastases.
Distant metastases separate tumor nodules in
different lobes.

Clinical staging of lung cancer based on TNM classification

Ia T1 N0 M0
Ib T2 N0 M0
IIa T1 N1 M0
IIb T2 N1 M0
T3 N0 M0
IIIa T1 or T2 N2 M0
T3 N1 or N2 M0
IIIb any T N3 M0
T4 Any N M0
IV any T any N M1

Pulmonary vascular disease:

Pulmonary venous hypertension
Elevation in pulmonary venous pressure
Causes: obstruction to left ventricular inflow left ventricular systolic dysfunction mitral valve
regurgitation.
Radiographic findings include: enlargement of pulmonary veins and redistribution of pulmonary
blood flow to nondependent lung zones.
Pulmonary arterial hypertension:
Defined as systolic pressure in the pulmonary artery of 30 mm Hg
Causes: increase resistance to pulmonary blood flow (emphysema, chronic hypoventilation
cystic lung disease constrictive bronchiolitis cystic fibrosis)
Typical radiographic findings are enlarged main and hilar pulmonary arteries that taper rapidly
toward the lung periphery.
There may be associated right ventricular enlargement.
Enlarged pulmonary artery a transverse diameter of the proximal interlobar pulmonary artery
on PA chest radiograph exceeding 16 mm
Pulmonary edema:
The interstitial spaces of the lungs are kept dry by pulmonary lymphatic located within the
axialand peripheral interstitium of the lung.
There are no lymphatic structures immediately within the alveolar walls, alveolar interstitial
fluid is drawn to the lymphatics by pressure gradient.
When the rate of fluid accumulation exceeds the lymphatic drainage capabilities of the lungs
fluid accumulate first within the interstitial space
Progressive fluid accumulation eventually produces flooding of the alveolar spaces.
Hydrostatic pulmonary edema most common cause.
Interstitial edema:
Radiologic appearance of results from thickening of the components of the interstitial spaces by
fluid.
Peribronchial cuffing and tram tracking thickening of the peribronchovascular interstitium.
Loss of definition of the intrapulmonary vascular shadows thickening of the axial interstitium.
Kerley lines.
Airspace edema:
Occurs when fluid from the interstitum spills into the alveoli
Upright radiograph show bilateral symmetrical airspace opacities predominantly in the mid to
lower lobes.

Pleura:
The pleura is a serous membrane subdivided into:
Visceral pleura covers the lungs and forms the interlobar fissure.
Parietal pleura lines the mediastinum diaphragm and thoracic cage
The potential space between the visceral and parietal pleura is the pleural space which contains
2 to 5 ml of fluid which serves as a lubricant during breathing.
Under normal conditions, pleural fluid is formed by filtration form systemic capillaries in the
parietal pleura and resorbed via the parietal pleural lymphatics.
Pleural effusion:
Occurs when there is imbalance between the formation and resorption of pleural fluid.
Pleural effusions may be classified by:
Gross appearance (bloody, chylous, purulent, serous)
Causative disease
Pathophysiology of abnormal pleural fluid formation (transudative versus exudative)
The radiographic appearance of pleural effusions depends upon:
Amount of fluid present
Patients position during the radiographic examination
Presence or absence of adhesions between the visceral and parietal pleura
Small amounts of pleural fluid initially collect between the lower lobe and diaphragm in a
subpulmonic location as more fluid accumulates, it spills into the posterior and lateral
costophrenic sulci.
On upright PA chest radiographs
Moderate amount of pleural fluid (>175 ml) in the erect patient will have homogeneous
lower zone opacity.
The lateral costopherenic sulcus will show a concave interface towards the lung
(meniscus sign)
Pleural fluid may extend into the interlobar fissures
Free fluid within the minor fissure is usually seen as smooth, symmetric thickening on a
frontal radiograph.
In patients with suspected pleural effusion, a lateral decubitus film with the affected side down
is the sensitive technique to detect small amounts of fluid.
There will be fluid shifting to the dependent portion of the thorax
A large pleural effusions can cause passive atelectasis of the entire lung producing an opaque
hemithorax.
The radiographic detection of pleural effusion in the supine patient can be difficult because fluid
accumulates in a dependent location posteriorly.
The most common findings is a hazy opacification of the affected hemithorax with obscuration
of the hemidiaphragm and blunting of the lateral costophrenic angle.
On axial CT scans pleural fluid layers posteriorly with a characteristic meniscoid appearance and
has a CT attenuation value of 0 to 20 H.

MEDIASTINUM
A narrow vertically oriented structure that resides between the medial parietal pleuraol layers of the
lungs.
Contains central cardiovascular tracheobronchial structures and the esophagus enveloped in fat with
intermixed lymph nodes
Divided into superior (thoracic inlet) and inferior components with the inferior mediastinum subdivided
into anterior middle and posterior compartments.
A line drawn through the sternal angel anteriorly and fourth thoracic intervertebral space posteriorly
divides the mediastinum into superior and inferior compartments.

compartments
Thoracic inlet

Anterior mediastinum

Middle mediastinum

Posterior mediastinum

Contents of the thoracic inlet and mediastinum

contents
Thymus
Confluence of the right and left internal jugular
and subclavian veins
Right and left carotid arteries
Right and left subclavian arteries
Trachea
Esophagus
Prevertebral fascia
Phrenic, vagus, recurrent laryngeal nerves
muscles
Internal mammary vessels
Internal mammary and prevascular lymph nodes
thymus
Heart and pericardium
Ascending and transverse aorta
Main and proximal right and left pulmonary
arteries
Confluence of pulmonary veins
Superior and inferior vena cava
Trachea and main bronchi
Lymph nodes and fat within mediastinal spaces
Esophagus
Azygos and hemiazygos veins
Thoracic duct sympathetic ganglia and intercostal
nerves
Lymph nodes

Mediastinal mass:
Patients with mediastinal masses tends to present in one of two fashions:
With symptoms related to local mass effect or invasion of adjacent mediastinal structures (stridor in a
patient with thyroid goiter)
Incidentally with an abnormality on a routine chest radiograph
Thoracic inlet masses
Marginated by the first rib and represents the junction between the neck and thorax
Commonly present as neck masses or with symptoms of upper airway obstruction resulting from
tracheal compression.
Thyroid masses lymphomatous nodes and lymphangiomas are the most common thoracic masses

Thyroid mass

Parathyroid mass

Lymph node mass

lymphangioma

Thoracic lnlet masses

Goiter
Malignancy
Thyromegaly resulting from thyroiditis
Hyperplasia
Adenoma
carcinoma
Lymphoma
Hodgkin
Non-Hodgkin
Matastases
Inflammatory
tuberculosis