Lung Imaging.

pptx
Lung imaging
General anatomy of lung: lobes and segments
Lung segments on CT
pneumonia
Pneumonia is an infection that inflames the air sacs in one or both lungs. The air sacs may fill with
fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty in
breathing
Many organisms, including viruses and fungi, can cause pneumonia, but the most common causes
are bacteria, in particular species of Streptococcus and Mycoplasma.

What ever are the cause, x-rays appearance look very much same, because x-rays appearances
are so non-specific
No useful classification of pneumonia can be based on x-rays alone
Radiologist can draw most useful distinction between primary and secondary pneumonia
Major purpose of chest imaging: to establish whether or not pneumonia.
Basic radiological feature: one or more areas of Consolidation varying from a small ill-defined
shadow to a large shadow involving the whole of one or more lobes
X-ray of Right Side Pneumonia
RUL Consolidation
RML Consolidation
RLL Consolidation
chest radiograph reveals a left lower lobe opacity with pleural effusion.
pneumococcal pneumonia
CT of right lower lobe pneumonia
Ground glass opacity
Ground glass opacity (GGO) refers to the hazy gray areas that can show up in CT scans of the
lungs. These areas show increased density inside the lungs which could indicate pneumonia or
other respiratory disorders.
The term comes from a technique in glassmaking during which the surface of the glass is blasted
by sand. This technique gives the glass a hazy white or frosted appearance.
High-resolution CT image showing ground-glass opacities in the periphery of both lungs in a patient
with COVID-19 (red arrows). The adjacent normal lung tissue with lower attenuation appears as
darker areas.
Ground glass opacity
Infections are common causes of GGO. Such infections include:
Pneumonia
COVID-19
A 2020 systematic review and meta-analysis found that just over 83%Trusted Source of people with
COVID-19-related pneumonia had GGO.
Another 2020 studyTrusted Source in 54 participants found that GGO most commonly showed up
in the lower lobes of the lungs as round opacities, but that as the disease progressed, it became
more patchy and affected all lobes.
Pulmonary abscess
Large pulmonary cavity with a small dependant air-fluid level within the left mid zone, in keeping
with pulmonary abscess. Patchy airspace opacification more inferiorly within left lower zone.
Lung abscess is defined as necrosis of the pulmonary tissue and formation of cavities containing
necrotic debris or fluid caused by microbial infection.
Pulmonary abscess
CT findings in keeping with the plain film appearances, demonstrating a large cavity within the left
lower lobe, with an air-fluid level within.
Relatively extensive adjacent ground-glass changes and consolidation. Further areas of
ground-glass change and consolidation in both upper lobes.
Small bilateral pleural effusions.

Medical Radiology [Link]

MEDICAL IMAGING
[Link] iordanidi
WHAT IS RADIOLOGY?
Radiology represents a branch of medicine that deals with radiant energy in the diagnosis and
treatment of diseases by using imaging technologies (Modalities), This field can be divided into two
broad areas
Diagnostic radiology
Interventional radiology.
MEDICAL IMAGING
- Medical imaging is the visualization of body parts, tissues, or organs, for use in clinical diagnosis,
treatment and disease monitoring. Imaging techniques encompass the fields of radiology, nuclear
medicine
and optical imaging and image-guided intervention
RADIOLOGY TECHNIQUES (MODALITIES)
■ X-ray radiography
■ Fluoroscopy
■ CT - computer tomography
■MRI - magnetic resonance imaging
■PET - positron emission tomography
■SPECT - single photon emission computed tomography
■ Ultrasound
lectureI
6
On November 8th, 1895, German physicist Wilhelm Roentgen was
conducting experiments in his laboratory on the effects of cathode rays.
Working with a cathode-ray tube in his laboratory, Roentgen observed a fluorescent glow of crystals
on a table near his tube. The tube that Roentgen was working with consisted of a glass envelope
(bulb) with positive and negative electrodes encapsulated in it. The air in the tube was evacuated,
and when a high voltage was applied, the tube produced a fluorescent glow. Roentgen shielded the
tube with heavy black paper, and discovered a green colored fluorescent light generated by a
material located a few feet away from the [Link] Roentgen conclusion from his experiments is
(unknown type of radiation)
that he name it X-RAYS
Who discovered the x-ray?
X meaning unknown

World's first X-Ray image

The first x-ray image obtained was of the hands of Wilhelm Rontgen's wife, taken on 22nd
December,1895.
X-rays are a form of electromagnetic radiation, similar to visible light.
Unlike light, however, x-rays have higher energy and can pass through most objects, including the
body.
Medical x-rays are used to generate images of tissues and structures inside the body. If x-rays
traveling through the body also pass through an x-ray detector on the other side of the patient, an
image will be formed that represents the “shadows” formed by the objects inside of the body.

PROJECTION (PLAIN) RADIOGRAPHY / X-RAY RADIOGRAPHY

Radiographs are produced by the transmission of X-Rays (without added contrast materials such
as barium or iodine) through a patient to a capture device then converted into an image for
diagnosis.
Radiological density is determined by both the density and the atomic number (the number of
protons in an atom’s nucleus) of the material being imaged. For example, our bones contain
calcium, which has a higher atomic number than most other tissues.
Because of this property, bones readily absorb x-rays and therefore produce high contrast on the
x-ray detector. As a result, bony structures appear whiter than other tissues against the black
background of a radiograph.
Conversely, x-rays travel more easily through less radiologically dense tissues, such as fat, muscle,
and air-filled cavities such as the lungs. These structures are displayed in shades of gray on a
radiograph.
How are X-ray images formed?

FLUOROSCOPY
Fluoroscopy is a type of medical imaging that shows
a continuous X-ray image on a monitor, much like an X-ray movie.
During a fluoroscopy procedure, an X-ray beam is passed through the body. The image is
transmitted to a monitor so the movement of a body part or of an Instrument or contrast agent
("X-ray dye") through the body can be seen in detail.
Fluoroscopy: Real-time imaging viewed on display monitor in clinical room. Higher temporal but
lower spatial resolution than fluorography
Fluorography: Image displayed after x-ray exposure
Advantages of X-Ray:
Following are the advantages of X-Ray: ➨It is cheaper and simple technique. ➨It has lower
radiation compare to CT scan. ➨X-rays are widely used by radiologists to identify cracks, for
infections, to identify level of injury, and to identify abnormal bones. ➨It helps to locate foreign body
inside or around bones.
Disadvantages of X-Ray
The following are the disadvantages of X-Ray: ➨It does not provide 3D information. ➨Bones can
block significant diagnostic data as it absorbs the radiation. ➨Due to its radiation, it mutates cells
which causes ionization. ➨It does not produce the best image but a medium-quality image.
- CT (COMPUTED TOMOGRAPHY) SCANNING
Refers to a computerized x-ray imaging procedure in which a narrow beam of x-rays is aimed at a
patient and quickly rotated around the body, producing signals that are processed by the machine's
computer to generate cross-sectional images-or "slices" of the body.
These slices are called tomographic images and contain more detailed information than
conventional x-rays.
HOW DOES CT WORK?
■ Unlike a conventional x-ray-which uses a fixed x-ray tube- a CT scanner uses a motorized x-ray
source that rotates around the circular opening called a Gantry.
During a CT scan, the patient lies on a bed that slowly moves through the gantry while the x-ray
tube rotates around the patient, shooting narrow beams of x-rays through the body.
■ CT scanners use special digital x-ray detectors, which are located directly opposite the x-ray
source.
■ As the x-rays leave the patient, they are picked up by the detectors and transmitted to a
computer.
■ Each time the x-ray source completes one full rotation, the CT computer generated 2D image
slice of the patient.
■ Image slices can either be displayed individually or stacked together by the computer to generate
a 3D image

CT SCAN - USES
■ Diagnose muscle and bone disorders - such as bone tumors and fractures
Pinpoint the location of a tumor, infection or blood clot
■ Guide procedures such as surgery, biopsy and radiation therapy
Detect and monitor diseases and conditions - such as cancer, heart disease, lung nodules and liver
masses
■ Monitor the effectiveness of certain treatments, such as cancer treatment
■ Detect internal injuries and internal bleeding
TYPES OF CT-SCANS
■ Head or brain CT
■ Neck CT
■ CT of the chest
■ Abdominal and pelvic CT (CT Scanning of the Abdomen)
■ Sinus CT
■ Spine CT
■ CT Angiography (computed tomography technique used to visualize arterial and venous vessels
throughout the body)
Hounsfield Units (HU) are a dimensionless unit universally used in computed tomography (CT)
scanning to express CT numbers in a standardized and convenient form.

WHAT IS A CT CONTRAST AGENT?

As with all x-rays, dense structures within the body-such as bone, are easily imaged, whereas soft
tissues vary in their ability to stop x-rays and, so, difficult to see.
■Radiocontrast agents are substances used to enhance the visibility of internal structures in
X-ray-based imaging techniques such as CT & fluoroscopy.
Radiocontrast agents are typically iodine or barium compounds..
■ lodine-based compounds is injected into the bloodstream to help illuminate blood vessels,
including those in the heart.
■Barium-based compounds, are used for imaging the digestive system, including the oesophagus,
stomach, and Gl tract.
Usually, the contrast agent is injected into a vein (intravenous contrast), artery (angiography), taken
by mouth (oral contrast), inserted through the anus (rectal contrast), or injected into a joint using a
needle.
The contrast agent used depends on what type of test is done and which body part is being
evaluated:
For blood vessels: Usually contrast agents that contain iodine (iodinated contrast agents)
For the gastrointestinal tract: Contrast agents that contain barium or iodine (gastrografin)
lectureI
27
Shielding - Attenuation of radiation exposure by protective devices between the source of radiation
and the exposed individual. It includes personnel shielding and patient shielding of organs not
under investigation. Personnel shielding devices includes lead apron, lead goggles, gonad shields,
thyroid masks and gloves.
The most commonly used material for radiation shielding is lead. It's the highest atomic number
element that isn't radioactive. With 82 electrons per atom, it's excellent at blocking x-rays and
gamma rays. This soft, malleable metal is very easy to form into many different products from thin
foils to thick blocks.

Computed Tomography (CT)

The CT image is a digital image and consists of a square matrix of elements (pixel), each of which
represents a voxel (volume element) of the tissue of the patient.
Voxels are just 3D counterpart of pixels.
CT Windowing
• Windowing, also known as grey-level mapping, contrast stretching, histogram modification, or
contrast enhancement is the process in which the CT scan greyscale component of an image is
manipulated via the CT numbers (Hounsfield Units).
• Windowing - is an image processing task for a CT scan that helps highlighting key anatomy so
that the images can be analyzed easily.
• Changing windowing settings helps us modify/enhance the appearance of the CT image and
highlight particular features in it
The chest radiograph remains one of the most commonly performed examinat
Radiography allows visualization and assessment of the chest wall, mediastinum, and hila including
the heart and great vessels, central airways, the lungs including the pulmonary vasculature, the
pleural surfaces including the fissures and the [Link] in radiology.
What is enhancement?
intravenous (IV) contrast can be used to improve the details in CT images.
IV contrast mixes with and is carried through the blood. When it enters a structure, the structure will
appear brighter on CT; it enhances. IV contrast will make the structure look brighter than it would
without contrast.
CT abdomen with liver enhancement

What is enhancement?
Assessing enhancement can help you identify abnormalities. For example, inflammation often
increases enhancement making the structure brighter than normal. When blood flow is blocked, as
in ischemia, the structure will enhance less, appearing less bright than normal.
Below is an example of kidneys, without and with contrast. Notice how the enhanced kidneys
appear brighter. In the image with contrast, you may have noticed that the upper part of the left
kidney appears darker. This difference in enhancement is caused by blocked blood flow, which
could only be detected with the use of contrast.
we have terms to orient ourselves when describing findings:

Despite the indisputable diagnostic efficacy of radiological imaging, exposure to ionising radiation
presents potential risks to patient safety. As such, it is incumbent to shed light on the possible
hazards patients may encounter.
Ionising radiation, by its very nature, possesses the capacity to inflict harm at the cellular level,
exhibiting both immediate and long-term risks . Acutely, high-dose exposure may induce radiation
sickness, manifesting as nausea, vomiting, and, in severe cases, organ failure and death.
Nevertheless, such extreme scenarios are practically non-existent in the realm of diagnostic
radiology.

The Radiological Diagnostics of the Respiratory

[Link]
The Radiological Diagnostics of the Respiratory System
Basics of X-Ray
Organs absorb X-rays differently and thus their shadow on the film is different
Bone: high absorption (film appears white)
Tissue: moderate absorption (film appears grey)
Air/Lungs: little absorption (film appears black)
Types of CXRs
PA and Lateral
-Patient facing cassette
X-ray 6 feet away
• Supine AP
- X-ray 40 inches away
-Magnifies anterior
structures and pulmonary vasculature
PA
Preferred method
AP
Note heart enlarged, lung fields not as clear
Comparing Chest X-rays Protocols
Carina and bronchi
The carina is cartilage situated at the point at which the trachea divides into the left and right main
bronchus.
On appropriately exposed chest X-ray, this division should be clearly visible.
The right main bronchus is generally wider, shorter and more vertical than the left main bronchus.
As a result of this difference in size and orientation, it is more common for inhaled foreign objects to
become lodged in the right main bronchus.
Depending on the quality of the chest X-ray you may be able to see the main bronchi branching into
further subdivisions of bronchi.

X-RAY TECHNIQUES
Assessing Film Technique
Inspiration
Penetration
Rotation
Inspiration
Image should be at full inspiration
Diaphragm at level of 8-10 rib
Allows reader to see intrapulmonary structures
Poor Inspiration mimics RML Infiltrate
Same patient with proper inspiration

Penetration
Amount of radiation required for a quality image
PA film: should barely see thoracic spine disc spaces
Lateral: spine should appear darker as move caudally
Examples of adequately penetrated images
Penetration
Overpenetrated
Underpenetrated
Rotation
- Patient should be flat against the cassette
- Rotation of the patient will alter appearance of mediastinum
- Observe rotation by comparing location of clavicular heads
-Should be equal distance from spinous process of thoracic vertebral bodies
Rotation
Normal
Rotated to the Right

How to Read an X-Ray

Patient Data (Name, history, age, sex)
Technique (PA vs. AP, rotation, penetration, etc)
Trachea: midline or deviated, any masses?
Lungs: masses, infiltrates?
Costophrenic angles should be sharp (if not = effusions)
Silhouette signs, air-bronchograms, pulmonary edema
Pulmonary vessels: enlarged?
Abnormalities in chest radiography and CT are either result of abnormal density or lucency.
The silhouette sign
The differential attenuation of x-ray photons by two adjacent structures defines the silhouette, e.g.
heart borders against the adjacent lung segments, and it is the pathological loss of this
differentiation, which the silhouette sign refers to. In short, it denotes that a mediastinal border can
only be obscured by pathology which is in direct anatomical contact.

Signs: Air Bronchogram

• Tubular outline of an airway made visible by filling of the surrounding alveoli by fluid or
inflammatory exudates
Causes
-Pulmonary edema
-Lung Consolidation
-Severe Interstitial Disease
-Neoplasm

Atelectasis
• Atelectasis is defined as the collapse or closure of the lung resulting in reduced or absent gas
exchange. It may affect part or all of one lung
• Atelectasis is the collapse of alveoli or lung tissue.
• It develops when the alveoli becomes airless from absorption of their air without replacement of
the air with breathing.
Left upper lobe atelectasis

Air-space opacification is a descriptive term that refers to filling of the lung parenchyma with
material that attenuates x-rays more than the unaffected surrounding lung tissue. It is the
radiological correlate of the pathological diagnosis of pulmonary consolidation.
Consolidation describes increased lung attenuation sufficient to obscure bronchial walls and blood
vessels occurs when the normal, air-filled spaces of the lung are filled with the products of disease.
It may be caused by atelectasis, infection, pulmonary hemorrhage, aspiration, or lung cancer.
Doctors often use the term when describing a finding on imaging of the chest, like an X-ray or CT
scan.
Examples: Pneumonia
Airspace disease and consolidation
CXR Findings
Airspace opacity
Lobar consolidation
Interstitial opacities

Pleural effusions
A pleural effusion is a collection of fluid in the pleural space. Fluid gathers in the lowest part of the
chest, according to the patient's [Link] the patient is upright when the X-ray is taken, then fluid
will surround the lung base forming a 'meniscus' – a concave line obscuring the costophrenic angle
and part or all of the [Link] a patient is supine, then a pleural effusion layers along the
posterior aspect of the chest cavity and becomes difficult to see on a chest X-ray.

Pleural effusion with tracheal deviation

A homogenous opacification is noted in the right lower zone with the opacity seen to track along the
lateral chest wall. The right costophrenic angle is obliterated with a meniscus noted. Findings are
suggestive of a right sided pleural effusion.
Examples: Pleural Effusions
Blunting of Costophrenic Angles
Fluid in Costophrenic Angle

PlEURAL EFFUSION VS ATELECTASIS OF LUNG

Massive effusion on left
Mediastinal shift to opposite side
Larger hemithorax
Atelectasis of left lung
Mediastinum pulled towards atelectasis
Smaller hemithorax

Examples: Pneumothorax (PTX)

Air inside the thoracic cavity but outside the lung
PTX appears as air without lung markings in least dependent area of chest

Examples: Hemopneumothorax
Computed tomography (CT) of the chest demonstrating bilateral pleural effusions.
I
Hilar Enlargement
Enlarged Pulmonary Artery
Hilar Adenopathy