IMAGISTICA IN BOLILE PULMONARE

CLINICA MEDICALA CARITAS

METODE

RG TORACO-PLEURO PULMONAR CT TORACIC RMN TORACIC SCINTIGRAMA PULMONARA-VENTILATIE - PERFUZIE TOMOGRAFIE CU EMISIE DE POZITRONI (PET) ECOCARDIOGRAFIA PLEURALA BRONHOSCOPIA

Rx PULMONAR
Imagine standard

postero-anterioara, laterala sau oblica in inspir profund simetrica (claviculele simetrice fata de manubriul sternal) distanta de 2 m intre tubul focal si ecran, Imagine antero-posterioara: umbra cordului pare mai mare

ANATOMIA RADIOLOGICA

CT TORACIC

CT:

sectiuni anatomice fara imagini de sumatie Rezolutie de 10 ori mai mare CT multislice: achizitionare de imagini continue, isotropice, cu posibilitati de reconstructie bi sau tridimensionala de inalta fidelitate, in orice plan CT cu rezolutie inalta: frecventa spatilala inalta ce evidentiaza detalii anatomice

RMN

RMN

Depinde de proprietatile magnetice ale atomilor de H; Mediul molecular inconjurtor afecteaza rata cu care atomii de H elibereaza energie Aceasta energie duce la o distribuite spatiala a semnalelor care este convertita in imagini Specificitate pentru tesuturile moi Evalueaza invazia peretelui toracic, infiltrarea mediastinala, invazia diafragmului in neoplazii pulmonare sau pleruale

PET SI ECOGRAFIA

Positron Emission Tomography

Fluorodeoxyglucose positron emission tomography (FDG-PET) foloseste fluorodeoxyglucose marcata pentru a evidentia calea glicolitica a celulelor tumorale sau a altor celule metabolic active avide de glucoza Tumorile intratoracice; evaluarea nodulilor pulmonari solitari . revarsatele pleurale: mai sensibila ca Rx (10 ml lichid) Semnul cozii de cometa in edemul pulmonar

Ecografia:

Bolile difuze pulmonare

Bolile difuze pulmonare

alveolar versus interstitiale: nu exista o corelatie intre aspectul RX si localizarea HP (alveolara sau interstitiala). Nu se mai recomanda distinctia: infiltrat alveolar/ infiltrat interstitial
Aspectul nodular poate fi dat de boli alveolare dar si interstitiale Bolile alveolare pot produce reactie interstitiala Aspectul de geam mat poate fi indus de bolile alveolare sau interstitiale Bronhograma aerica, considerata patognomonica pentru bolile alveolare apare, rar, si in boli interstitiale:

Sarcoidoza Limfom pulmonar Calcinoza pulmonara.

Se recomanda renuntarea la termenul infiltrat Dg se pune pe analiza combinata a :

Tipului predominent de opacitati: macronodulare: > 1 cm; micronodulare : < 1 cm Volumul pulmonar Distributia leziunilor predominant opacities, assessment of lung expansion, and distribution and profusion of disease yields a differential diagnosis.

Opacitati mari

Opacitatile mari:

Difuze omogen: omogen:

leziuni difuze alveolare Edem pulmonar (noncardiogenic ), Pneumonie virala difuza sau cu Pneumocystis jiroveci

Opacitati multifocale
bronchopneumonia, Aspiratie recurenta vasculitis.

Opacitati lobare fara atelectazie: atelectazie:

Pneumonia lobara

Opacitati lobare cu atelectazie

Obstructia unei bronhii lobare cu obstruction of a lobar cu corpi straini, tumori, mucus

Opacitati perihilare :
Edem pulmonar cardiogen din insuficienta cardiaca, insuficienta renala, supraincarcarea de volum, hemoragii pulmonare.

CLASSIFICAREA OPACITATILOR MARI Difuze omogene MUltifocale Lobar fara atelectazie Lobar cu atelectazie Perihilare Periferice

FIGURE 84-1 A, Patient with diffuse alveolar damage. Chest radiograph shows diffuse homogeneous opacification of both lungs with clearly visible air bronchograms. B, Patient with acute varicella pneumonia. Chest radiograph demonstrates multiple acinar nodules with tendency for confluence, yielding multifocal patchy parenchymal opacification.

FIGURE 84-2 Patient with hydrostatic pulmonary edema due to left-sided heart failure. Chest frontal radiograph demonstrates classic batwing distribution of pulmonary edema

Opacitati mici

Micronodulare: noduli < 1 mm,

Granulomatoza la talc la consumatorii de droguri iv, Microlitiaza alveolara Cazzuri rarre de silicoza talcosis, coal workers' pneumoconiosis , Beryllium rar sarcoidosis sau hemosiderosis. Granuloame inflamatorii sau infectioase: miliare TBC, sarcoidoza, infectii fungice, alveolita alergica extrinseca, histiocitoza Langerhans

Nodulare: > 1 cm

Tipuri de opacitati mici pulmonare Micronodulare Acinare Lineare Reticulare Bronhice Arteriale Distructive

FIGURE 84-3 Patient with known transfusion reaction. Chest radiograph displays ground-glass opacification of both lungs and bilateral Kerley's A lines, presenting as long linear structures extending from the hilar regions into the pulmonary periphery.

Opacitati liniare

Opacitatile liniare (liniile Kerley): ingrosarea septurilor interlobulare.

Liniile Kerley A:
pleaca de la hil, 2 - 4 cm spre periferia plamanului, mai ales spre lobii superiori; Reflecta ingrosarea interstitiului axial Insuficienta ventriculara stanga reactii alergice 1 cm lungime si 1 mm grosime La periferia lobilor inferiori, subpleurali Ingrosarea interstitiului subpleural. Insuficienta ventriculara stanga subacuta sau cronica Boli ale mitralei Limfangita carcinomatoasa Pneumonii virale Fibroza pulmonara Aspect reticular Ingrosarea interstitiului parenchimal Apar rar

Liniile Kerley B:

Liniile Kerley C:

Opacitati reticulare
Opacitatile rericulare sunt opacitati mici, poligonale, neregulate, curbe. Dg dif in functie de debut:

Debut acut:
Edem interstitial (insuficienta ventriculara stanga) Pneumopatii acute (virale, micoplasme) Modificari precoce exsudative in boli de colagen (LES) Reactii alergice ( posttransfuzionale sau la intepaturile de Himenoptere) pneumonia idiopatica interstitiala, Boli de colagen: scleroderma, poliartrita reumatoida, asbestosis, pneumonia de iradiere, pneumonia de hipersensibilizare stadiile finale, reactii la medicamente, metastaze pulmonare limfangitice , infectii granulomatoase terminale, forma bronhovasculara a limfoamelor, manifestarile bronhovasculare ale sarcomului Kaposi , sarcoidoza

Debut cronic

FIGURE 84-4 Diffuse reticular lung disease. Chest radiograph in a 94-year-old patient with diffuse reticular opacities due to idiopathic pulmonary fibrosis with honeycombing and traction bronchiectases. The lung volumes are typically reduced by a decreased pulmonary compliance

Aspect de fagure de miere

Apare in stadiile finale ale bolilor pulmonare Restructurarea anatomiei pulmonare insotita de bronhiolectazii. Retea dispusa in mai multe straturi, formata din spatii mici subpleurale, intre 3-10 mm diametru. Dg dif emfizem paraseptal prin: peretii mai grosi si dispunerea in mai multe straturi

Leziuni alveolare

Noduli acinari, de 0,6-1 cm, care cuprind un acin anatomic si tesutul peribronhiolar din jur Alte aspecte:

Geam mat: umplere incompleta alveolara Coalescenta unor opacitati mari, Consolidarea unor intregi lobi sau segmente, Opacifierea cu distributie bronhocentrica Bronhograma aerica, Alveolograma aerica

Opacitatile alveolare nu corespund strict anatomic implicarii alveolare ,implicand si interstitiul Numite si opacitati sau condensari parenchimatoase

Leziuni bronsice

Bronsiectazii difuze: transparente liniare, tubulare, chistice si opacitati care sunt distribuite de-a lungul bronhiilor (linii de tramvai). Impactul mucusului (astm, aspergiloza bronhopulmonara, bronsita plastica): opacitati ca : pasta de dinti, ciorchine, deget de manusa Plamanul murdar la fumatorii cu bronsita cronica: ingrosarea peretilor bronsici, fibroza peribronsica, bronsiolita, hipertensiune arteriala pulmonara

Leziuni vasculare

Leziuni arteriale: modificari in perfuzia pulmonara:

caudalizarea distributia normala a vascularizatiei in ortostatism: vasele din bazele plamanilor au diametrul de 2-3 ori mai mare decat vasele cefalizarea=redistributia sanguina: raportul intre diametrele vaselor bazale si apicale este inversat
Normal in clinostatisminl; Patologic in ortostatism: insuficienta ventriculara stanga, boala mitrala, emfizem bazal Circulatia hiperkinetica (anemie, obezitate, sarcina), tireotoxicoza, sunturi stanga-dreapta) Egalizare + oligemie: hipovolemie, emfizwem difuz, sunturi dreapta-stanga

egalizarea: fluxul sanguin egal distribuit in lobii superiori si inferiori: centralizarea: dilatarea vaselor centrale pulmonare, insotita de circulatie periferica normala sau.
Hipertensiunea arteriala pulmonara Emfizem unilateral Bronhiolitis obliterans unilaterala ( sindromul Swyer-James-McLeod ), Obstructia unilaterala a unei artere pulmmonare emfizem cu distributie inegala, Embolii multiple pulmonare Malformatii arterio-venoase Bronsiolitis obliterans neuniforma. La CT cu rezolutie inalta: perfuzie in mozaic.

lateralizarea fluxului: perfuzia inegala, asimetrica, a celor 2 plamani

cresterea localizata a diametrului arterial:

FIGURE 84-5 Patient with left ventricular failure. Chest frontal radiograph shows cephalization of pulmonary blood flow.

FIGURE 84-6 Patient with primary pulmonary arterial hypertension. Chest frontal radiograph

shows centralization of flow with pulmonary artery aneurysms and peripheral pulmonary oligemia.

Volumul pulmonar

Crescut:

emfizem difuz astm crronic Bronhiolita difuza Atleti

Redus : bolile difuze infiltrative cronice pulmonare

TABEL Volumul pulmonar la bolnavi cu boli difuze pulmonare Volum crescut: emfizem crescut: astm cronic bronsiolita difuza obliternata atleti limfangioleiomiomatoza Volum redus: fibroza pulmonara in stadiile finale redus: paralizia bilateralas diafragmatica ascita masiva Volum normal: Sarcoidosa normal: Histiocitoza X (Langerhans ) Neurofibromatosa emfizemul cu fibroza poulmonara

FIGURE 84-7 Patient with severe emphysema. Chest radiograph shows hyperexpansion of both lungs with bullous changes at the right lung base and leftward mediastinal shift.

Distributia anatomica a leziunilor

Varfurile pulmonare:

tuberculoza, Micoze sarcoidoza, Pneumoconioze (expeptand asbestoza) histiocitoza X ( Langerhans) spondilita ankilopoietica, Fibroza chisticabrosis, Pneumonia cu Pneumocysti. jiroveci Pneumonia de iradiere Pneumoniile de hipersensibilizare in stadiile finale.

Bazele plamanilor:

bronchiectazii, Pneumonia de aspiratie, Pneumonia interstitiala descuamativa, Pneumonia interstitiala nespecifica reactii medicamentoase, asbestoza, sclerodermia, Poliartrita reumatoida. Orice proces difuz pulmonar poate progresa in ambii plamani, fara limite zonale

FIGURE 84-8 A, Basilar pulmonary disease. Chest radiograph in a 48-year-old patient with known scleroderma. Bibasilar fine reticular opacities and parenchymal bands are visible in both lower lobes. B, Apical lung disease. Chest radiograph in a 42-year-old patient with ankylosing spondylitis. Severe architectural distortion with cicatrizing atelectasis of both upper lobes, retraction of both pulmonary arteries cephalad, and bilateral bulla formation containing fungus balls are evident.

Ganglionii

Adenomegalie hilara si/sau mediastinala+ boli difuze pulmonare

sarcoidosis limfoame; micoze pulmonare; tuberculoza; pneumoconiose, mai ales silicoza si asociate cu berilliu (berilioza); neoplasm pulmonar; metastaze.

Nodulii pulmonari

Multiplii:

metastaze pulmonare, HIV, sarcom Kaposi, limfoame

o Predilectie pt regiunile subpleurale, inclusiv fisurile interlobare.
-

Infectii
Abcese multiple prin aspiratie recurenta sau emboli septici Granuloame tuberculoase sau nontuberculoase cu micobacterii; Micoze ( histoplasmoze, coccidioidomycosa, cryptococcosis; Paragonimus westermani . Granulomatoza Wegener, Nodulii reumatoizi, sarcoidoza , amiloidoza.

Inflamatii neinfectioase:
-

FIGURE 84-9 Multifocal pulmonary opacities. Chest radiograph in a 70-year-old patient with known carcinoma of the thyroid gland widening the superior mediastinum and displacing the cervical trachea to the right. Bilateral large and small pulmonary nodules and masses due to metastatic tumor are present.

Bolile pleurale

Rg:

75 mL obstrueaza sinusul costodiafragmatic posterior, 150 mL obstrueaza sinusul costo-diafragmatic lateral, 200 mL produce o coaja de 1 cm grosime in decubit, 500 mL ascheaza diafragmul si se vad pe filmele in decubit 1000 mL atinge nivelul arcului anterior al coastei a 4-a in ortostatism Pot fi punctionati 200 ml 10 ml: cantitatea minima vizibila in decubit si 175 ml minimum vizibil in ortostatism Lichid liber in cantitate medie: opacitate difuza, prin care se vad vasele pulmonare si fara bronhobrama aerica

Revarsatul pleural supradiafragmatic

Supradenivelarea unui hemidifragm cu punctul maxim lateral Revarsatele mari pot duce la invertsarea diafragmului Cresterea distantei intre baza plamanuli si punga de aer a stomacului, care este deplasata infero-medial Pleurezii inchistate: aderente pleurale; bine definite fta de plamanul din jur; unghiuri obtuze fata de peretele

Placile pleurale

Acumularea pe pleura parietala a fibrelor de colagen hialinizate Expunere la azbest Localizare predilecta: pleura parietala adiacenta Plaques preferentially involve the parietal pleura adjaccoastelor Vl-lX si diafragmului. Mai putin pronuntate in spatiile intercostale Nu afecteaza sinusurile costo-diafragmatice si apexul Calcificarile se vad in 20% (Rx) si 50% (CT) cazuri Profil: arii focale de ingrosare pleurala Calcificari curbilinii supradiafragmatice. Rar calcificari interlobare in pleura parietala Imaginea de fata: structuri in harta geografica, punctiforme sau neregulate.

FIGURE 84-10 Patient with known prior occupational asbestos exposure. Chest radiograph shows extensive bilateral calcified plaques seen en face, in profile, and along the diaphragmatic contour.

Ingrosarea pleurala difuza

Apare dupa expunerea la

Infectii, inflamatii, traume, tumori, tromboembolism, iradiere, asbestos.

Cand este severa: ingrosare pleurala difuza, cu marginile netede si grosime < 2 cm.

Rx: opacitate pleurala difuza, continua, ce ocupa cel putin un sfert din circumferinta peretelui toracic, oblitereaza sinusul costo-difragmatic si poate cuprinde si varfurile CT ingrosare a pleurei de cel putin 3 mm.

Tumori pleurale

Mai frecvente decat tumorile benigne, mai ales metastazele, comparativ cu mezotelioamele. Metastaze prin:

Invazie pleurala de catre cancerul pulmonar Placi subpleurale in limfoame, Diseminare hematogena Extensia directa la pleura. lipoame (CT) , cele mai frecvente fibroame, origine in celulele mezenchimale pluripotente din pleura viscerla, mai rar parietala. Pot induce sindroame paraneoplazice: osteoartropatie, hipoglicemie; rar invadeaza sau metastazeaza; uneori pediculate si mobile Tumori neurogene.

Tumori benigne:

Pneumotoraxul

Gaz in spatiul pleural. Pleura viscerala este convexa, ca o linie , separata de pleura parietala prin spatiu aeric fara parenchim pulmonar (nu se vad. Rx in ortostatism: initial aerul este in spatiul apicolateral. Rx in decubit: aerul se acumuleaza in sinusul costofrenic. Pneumotoraxul in tensiune:

Deplasarea mediastinului controlateral leads to marked shift of the mediastinum to the contralateral aplatizarea sau inversarea hemidiafragmului ipsilateral

FIGURE 84-11 Patient with spontaneous tension hydropneumothorax. Chest radiograph shows complete atelectasis of the left lung with a large pneumothorax and a left basilar gas-liquid level. The patient had primary tuberculosis.

Imaginea radiologica a mediastinului

Mediastinul este delimitat de :

Apertura toracica; coloana vertebrala Sternul; Pleurele mediastinale

Tehnica:

Pe filmele cu penetrabilitate buna se evidentiaza liniile din fig 84-12.:

FIGURE 84-13 A, Patient with anterior mediastinal teratoma. Chest radiograph shows a mediastinal contour abnormality due to projection of the mass into the right hemithorax. Note the obtuse angle of interface formed by the pleura covering the mass with the mediastinum. B, Patient with Castleman's giant lymph node hyperplasia. Chest frontal radiograph shows large subcarinal middle mediastinal mass that projects lateral to the right atrium. C, Patient with paraspinal ganglioneuroma. Chest radiograph shows right lower paraspinal contour abnormality widening the right paraspinal region and encompassing the height of three thoracic vertebrae.

FIGURE 84-12 Chest radiograph with superimposed mediastinal stripes. Yellow: right paratracheal stripe. Light blue: right and left paraspinal stripes. Red: azygoesophageal stripe. Brown: pleuroesophageal stripe. Purple: anterior junction line complex. Pink: left subclavian artery border. Light green: posterior-superior junction line. Dark green: para-aortic line

Compartimentele mediastinului

Mediastinul anterior : contine timusul (sau tesutul gras care il inlocuieste) si ganglioni.

Patologic:
thymoame, lymfoame, teratome si alte tumori germinale Gusa substerna, lipoame, hemangioame lymphangioame.

Mediastinul mediu: subdivizat:

spatiul subcarinal , Regiunea paratraheala, Regiunea retrotraheala, Fereastra aorto-pulmonara, Spatiu retro-cardiac. Retrotraheal: In the retrotracheal region, artera subclaviculara dreapta aberanta; gusa plonjanta posterioara , tumori esofagiene, diverticuli, chiste ale ductului toracic . Fereatra aorto-pulmonara: canal arterial patent; malformatii bronhopulmonare; anevrisme aortice sau pulmonare.

Patologic: adenopatii , malformatii bronhopulmonare

Mediastinul posterior: regiunea paraspinala:

Patologic:
tumori neurogene din lantul simpatic sau din radacinile nervoase Hematopoieza extramedulara: mase paravertebrale rezultate din maduva osoasa care protruzeaza din coaste sau din corpiui vertebrali Adenopatii: metastaze, limfoame Boli ale coloanei vertebrale: spondilita bacteriana sau TBC, tumori, hematoame posttraumatice

extrapleural pneumonolysis (plombage) with polymethyl methacrylate balls for the treatment of tuberculosis. The balls are visible in the radiograph.

tracheal deviation. Ultrasonography of the neck revealed a large goiter with the right lobe extending into the anterior superior mediastinum.

A pulmonary mass is visible in the left upper lung.

diffuse bilateral ground-glass opacity

Findings Air is lucent (jet black) on plain film. There is streaky air in the subcutaneous tissue bilaterally.