Alternative modalities

of chest imaging
 Introduction
• The radiology of 50 years ago was a primitive science
compared with the radiology of today.
• Examinations consisted primarily of radiographs of the
chest, bones, and gastrointestinal tract, although some
early neuroradiologic studies were performed.
• Chest fluoroscopy was common.
• Radiographic examinations of the chest were likewise
unsophisticated by today's standards.
• There were no image intensifiers, nuclear medicine
studies, ultrasonography, computed tomography, or
magnetic resonance studies.
• How far we have come!
 Imaging Modalities

• A. Plain radiographs
• B. Ultrasonography
• C. CT (including high resolution)
• D. MR
• E. Ventilation-perfusion Scintigraphy
• F. Positron emission tomography (PET)
scanning
• G. Pulmonary & Bronchial Arteriography
 Plain radiographs

o The chest x-ray, an invaluable first line investigation,

is a source of information and an indispensable
diagnostic tool in medicine.

o The careful examination of the chest radiograph

constitutes an essential component in the
management of a number of different diseases.

o It is also used in emergency medicine and can

detect systemic diseases such as metabolic bone
disease and pulmonary metastases.
How to take a proper Chest X-
ray
 Difference between PA and
AP views
PA View AP View
• Spine and post ends of ribs • Not visualized clearly
clearly seen
• • More horizontal
Ribs obliquely oriented
• Scapulae not overlapping the • They do overlap
thorax
• Clavicles are horizontal • More oblique
• Normal sized cardiac
silhouette • Enlarged
PA VIEW AP VIEW
• The lung fields are divided in three zones only for convenience
of the description of the lesion. However, they do not
correspond to the anatomical lobes.

• Upper zone: from apex to the lower border of the anterior end
of second rib.

• Middle zone: from the lower border of the second rib to the
lower border of the anterior end of fourth rib.

• Lower zone: below the lower border of the anterior end of

fourth rib.
o Each lung is divided
into lobes
surrounded by
pleura.

o There are two lobes

on the left , upper &
lower, separated by
major fissure.

o Three on the right :

upper, middle &
lower, separated by
major fissure & minor
fissure.
Segmental anatomy of
the lung
 Limitations of Chest Radiography
o The chest x-ray is a very useful examination, but has
limitations.

o Some conditions of the chest will not show up on the

chest x-ray, so a normal chest x-ray doesn't necessarily
rule out all problems in the chest.

o For example, patients with asthma exacerbations can

have a normal chest x-ray. There are some cancers that
are too small or are difficult to visualize and may not be
identified. Pulmonary embolism cannot be seen on chest
x-rays and require additional study.
o A chest CT may be requested to further clarify a finding
seen on the chest x-ray or to look for an abnormality not
visible on a chest x-ray .

o The degree of involvement of the lung, as well as the

distribution of disease, and anatomic location may be
better evaluated with chest CT.

o Some diseases, such as chronic lung diseases, are

frequently evaluated with HRCT .
 Ultrasonography
• Ultrasonography (US) has been underused or often
ignored as a diagnostic tool in the chest, especially in the
lung, because air and the bony thorax were traditionally
considered an obstacle to transmission of the ultrasound
beam .

• US has been gaining recognition as a highly useful tool in

the evaluation of pleural lesions, its role in imaging of the
lung and extracardiac mediastinum has expanded and its
usefulness has been recognized .

• It provides images in real time and so can also be used to

interrogate the movement of structures such as cardiac
valves.
• US may be helpful in evaluation of persistent or unusual
areas of increased opacity in the peripheral lung, pleural
abnormalities, and mediastinal widening.

• US is particularly useful in patients with complete

opacification of a hemithorax at radiography.

• US allows characterization of pleural fluid collections as

simple, complicated, or fibro adhesive, which is important
information for planning thoracocentesis or thoracotomy.
• US allows easy distinction of pleural fluid from peripheral
pulmonary infiltrates and also permits localization of
pleural fluid for aspiration.

• At US, pleural fluid may be characterized as a simple

effusion, a complicated effusion, or fibrothorax.

• A simple effusion appears as clear anechoic or cloudy

hypoechoic fluid with or without swirling particles .

• A complicated effusion appears as septated or

multiloculated, hypoechoic fluid partitioned by fibrin
strands with no clear demarcation between the lung and
pleural components .

• Fibrothorax appears as a thickened, echogenic rind of

pleural plaque.
 Simple pleural effusion with floating debris. Chest radiograph
shows an ill-defined area of increased opacity in the left lower
lobe. Longitudinal US scan of the left lower lobe shows a large
amount of hypoechoic fluid containing swirling particles, an
appearance indicative of a simple effusion amenable to aspiration.
(SP) and an echogenic area of lower lobe consolidation (L).
 Complicated pleural
effusion with fibrin
bands. Transverse US
scan shows anechoic
fluid containing mobile
echogenic bands. This
type of fluid collection is
amenable to
thoracentesis.
• Intercostals oblique US
scan shows thickening
of the visceral and
parietal pleura (arrows).
The pleural space is
filled with profusely
septated fluid, which
has a honeycomb
appearance. This type
of Complicated pleural
effusion is not really
amenable to
thoracentesis.
• US clearly demonstrates the diaphragm & differentiates
subpulmonic effusion from subphrenic abscess.

• US often allows detection of associated lung or pleural

masses hidden by pleural effusion.

• The patient with a completely opaque hemithorax is an

ideal candidate for differentiation of massive pleural
effusion from pleural or lung masses .
• Chest radiograph shows complete opacification of the right
hemithorax. Longitudinal US scan shows a massive
pleural effusion containing echogenic masses (M) s/o
pleural metastases in a 4 yr old child with wilm’s tumour.
• In cases of chest wall lesions, US may enable
localization of the site of origin to soft tissues or an
extrapleural intrathoracic location .

• US may aid in diagnosis by allowing localization of

the lesion and characterization of it as cystic or solid.

• Osseous involvement, particularly rib involvement, is

easily evaluated with US.
• An important feature of diagnostic ultrasound is its
apparent safety, so it can be used in children & pregnant
females without concern for injury.

• Patients readily accept an ultrasound examination

because the procedure requires only slight pressure on
the skin & minimal preparation.

• Mobile ultrasound systems that can be taken to the

bedside, to intensive care & into the operating room are
widely used.
• Mediastinal US may have a screening role in the
evaluation of mediastinal masses somewhere
between the role of chest radiography and those of
the more expensive imaging techniques .

• It is still uncommon to use US in the mediastinum.

• Chest radiography allows localization of masses
into the anterior, middle, or posterior mediastinum,
whereas US allows characterization of masses as
solid or fluid filled and detection of calcifications.

• Both modalities are thus valuable in arriving at the

most likely diagnosis.
• Chest radiograph shows a well-defined mass. The question was whether the
mass was in the lung or the mediastinum. Subtle thoracic scoliosis is seen.
Transverse US scan shows a fluid-filled cyst attached to a vertebra (V). On
the basis of the location and cystic nature of the lesion, a diagnosis of
posterior mediastinal enteric or neurenteric cyst was suggested.
• However, US may permit rapid clarification of
radiographically equivocal findings.

• It may also partially replace CT and MR imaging in

certain situations, for example, in young children with
widening of the superior mediastinum to differentiate
normal thymus from mediastinal masses and in
critically ill patients in intensive care units.
• The normal thymus sometimes has a confusing
appearance on plain chest radiographs.

• Commonly encountered problems are a normal but

prominent thymus mimicking a mediastinal mass or upper
lobe pneumonia or atelectasis .

• Under these circumstances, US allows easy identification

of the normal thymus, thus enabling unnecessary further
investigations to be avoided .
• Technologic improvements in transducers as well as
color flow imaging have made chest US even more
useful by revealing the morphology of pulmonary,
pleural, and mediastinal structures in more detail.

• Color flow imaging may be helpful in characterizing the

lesion by demonstrating the vascularity and flow pattern
and in searching for anomalous vessels, such as occur
in pulmonary sequestration.
• US is an effective, easily performed complement to
chest radiography in the evaluation of puzzling areas of
increased opacity in the chest.

• US may provide useful information that eliminates the

need for more invasive or expensive studies.
• Identification of air bronchograms and fluid
bronchograms at US and pulmonary vessels at color
flow imaging is useful in differentiating pulmonary
consolidation from lung masses and pleural lesions,
which are the main causes of puzzling areas of
increased opacity on chest radiographs.
• For evaluation of chest wall lesions, CT or MR
imaging is ultimately required. However, initial US
screening to determine whether the lesion is solid or
fluid filled and whether an underlying rib abnormality
is present may help limit the differential diagnosis.
• Sonography has become the imaging modality of
choice for guidance of many interventional
procedures in the pleural space.

• Following invasive procedures can be done under

USG guidance
~ diagnostic thoracentesis
~ therapeutic thoracentesis
~ catheter drainage of pleural effusion
~ sclerosis of pleural space
~ pleural biopsy.
• The incidence of pneumothorax is 18% for clinically
guided thoracentesis 3% for sonographically
guided thoracentesis.
 CT evaluation of lung
pathology
• Chest radiography remains the primary technique for
detecting most parenchymal & pleural abnormalities.

• Both pleural and pulmonary parenchymal processes can

cause opacification that cannot be discriminated or
completely characterized on standard chest
radiographs.

• Computed tomography can be helpful in confirming the

presence and extent of a lesion, and also may be helpful
in characterizing the abnormality.
• The indications for CT are…….

- Further evaluation of an abnormality identified on chest

radiography.
- Assessment of patients with clinical suspected pulmonary
disease who have a normal or near-normal chest x-ray.
- Investigation of suspected airway abnormalities.
- Staging of lung cancer.
- Evaluation of thoracic trauma.
- Evaluation of thoracic manifestation of known extra-
thoracic diseases, especially metastasis.
- Guidance for biopsy & drainage procedures.
With CT, the distinction between pleural and
parenchymal processes, such as
• a peripheral lung abscess versus empyema,
• or a peripheral pulmonary nodule versus localized
pleural thickening,
• and assessment of the relative amounts of
consolidation and pleural effusion, can be made.

• Concomitant disease, involving more than one

compartment, such as bronchogenic carcinoma
directly invading the pleura & ribs can be assessed.
Important clues can be made with the help of CT
imaging are…….

• the fat content of lipomas,

• calcifications,
• and extrapleural fat thickening in asbestos-related
pleural disease,
• water density of loculated effusions
The CT features useful in localizing a lesion to the pleura
are similar to those employed when evaluating chest
radiographs and include:

• (i) a lenticular or crescent shape;

• (ii) an obtuse or tapering angle at the chest wall
interface; and
• (iii) a well-defined margin with the adjacent lung.
Extrapleural lesions may have an associated

• extrapleural soft-tissue mass,

• bone destruction,
• or displaced extrapleural fat can help confirm the site of
origin.
• The routine administration of intravenous contrast media
helps to differentiate atelectasis and consolidation, which
usually demonstrate marked enhancement, from
unenhancing pleural fluid.

• Pleural malignancy and metastases usually enhance.

• may be helpful in delineating areas of necrosis and

identifying peripheral enhancement of abscesses and
empyemas.

• The demonstration of pulmonary vessels within a lesion

unequivocally identifies it as parenchymal.
• Computed tomography also may be valuable in
characterizing confusing paramediastinal air collections
as well as in distinguishing a medial pneumothorax from
a pneumomediastinum or a parenchymal pneumatocele.

• It may confirm a coexistent pneumothorax when

extensive subcutaneous air obscures findings on chest
radiographs.

• CT is useful in differentiating a large bulla from a

pneumothorax suspected on a conventional radiograph
• Computed tomography is more sensitive than
conventional radiography in demonstrating focal pleural
plaques, especially in depicting involvement of the
mediastinal and paravertebral pleura.
Extensively calcified pleural plaques are seen involving
the posterior paraspinal pleura & pleura along the
diaphragmatic surface.
• Although oblique radiographs increase the sensitivity for
detecting pleural plaques, large calcified plaques can
simulate parenchymal disease and present a confusing
appearance on chest radiographs.

• CT can clearly demonstrate the extent and

characteristics of the pleural disease and reveal the true
nature of obscured or simulated lung disease.
• CT demonstrates the anatomy of the mediastinum
very well; & thereby is very helpful in evaluation of the
pathologies as well.

• CT shows the mediastinal structures in the cross-

sectional view, & thereby eliminates the confusion
produced by the overlapping, as occurs in the
conventional chest radiograph.
• CT is the imaging modality of choice in the
assessment of the patient with clinical or radiographic
findings s/o aortic injury, thoracic spine fracture or
diaphragmatic tear f/b blunt chest trauma.

• CT has overall greater sensitivity then radiography in

c/o pulmonary laceration, contusion, tracheo
bronchial injury.

• CT provides optimal visualization of thoracic spine

fracture, sternal fracture and diaphragmatic injury.
• Spiral or helical CT scanning & electron beam ultrafast
CT scanning has altered several of the CT scanning
protocols traditionally used for examining the thorax.

• Advantages of spiral CT scanning are…

- rapid scan in one or two breath holds
- reduction in volume of contrast needed for optimal
opacification of vessels
- the potential for multi-planar or three-dimensional
reconstructions.
 HIGH RESOLUTION
COMPUTED
TOMOGRAPHY (HRCT)
• Plain x-ray chest-is indispensable and remains the
screening modality of choice in patients with
suspected diffuse lung disease.

• 10-15% of diffuse lung diseases, 30-50% of

bronchiectasis and 20-60% of patients with
emphysema will have a normal chest x-ray normal.
• Large part of the lung is obscured by the mediastinum
and diaphragm.
• X-ray seldom allows a confident specific diagnosis.
• X-ray findings seldom correlate with the functional,
pathological and clinical impairment.
• Interobserver variation
 A NEW LOOK AT A PATTERN
RECOGNIZATION OF DIFFUSE
LUNG DISEASE
• “The common practice of describing the histologic
distribution of pulmonary lesions from their radiographic
patterns is often inaccurate.
• Thus chest radiographs are limited in their ability to
characterize lung morphology precisely and to represent
the pathological alteration in morphology that occurs in
the presence of lung disease.”
• High-resolution CT (HRCT) is currently the most
accurate noninvasive tool for evaluation of lung structure
AND diffuse lung disease.
• clarity and precision
• Detection and characterization
• Confidence
 INDICATIONS FOR HRCT
• I don’t know pattern on radiograph
• Abnormal PFT/Clinically diffuse lung disease with
normal radiograph
• X-ray findings not correlate with the clinical picture
• To monitor the activity of a disease and response to
treatment
• Prior to taking a lung biopsy
• To determine the reversibility of the disease
• Metastatic disease?
• HRCT is indispensible part of work-up of a patient
with suspected diffuse lung disease.

• In view of clinical background and laboratory

investigation- the most appropriate diagnosis can be
reached with reasonable confidence.
 Magnetic resonance imaging
• MRI is no substitute for CT in the investigation of
most thoracic conditions that require cross-sectional
imaging.

• There are few specific instances in which MRI is

useful problem solving technique.

• There is increasing interest in the role of MR

angioraphy for the diagnosis pulmonary embolism.
• MRI can identify cystic mediastinal lesions such as
bronchogenic cysts that may appear solid on CT scans.

• In lung cancer staging, MRI has only a secondary

problem solving role where CT is inconclusive or in whom
contrast media injection is contraindicated.

• MRI may also be helpful in the assessment of lesions

localized to the diaphragm
• In patients with lymphoma, MRI has no advantage over
CT in staging, but it may be useful in patient follow-up. In
patients treated for lymphoma, MRI is highly
recommended for those having a residual mass to
attempt a distinction between active tumour and inactive
fibrous residual soft tissue.

• MRI is also useful for detecting recurrence of lymphoma

in the chest wall.
• The ideal MRI technique should include cardiac gating
and presaturation studies of incoming blood, fat
suppression techniques and combined interpretation of
both T1- and T2-weighted images.

• Intravenous injection of gadolinium may be required.