Brian R. J.

Williamson, MD John
#{149} C. Gouse, MD
#{149}
Dennis C. Rohrer, MD C.
#{149} David Teates, MD

Variation in the Thickness of the

Diaphragmatic Crura with Respiration’

Misinterpretation of the diaphrag-

matic crura on axial computed to-
mography images is a recognized
pitfall in diagnosis. The right dia-
phragmatic crus is generally longer
and thicker than the left. The au-
thors observed a case in which the
left crus was thicker than the right,
causing diagnostic difficulty Ob-
taining scans at full expiration and
full inspiration clarified the situa-
tion. Confirmation of respiratory
variation in crural thickness was
obtained in ten patients. The crura
increased in thickness on inspira-
tion, compared with the size on ex-
piration. a. b.
Figure 1. CT scans obtained at full expiration (a) and full inspiration (b). A left paraaortic
Index terms: Abdomen, CT, 795.1211 Dia-
#{149} mass (straight arrow) became altered in configuration and increased in thickness at full in-
phragm, CT, 66.1211, 795.1211 Thorax,
#{149} CT. spiration. This confirmed that the structure was crural muscle. The right crus (curved ar-
66.1211 rows) similarly increased in thickness at full inspiration.

Radiology 1987; 163:683-684

T HE diaphragmatic crura have a solve the problem. Scans were then
variable thickness and shape. obtained at full inspiration and full
The right crus is generally longer expiration. The tissue in question al-
and thicker than the left (1-3). We tered in configuration and increased
describe a case in which the left crus in size on inspiration, confirming
was thicken than the right and mim- that it represented a muscle and mdi-
icked an abnormality. Repiration-in- cating a normal variant rather than
duced variation in crural thickness an abnormality (Fig. ib).
(4-6) was instrumental in clarifying
this situation. Confirmation that res-
MATERIALS AND METHODS
piration-induced variation in crural
thickness occurs was obtained in ten The patient described here was scanned
patients. with use of 10-mm-thick, contiguous sec-
tions on a Technicare (Solon, Ohio) Delta
2020 scanner. Subsequently, ten patients
who were undergoing CT scanning of the
CASE REPORT abdomen, both before and after intrave-
nous administration of contrast material,
A 46-year-old asthmatic man had were chosen at random. There were six
chronic abdominal pain and subse- men and four women. Their ages ranged
quently underwent abdominal com- from 29 to 62 years, with a mean of 43.1
puted tomography (CT) scanning. A years. The precontrast scans were ob-
left paraaortic mass was identified in tamed in full expiration and the postcon-
the upper abdomen (Fig. la). The trast scans were taken in full inspiration.

possibility that this mass represented Ten-millimeter-thick, contiguous sections

‘From the Department of Radiology, Univer- were obtained with a General Electric
a left crus that was thicker than that
(Milwaukee) 9800 scanner in the trial
sity of Virginia Medical School, Charlottesville, on the right was considered, though
group. All scans were obtained with a 2-
VA 22908. Received October 17, 1986; revision
an abnormality such as a left adrenal second scan time. The right and left crura
requested December 19; revision received Janu-
ary 20, 1987; accepted January 27. Address re-
tumor or adenopathy could not be were individually evaluated to determine
print requests to B.R.J.W. excluded. Sequential sections were whether the thickness increased, de-
RSNA, 1987
helpful but did not completely ne- creased, or showed no change with respi-

683
 CT images (2, 3). This pitfall can gen-
erally be avoided by recognizing that
variation is possible and by follow-
ing the structure on sequential sec-
tions (2, 3).
Our case (Fig. 1) was unusual in
that the left crus was thicker than the
right. Sequential sections were help-
ful but did not resolve the question
of whether the mass was a normal
variant or an abnormality. The
change in configuration between ex-
piration and inspiration was instru-
mental in confirming the diagnosis.
a.b. In the ten trial cases (Table 1) both
Figure 2. (a) Expiration baseline size. (b) The crura have increased in thickness at full in-
crura showed an increase in thick-
spiration. ness at full inspiration as compared
with the size at full expiration. There
was not a direct correlation between
the degree of diaphragmatic excur-
sion and the change in crural thick-
ness (Table 1). Clearly, however,
change in liver position is an indirect
and possibly imprecise method of de-
termining diaphragmatic motion. It
makes no allowance for possible van-
ations in liver compressibility, vania-
tions in respiration from one section
to the next, or the variable degree of
Valsalva during suspended respira-
tion. It also assesses right hemidia-
phragmatic motion only.
Respiratory variation in crural
thickness would be helpful in those
situations in which sequential scans
do not adequately permit distinction
between a normal crus and an abnon-
mality. U
ration. The thickness at expiration was 2). The mean change in thickness of
used as the baseline size. We measured the right cnus was 3.0 mm (37.2%); References
the largest short-axis thickness of the cru- 1. Gray H. Anatomy of the human body.
the range was from 1.0 to 7.0 mm.
ra on each occasion (Fig. 2b). Measure- 36th British ed. Williams PL, Warwick R,
The mean change in thickness of the
ments were obtained at the level of the eds. Philadelphia: Saunders, 1980; 548-549.
left crus was 2.4 mm (53.1%), with a 2. Kuhns LR, Seeger J. Atlas of computed to-
origin of the superior mesenteric artery
so that a fixed level could be obtained for
range from 1.0 to 4.0 mm. mography variants. Chicago: Year Book
Medical, 1983; 212-217.
comparison purposes. The degree of dia-
3. Callen PW, Filly RA, Korobkin M. Com-
phragmatic movement was assessed on puted tomographic evaluation of the dia-
DISCUSSION
the basis of liver movement at the level of phragmatic crura. Radiology 1978; 126:413-
the origin of the superior mesenteric ar- The diaphragmatic crura are pre- 416.
tery. When the appearance of the liver dominantly muscular in nature (1). 4. Nightingale RC, Dixon AK. Crura! change
section was not identical on both inspira- The night crus is broader and longer
with respiration: a potential mimic of dis-
tion and expiration, the distance was ease. Br J Radiol 1984; 57:101-102.
than the left and arises from L-1, L-2, 5. Rosen A, Auh YH, Rubenstein WA, Engel
halved. Thus, some measurements regis-
and L-3. The left crus arises from L-1 IA, Whalen JP, Kazam E. CT appearance of
ter half centimeters even though 10-mm-
and L-2. They both blend with the diaphragmatic pseudotumors. J Comput
thick sections were used (Table 1).
Assist Tomogr 1983; 7:995-999.
anterior longitudinal ligament of the
6. Anda S. R#{216}ysland P. Fougner R, St#{216}vring J.
vertebral column (1). CT appearance of the diaphragm varying
RESULTS In cross section, the crura are usu- with respiratory phase and muscular ten-
ally oval on comma shaped and are of sion. J Comput Assist Tomogr 1986; 10:744-
In all ten patients, the crural thick-
745.
ness increased on inspiration as com- variable thickness. Alterations in the
usual size on shape of the cruna can,
pared with expiration (Table 1) (Fig.
however, cause confusion and lead to
possible misinterpretation on axial

684. Radiology June 1987