Basic&Diagnostic&Radiology&(for&Medical&Students)& _______________'

Anthony'R.'Vera'Cruz,'MD,'FPCR,'FUSP'FCTMRISP' !! Ultrasound'
' !! MRI'
PART'I'(CHEST)' '
!! 'INTRO'AND'BASICS'OF'RADIOLOGY' Perfect'Diagnosis:'
!! ID'NORMAL'CHEST' 90%'D'Clinical'Exam,'History'and'PE'
!! IID'PULMONARY'INFECTION' 10%'D'Diagnostic'Exam'
!! IIID'PULMONARY'MASSES'AND'NODULES' &
!! IVD'CHEST'EMERGENCIES' RADIOGRAPHIC&DIAGNOSIS'
!! VD'AIRWAY'DISEASES' BASIC&PRINCIPLES&OF&XBRAY'
!! VID'PULMONARY'EDEMA'AND'OTHER'''RELATED' Air'>>>Fat'>>>Water'>>>Bone'>>>Metal'
CARDIODVASCULAR'DISTURBANCES' ''''(increasing'density)'
PART'II' Radiolucency'(Blackness)'–'Decrease'in'density'
!! VIID'ABDOMEN'(PLAIN)' ex.'AirDcontaining'organs'(Lungs,'Trachea)'
!! VIII'–'ABDOMEN'(CONTRAST'STUDIES)' RadioDopacity'(Whiteness)'–'Increase'in'density'
!! IXD'BONES'(TRAUMATIC)' ex.'FluidD'containing'organs'(Heart,'Aorta)'
!! XD'BRAIN'I' Solid'organs'(Liver,'Diaphragm,'Bones)'
!! XID'BRAIN'II' '
' Lesson&1&–&NORMAL&CHEST&
INTRODUCTION& '
& NORMAL&CHEST&(PA)&
RADIOLOGY'–'medical'specialty'that'employs'the'use'of' DLungs'
IMAGING'to'both'DIAGNOSE'and'TREAT'diseases' DHeart'
visualized'within'the'human'body' DMediastinum'
Radiologist'–'Diagnostician'/'Clinician' DDiaphragm/'Sulci'
DBony'Thorax'
!! '''
XBRAY& DSoft'Tissues'
!! Produced'when'fastDmoving'electrons'with'
sufficient'energy'strikes'a'target'(ex.'Tungsten'
target)'

'
!! Most'of'the'electron'energy'(>99%)'are'
converted'to'heat'and'only'<1%'is'converted'to' '
'
XDray'
Normal&Chest&–&Lateral&
!! Accidentally'discovered'by'Conrad'Roentgen'
(1895)'
!! Uses'of'XDray'
!! Diagnostic'
!! Medical/'Therapeutic'(Cobalt,'
Radiotherapy)'
!! Research'
!! Industrial'
!! Application'of'Diagnostic'XDray'
!! General'Radiography'
!! Fluoroscopy'
!! CT'Scan'
!! Mammography'
!! PET'Scan' '
NORMAL&CHEST&(PA)& Trachea&–&ends&at&T5&level&
1.! LUNGS'
RT'Lung'(3'lobes/10'segments)'
LEFT'Lung'(2'lobes/8'segments)'
2.! HEART'
CT'RATIO'='A/B'
PA'(0.50'to'0.52)'
AP'(0.55)'

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'
Diaphragm&and&sulci&

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3.! Mediastinum'
'
Mediastinum& ' &
1.! ANTERIOR&“Prevascular&Zone”' Diaphragm'–'level'of'10th'D11th'posterior'rib'
(areolar'tissue,'LN,'lymph'vessels,'thyroid,' '
thymus,'internal'mammary'vessels)' Bony&Thorax&
2.! MIDDLE&“Vascular&Zone”' Bony'Thorax'(Spine)'
(heart,'pericardium,'ascending/'arch'of'aorta,'
SVC,'pulmonary'vessels,'brachiocephalic'trunk,'
phrenic'nerve,'superior'vagus'nerve,'trachea,'
bronchi'
3.! POSTERIOR&“Postvascular&Zone”'
(descending'aorta,'esophagus,'thoracic'duct,'
azygous/'hemiazygous'veins,'LN,'sympathetic'
chain,'inferior'vagus'nerve'
'
Mediastinal&Borders&
'
Bony'Thorax'(Ribs)'

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'
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Bony'Thorax'(Ribs)' Patterns'of'parenchymal'infiltrates/'densities'as'seen'in'
XDray'

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' '
'
Soft'Tissues'

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Pneumonia

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Chest'Lateral'

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"! (Consolidation)'in'the'Right'Middle'Lobe'

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Lesson&2&–&Pulmonary&Infection&
&
I.&ACUTE&PULMONARY&INFECTION&
(PNEUMONIA)'
' '
PNEUMONIC'INFILTRATE/'DENSITY/'OPACITY'D'at'least'6'
mm'of'focus'for'it'to'be'visible'in'the'CXR'

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'
Pneumonia'

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"! Round'Pneumonia'(Consolidation)'
'
' Other&Facts&about&Pneumonia:'
'
•!Lower'lobes'and'Posterior'Segments'are'commonly'
Pneumonia'(Pedia)'
involved'
•!Peripheral'Zones'more'than'Central'Zones'
•!In'Aspiration'Pneumonia'–'Right'Lower'and'Right'
Middle'Lobes'are'more'commonly'involved'
•!“Mendelson'Syndrome'“–'aspiration'of'acidD
containing'gastric'contents'(chronic'chemical'
pneumonitis)'
'
II.&CHRONIC&PULMONARY&INFECTION&(PTB)'
PULMONARY'TUBERCULOSIS'(PTB)'

'
"! CXR'of'child'with'presumptive'VIRAL'
PNEUMONIA'

'
PARENCHYMAL&DENSITIES:&
•!Exudative'(Hazy)'–'Active,'Heals'Completely'w/o'scar'
•!Fibrosis/'Calcified'–'Chronic,'w/'Scarring'
' ' •!Cavitations'
"! Pneumonic'Consolidation,'Right'Lower'Lobe' •!Tuberculoma/'Granuloma'–'Small'nodules'(1D3'cm)'
(Bacterial)' '
Staging&of&PTB&(Adult)&
MINIMAL'
D!Cummulative'infiltrates'is'equal'to'or'less'than'2'
intercostal'spaces'
MODERATE&
D!Cummulative'infiltrates'is'more'than'2'intercostal'
spaces'but'less'than'1'entire'lung'or'
D!Presence'of'Cavities'equal'to'or'less'than'4'cm'
FARBARVANCED&
' D'Cummulative'infiltrates'of'more'than'1'lung'or'
"! Pneumonic'Consolidation,'Left'Lower'Lobe'
D'Presence'of'Cavities'greater'than'4'cm'or'
D'Miliary'PTB'
'
'
Staging&of&PTB&(Adult)& FARBADVANCED&PTB'
•! MINIMAL'
•! EXTENSIVE'(MODERATE'OR'FARDADVANCED)'
'
PTB,&RIGHT&UPPER&LOBE'

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' '
CHRONIC&PTB,&RIGHT&UPPER&LOBE&& PRIMARY&PTB&(DIAGNOSTIC&CRITERIA)&
"! History'and'P.E.'
"! Signs'and'Symptoms'
"! PPD'
"! Laboratory'(histo,'cyto,'biochem,'molecular)'
"! XDRay'(3/5'of'the'CRITERIA)'
'
PRIMARY&PTB&or&PRIMARY&COMPLEX&or&GHON'S&
COMPLEX&D&XDRAY'findings:&
1.'Lung'parenchymal'Infiltrates'(Ghon’s'focus)'
2.'Regional'Mediastinal'Lymph&Nodes'
LYMPHADENOPATHIES'–most'common'radiographic'
finding'of'Primary'PTB'
' '
CHRONIC&PTB' PRIMARY&PTB'

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'
PRIMARY&PTB&(presenting&as&large&mediastinal&mass)'
' '
FARBADVANCED&PTB'

' '
PRIMARY&COMPLEX&(Gross&Appearance)&

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DSmall'Subpleural'Granuloma''
DHilar'Lymph'Nodes'
'
' '
Dissemination&of&PTB:& 1.! Hyperlucent'lungs'
1.! Bronchogenic'–'exudate'from'a'cavity'is'aspirated' 2.! LowDFlat'Diaphragm'
2.! Hematogenous'–'causes'“Miliary”'spread' 3.! Large'Central'Pulmonary'Art'(Pulmonay'HPN)'
3.! LymphangiticD'more'common'in'Primary'PTB' 4.! Decrease'in'Peripheral'vessels'
' 5.! Narrow'Tubular'Heart'
Complications&of&PTB:& 6.! Increase'Retrosternal'Space'
1.! PLEURAL'EFFUSION'–'due'to'peripheral'lesion' 7.! Increase'in'Intercostal'Spaces.'
2.! EMPYEMA'–'infected'P.E.' 8.! Decrease'Diaphragmatic'Motion'(Fluoroscopy)'
3.! PNEUMOTHORAX'–''rupture'of'caseous'subpleural' & & *BULLA'/'BLEBS'
focus'/'blebs' '
4.! BRONCHIECTASIS'–'parenchymal'destruction' EMPHYSEMA&
5.! BRONCHOSTENOSIS'–'pressure'from'L.N./'
fibrosis/granuloma'
6.! ATELECTASISD'volume'loss'due'to'cicatrization'
7.! MILIARY'SPREADD'extrapulmonary'TB''
'
LESSON&3&–&AIRWAY&DISEASES'
1.! Bronchial&Asthma&
2.! COPD&(Chronic&Bronchitis&and&Emphysema)&
'
AIRWAY&DISEASES&(CLINICAL)& '
' Bronchial&Asthma& Chronic&Bronchitis& EMPHYSEMA&W/&BULLAE'
Clinical& hyperDreactivity' expectoration'x'3'
of'the'airways' months'for'2'years'
due'to'several' or'more'(common'
stimuli' in'smokers)'
Symptoms& cough,'DOB,' cough,'DOB,'
wheezing,'chest' wheezing,'chest'
tightness' tightness'
XBray& Bnormal&(75%)& Dnormal'
BhyperBaerated' D“dirty&lungs”&/'
increase'lung'
markings'
' '
EMPHYSEMA& '
Clinical:'similar' BULLA&
Pathology:'destruction'of' Dlocalized'vesicular'emphysema'within'the'lung'
the'elastic'tissues' substance'
>>>>'loss'of'elastic'recoil' Dintact'pleura'
>>>'collapse'of'bronchi' Dif'rupture'>>>'produces'pneumothorax'
>>>'overinflation'of'the'acini/alveoli' '
 LESSON&4&CARDIOBVASCULAR&DISTURBANCES& PHASES&OF&PULMONARY&EDEMA&
(PULMONARY&EDEMA)' &
' 1.&INCREASE&CIRCULATORY&VASCULAR&VOLUME&
1.'Balance'between'Capillary'Pressure'(CP)'and'Plasma'
Oncotic'Pressure'(POP'greater'than'CP)'

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2.'Maintenance'of'the'Normal'Capillary'wall'
Permeability'
'
PULMONARY&EDEMA& '
#! Flooding'of'the'alveoli'with'fluid'due'to'
disturbance'of'the'normal'physiologic'factors'

'
' "! NORMAL'='43'to'53'mm'
' &
CLASSIFICATIONS&OF&PULMONARY&EDEMA& 2.&ENGORGEMENT&OF&PULMONARY&VASCULATURE&
&
I.'DUE'TO'ELEVATED'CAPILLARY'PRESSURE'(CP'>>>POP)'
1.! CARDIOGENIC'(MI,'HPN,'Cardiomyopathy)'
2.! RENAL'DISEASE'(hypervolemia,'hypoproteinemia)'
3.! OBSTRUCTIVE'DSES.'OF'THE'PULMONARY'VEINS'
4.! NEUROGENIC'AND'POSTDICTAL'(Inc.'ICP'due'to'
sympathetic'discharge)'
'
II.'DUE'TO'INCREASE'IN'VASCULAR'PERMEABILITY'
(INJURY'EDEMA)'
1.! INHALATION'OR'ASPIRATION'OF'NOXIOUS'
SUBSTANCES'(Drug'Abuse)' '
2.! HIGH'ALTITUDE'(vasoconstriction)' &
3.! REDEXPANSION'EDEMA'(anoxia>>>injury)' 3.&INTERSTITIAL&PULMONARY&EDEMA&
4.! POSTDTRAUMATIC/'POSTDINFLAMMATORY'
5.! ARDS'(sepsis,'DIC,'vasoconstrictive'agents,'
surfactant'deficiency,'oxygen'alveolopathy,'etc)'
'
PHASES&OF&PULMONARY&EDEMA&
(SERIES'OF'PROGRESSIVE'STAGES/CONTINUUM)'
' 0.'Normal'
' 1.'Increase'Circulatory'Vascular'Volume'
' ' (Cardiomegaly,'Increase'in'Vascular'Pedicle)'
' 2.'Engorgement'of'Pulmonary'Vasculature'
' 3.'Interstitial'Pulmonary'Edema'
' 4.'Alveolar'Pulmonary'Edema' '
4.&ALVEOLAR&PULMONARY&EDEMA& Exceptions&to&the&rule…&
&
PULMONARY'EDEMA'with'normal'heart'size'and'normal'
vascular'pedicle'
' DAcute'MI'
' DNeurogenic'Edema'
' DARDS'
(…injury'is'immediate,'no'time'to'adopt'the'sudden'
change'of'Hemodynamics)'
'
Pulmonary'Edema'

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'
Relation&of&Pulmonary&Capillary&Wedge&Pressure&(PCP)&
to&the&Stages&of&Pulmonary&Edema&as&seen&on&XBRay&
XDRAY'FINDINGS' PCWP'mmHg'(rule'of'6’s)'
0.'Normal' 6D12'
1.'Increase'Circ.'Vascular' 12D18'
Volume'
2.'Engorgement'of'Pulm.' 18D24'''
Vasculature' '
3.'Interstitial''Pulmonary' 18D24' '
Edema' ' ' ' ' ''''''''Resolution'of'Pulm.'Edema'
4.'Alveolar'Pulmonary' >24' '
Edema' Pulmonary'Edema'
'
RADIOGRAPHIC&FINDINGS:'

'
' ' ' ' ''''''''Resolution'of'Pulm.'Edema'
'
' '
STAGE&1& '
D!Cardiomegaly'
D!Increase'in'the'Vascular'Pedicle'
STAGE&2&
D!Increase'in'size'of'Pulm.'Vessels'or'Fullness'of'the'
Hilum'
D!Loss'of'the'Normal'definition'of'the'Pulmonary'
Vascular'markings'
STAGE&3&(IPE)&
D!Prominent'Interstitial'Lung'Markings'
STAGE&&4&(APE)&
D!Bilateral'diffuse'haziness'of'the'Lung'fields'
'