CT CHEST

Giselle Revah
University of Toronto
Class of 0T7
Dr. N. Jaffer
Staff Radiologist MSH
and University of
Toronto
 THE BASICS

INTRO 1. The different options for CT

imaging of the lung

CT TYPE
2. An approach to looking at chest
CT’s
ANATOMY

DISEASE 3. A few disease patterns that will

PATTERNS help you impress
 CT TYPES
1. Standard
INTRO
2. High Resolution
3. Low Dose
CT TYPE
4. CT Angio

ANATOMY

DISEASE
PATTERNS
 1. STANDARD CT
• Slice thickness: 3-10 mm
INTRO • scans a large volume, very quickly
• Covers the full lung
CT TYPE • +/- contrast

Indications
• CXR abnormality
ANATOMY
• Pleural and mediastinal abnormalities
• Lung cancer staging
• F/U metastases
DISEASE • Empyema vs abscess
PATTERNS
 2. HIGH RESOLUTION (HRCT)
• narrow x-ray beam collimation: 1-1.3mm
INTRO vs. conventional 3-10mm
• cross sections are further apart: 10 mm
• high definition images of lung
parenchyma: vessels, airspaces, airway
CT TYPE and interstitium
• No contrast
STANDARD CT HRCT
ANATOMY

DISEASE
PATTERNS
 2. HIGH RESOLUTION (HRCT)
Indications
INTRO
• Hemoptysis
• Diffusely abnormal CXR
• Normal CXR with abnormal PFT’s
CT TYPE
• Baseline for pts with diffuse lung disease
• Solitary pulmonary nodules
• Reversible (active) vs. non-reversible
ANATOMY (fibrotic) lung disease
• Lung biopsy guide
• F/U known lung disease
DISEASE • Assess Rx response
PATTERNS
 3. LOW DOSE
• Premise: lower dose radiation will not
INTRO reduce the diagnostic functionality of
the scan (eg. 250 mAs 50 mAs)
• Detail is decreased
CT TYPE
Uses
• Screening
ANATOMY – ongoing trials
• F/U
– infections
DISEASE – post lung transplant
PATTERNS
– metastases
 4. ANGIOGRAPHY (CTA)
• contrast injected into peripheral vein
INTRO • injection timing/rate controlled automatically
• dye is where you want it during scan
• replaced conventional catheter angiogram
CT TYPE
Indications
• Pulmonary embolism
• Aortic aneurysms
ANATOMY • Aortic dissection

Risks
DISEASE • Iodinated contrast:
– Allergic/ nephrotoxic
PATTERNS
 APPROACHING THE ANATOMY

INTRO
Three Windows
1. Soft Tissue
CT TYPE
2. Bone

ANATOMY 3. Lung

DISEASE
PATTERNS
 1. SOFT TISSUE WINDOW
Look at these structures
• Thyroid
INTRO • Chest wall
• Pleura

Heart
CT TYPE • Chambers
• CA calcifications
• Pericardium

ANATOMY Vessels
• Aorta
• PA
• Smaller vasculature
DISEASE
PATTERNS Nodes
• mediastinal
•
 Ascending aorta
Main pulmonary artery
SVC
INTRO L pulmonary artery

CT TYPE
R pulmonary artery

Descending aorta
ANATOMY
Esophagus

DISEASE Azygous vein

PATTERNS What is this
duct?
 2. BONE WINDOW
Manubrium/
INTRO Sternum

CT TYPE

ANATOMY

DISEASE R Ribs L Ribs

PATTERNS Vertebrae
 3. LUNG WINDOW
AIRWAYS Bronchial Tree

INTRO
Central

CT TYPE
PARENCHYMA
RUL
ANATOMY LUL
Fissure

DISEASE
PATTERNS
Fissure RLL LLL
 COMMON PATHOLOGIC
FEATURES
INTRO 1. Air Bronchograms
2. Bronchiectasis
CT TYPE 3. Septal Thickening
4. Ground Glass Opacity
ANATOMY 5. Emphysema
6. Nodules
7. Filling Defect
DISEASE
PATTERNS
 1. AIR BRONCHOGRAMS
Description
INTRO • Bronchi become visible due to increased
attenuation of surrounding lung
• Implies proximal bronchi patency
• Excludes pleural or mediastinal lesion
CT TYPE
DDx
• Non-obstructive atelectasis
ANATOMY
• Pneumonia
• Pulmonary edema
• Hemorrhage
DISEASE
• Bronchioloalveolar carcinoma
PATTERNS
• Lymphoma
 2. BRONCHIECTASIS
Dilatation of medium-sized bronchi (>2 mm)
 impaired clearance  recurrent infection bronchial
INTRO damage
What type
Types is this?
1. Cylindrical
2. Cystic
CT TYPE 3. Varicose

HRCT is diagnostic tool of choice

ANATOMY
DDx
• Infection • Immunodeficiency states
• Bronchial obstruction • alpha 1-Antitrypsin deficiency
• Cystic fibrosis • RA and Sjögren
DISEASE • Primary ciliary • Pulmonary fibrosis
PATTERNS dyskinesia
 3. SPETAL THICKENING
• abnormalities of interlobular septa or
INTRO peripheral alveoli

• thickening and outlining of the secondary

CT TYPE pulmonary lobules is best seen on HRCT

• often well depicted in the

apices
ANATOMY
Most Common Causes
• pulmonary edema
DISEASE • pulmonary hemorrhage
PATTERNS • lymphangitic cancer spread
 4. GROUND GLASS OPACITIES
• common nonspecific finding
INTRO • decreased air content without
totally obliterating the alveoli

• increased lung opacity not sufficient to

CT TYPE obscure pulmonary vessels Early
DDx
• Alveolitis or interstitial
pneumonitis
ANATOMY – Hypersensitivity pneumonitis
– IPF
– Sarcoidosis
• Pulmonary edema
DISEASE • Resolving pneumonia/
hemorrhage
PATTERNS
Dense
 5. EMPHYSEMA
• permanent enlargement of air
spaces distal to the terminal
INTRO bronchioles
• destruction of the walls without
obvious fibrosis

CT TYPE DDx
• smoking
• alpha 1-Antitrypsin deficiency
• IV drugs
ANATOMY • Immundeficiency
• Vasculitis
• Connective tissue disorders
Young pt with bullous
emphysema at the lung
DISEASE bases.
PATTERNS What’s the diagnosis?
 5. EMPHYSEMA
3 Types
1. Centriacinar/lobular
INTRO • respiratory bronchioles  periphery
• upper half of lungs
• smoking

CT TYPE 2. Panacinar
• destroys entire alveolus uniformly
• lower half of lungs
• homozygous alpha1-antitrypsin
ANATOMY deficiency

3. Distal acinar/paraseptal
• distal airway, alveolar ducts, and alveolar sacs
• What 2 types are found
DISEASE around the lung septae or pleura
here?
• apical bullae may spontaneously
PATTERNS
pneumothorax
 6. NODULES
CT can detect nodules 3-4 mm

INTRO Benign
• Small, unchanged over 2 years
• Less than 15-20 HU
• fat within (hamartoma)
CT TYPE • halo sign: ground-glass surrounding nodule
indicates infection
Malignant
• Enhancement of greater than 20 HU
ANATOMY • Caution: active granulomas/ infectious lesions
• Spiculated
• Multiple

DISEASE Can you spot the

PATTERNS nodule?
 6. NODULES

Neoplastic Infectious Inflammatory

INTRO
Benign (hamartoma) Granuloma Rheumatoid arthritis
Bronchogenic Ca Abscess Wegener’s
Mets Sarcoidosis
CT TYPE Lymphoma

Circumscribed nodules
ANATOMY
suspect metastatic disease
Septated nodules, suspect
primary lung malignancy
DISEASE
PATTERNS
 7. FILLING DEFECTS
• Pulmonary Embolism is a well defined hypodensity in the
pulmonary artery
INTRO •
•
CTA sensitive for PE (90%)
can’t evaluate arteries below 4th segmental level

DDx:
• Anatomical landmarks and variants eg intersegmental
CT TYPE nodes
• Vascular tumor invasion
• Technical psuedo filling defects (eg flow artifact)

ANATOMY

DISEASE
PATTERNS
 REFERENCES
1. Engeler CE, Tashjian JH, Trenkner SW, and Walsh JW.
Ground Glass Opacity of the Lung Parenchyma: A Guide to
INTRO analysis with High Resolution CT. AJR 1993; 160: 249-251.
2. Collins, J. CT signs and patterns of lung disease. Radiol
Clin North Am. 2001 Nov;39(6):1115-35.

CT TYPE 3. Lee JKT, Sagel SS, Stanley RJ, Heiken JP. Computed Body
Tomography with MRI correlation. 3rd ed. Raven Press NYC,
1998.

ANATOMY

DISEASE
PATTERNS