97i

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Review Article

High-Resolution CT of the Lungs: Findings in Various

Pulmonary Diseases
Stephen J. Swensen,1 Gregory L. Aughenbaugh,1 William W. Douglas,2 and Jeffrey L. Myers3

High-resolution CT (HRCT) is a technique that optimizes the Technique

spatial resolution of conventional scanners. HRCT shows exqui-
site detail of both normal and diseased lung. The findings seen HRCT uses a high-spatial-frequency reconstruction algo-
with HRCT of the lung correlate well with the microscopic and rithm and thin CT sections to increase spatial resolution. The
gross pathologic findings. In this review, we describe the tech- tradeoff is that this increases visible noise. However, in-
nical features of HRCT and discuss the HRCT findings in various creased visible noise is a negligible factor in pulmonary paren-
lung diseases. chymal imaging given the high ratio of air to tissue in the lung.
The mediastinal images appear “grainy” but are diagnostically
acceptable. It must be kept in mind, however, that during
High-resolution CT (HRCT) is a CT technique that maxi- scanning with sections i-i .5 mm thick at iO-mm intervals,
mizes spatial resolution. This allows superior
imaging of the 80-90% of the thorax is not imaged and small nodules can
fine structure of the lung and its airways [i 2]. , be missed.
HRCT closely reflects changes in lung structure and is well The high-spatial-frequency reconstruction algorithm also
suited to evaluate the pulmonary parenchyma and airways. has an edge enhancement effect that is most pronounced at
In the past few years, HRCT has been found useful in the tissue interfaces that have significantly different attenuations
evaluation of a variety of pulmonary diseases. It can be used (e.g., air and lung parenchyma). Because of this edge en-
to recognize and diagnose bronchiectasis and a number of hancernent artifact, HRCT may lead to erroneously high at-
diffuse lung diseases [3-6]. A combined examination with CT tenuation values at the periphery of a nodule and should
and HRCT (CT/HRCT) is particularly helpful in the detection not be used to evaluate the density of pulmonary nodules
and diagnosis of chronic diffuse lung disease [5, 6]. As with (Fig. i).
plain chest radiography, optimal radiographic technique and Slice thickness with HRCT is i .0-i .5 mm, compared with
knowledgeable pattern recognition of disease are important a standard CT slice thickness of 8-i 0 mm. A small focal spot
in realizing the full potential of this method. In this review, we is used with ultra-high-resolution reconstruction if available.
describe the pertinent technical features of HRCT and de- Our technique for conventional CT is i 30 kVp and i iO mA
scribe and illustrate the HRCT findings in several lung dis- with a 2-sec scan time. For HRCT, we use i 25 mA to improve
eases. image quality slightly [i].

Received March 12, 1991; accepted after revision November 25, 1991.
1 Department of Diagnostic Radiology, Mayo Clinic and Mayo Foundation, Rochester, MN 55905. Address reprint requests to S. J. Swenson.
2Division of Thoracic Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN 55905.
3Section of Surgical Pathology, Mayo Clinic and Mayo Foundation, Rochester, MN 55905.

AJR 158:971-979, May 1992 0361 -803X/92/1 585-0971 © American Roentgen Ray Society
 972 SWENSEN ET AL. AJA:158, May 1992
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Fig. 1.-High-resolution CT scan of 1-cm pul- Fig. 2.-A and B, Lung metastasis from renal cell carcinoma. Small nodules are more readily
monary nodule. Edge enhancement artifact at pa- identified on 10-mm-thick conventional CT scan (A) than on 1-mm-thick high-resolution CT scan (B)
riphery of nodule (arrow) Is from high-spatial-fre- obtained at same level.
quency reconstruction algorithm. Artifact was not
present when scan was reprocessed with stand-
ard imaging algorithm.

Fig. 3.-Scleroderma.
A, CT scan with patient supine shows linear
opacities (arrows) in posterior basilar-dependent
portions of lung. These opacities could be due to
fibrosis, edema, or atelectasis.
B, CT scan with patient prone shows that opac-
ities (arrows) persist in nondependent position
and therefore are most likely fibrotic. Findings are
compatible with eariy changes of usual interstitial
pneumonia, in this case due to scleroderma.

When surveying for bronchiectasis, we obtain only HRCT Retrospective targeted reconstruction of HRCT images
scans at i -cm intervals. Because small nodules and diffuse allows a further significant increase in spatial resolution by
nodular infiltrates are more readily detected on conventional decreasing pixel size. The spatial resolution is approximately
CT than on HRCT, a combination of conventional and high- i .5 times the pixel size [5]. The standard field of view of 40
resolution sections (CT/HRCT) has been recommended for cm uses a pixel of 0.78 mm. Targeting to a field of view of
evaluation of diffuse lung disease [5] (Fig. 2). When neoplasm i 2.8 cm decreases the pixel size to 0.25 mm. Further de-
is not suspected, we usually evaluate diffuse lung disease creases in field of view do not improve the image [i 2]. ,

with alternating conventional and high-resolution sections ob-

tamed at 1 0-mm intervals. First, conventional iO-mm sections
Bronchiectasis
are obtained at 20-mm intervals through the entire chest, and
then thin-section images (1 -1 .5 mm in thickness) are obtained HRCT has been used successfully in the evaluation and
at 20-mm intervals between the levels of the conventional early detection of bronchiectasis. CT findings in bronchiec-
images. tasis include thickened bronchial walls and dilated bronchi,
Scans are done at full inspiration and with the patient which result in visibility of bronchi more peripherally in the
supine. When there are opacities
in the dependent region of lung than normal [3, 4, 7]. Bronchi accompany pulmonary
the lung, we also scan with the patient prone to differentiate arteries into the lung and have approximately equal external
gravity-dependent hypostatic pulmonary atelectasis (“airway diameters. When bronchiectasis is present, the affected bron-
closure’) from interstitial fibrosis or infiltration (Fig. 3). Retro- chus is larger than its attendant artery. The “signet ring’ sign
spective targeted images are obtained as indicated to in- is formed when these structures are viewed in cross section
crease spatial resolution. (Fig. 4). This is virtually pathognomonic of bronchiectasis [7].
 AJA:158, May 1992 HIGH-RESOLUTION CT OF LUNG 973
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Fig. 4.-Bronchlectasis.
A, High-resolution CT scan shows multiple sig-
net ring signs (arrows), which are diagnostic of
bronchiectasis.
B, Shadows are much less distinct on conven-
tional CT image (with high-spatial-frequency re-
construction algorithm) obtained on same day at
same level.

A B

Fig. 5.-CT scan shows dilated bronchi (ar-

rows) within consolidated region of posterior and
lateral basal segments of left lower lobe. Infiltrate
was bacterial pneumonia. Radlologic and clinical
findings were consistent with pseudobronchlec-
tasis.

Fig. 6.-CT scan shows traction bronchlectasis

(arrows) due to radiation fibrosis from treatment
of lymphoma.

Bronchiectasis may also be identified as a linear array or lar pattern has diagnostic significance. The distribution of the
cluster of cysts, often with air-fluid levels. Sometimes a van- parenchymal changes is also an important feature to analyze
cose configuration can be seen when bronchi are coursing in [i 4, i 51. Some diffuse lung diseases are distributed predom-
the same plane as the CT section. Care must be taken to inantly in the upper zones rather than in the lung bases or
identify bronchiectasis with mucoid impaction, which will ap- have peripheral rather than penihilar involvement. For exam-
pear as a linear or branched solid tubular opacity when imaged pIe, usual interstitial pneumonia (UIP) typically has a peripheral
in profile or as a solid signet ring when imaged in cross basilar distribution, whereas silicosis has an upper, often
section. posterior predominance.
Bronchiectasis is defined as fixed bronchial dilatation. It is Over 100 entities are known to cause diffuse lung disease
important to be aware of pseudobronchiectasis, which is [i 6]. Fortunately, fewer than 20 of these processes account
reversible cylindrical bronchial dilatation. Pseudobronchiec- for nearly 90% of all nonneoplastic disorders assessed with
tasis results from inflammatory changes typically related to open lung biopsy [i 6, i 7]. The following is a summary of the
bacterial pneumonia (Fig. 5). After resolution of acute pneu- CT/HRCT features of some of the more common diffuse lung
monia, bronchial dilatation may persist for up to 3-4 months. diseases.
Consequently, HRCT examination for bronchiectasis should
be performed at least 4 months after the infection has re-
Usual Interstitial Pneumonia
solved to avoid this pitfall [8, 9]. Traction bronchiectasis,
associated with pulmonary fibrosis, is a type of airway dila- UIP is the most common abnormal finding in patients with
tation that should be distinguished when possible [i 0] (Fig. chronic progressive infiltrating lung disease. The clinical and
6). radiologic findings are often nonspecific. CT/HRCT is often
useful in demonstrating the typical features of UIP or those
of entities that can mimic this condition. UIP is a histopatho-
Diffuse Lung Disease
logic term referring to a pattern of nonspecific interstitial
Many diffuse infiltrative lung processes have distinguishing fibrosis that occurs in patients with various disorders, includ-
features when studied with CT/HRCT [5, i i-i3]. A nodular, ing idiopathic pulmonary fibrosis, asbestosis, rheumatoid ar-
cystic, polygonal, irregular linear, ground-glass (homogene- thnitis, mixed connective tissue disease, and sclerodenma.
ous, hazy region of increased attenuation without air bron- The patient’s clinical presentation determines the specific
chograms or obscuration of pulmonary vasculature) or alveo- diagnosis in these situations.
 974 SWENSEN ET AL. AJA:158, May 1992
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Fig. 7.-High-resolution CT scan of usual inter-

stitial pneumonia. Note characteristic basilar and
peripheral subpleural honeycomb pattern (ar.
rows).

Fig. 8.-Silicosis. CT scan shows upper lung

distribution of small nodules. Note difference in
nodule distribution between silicosis and sarcoid-
osis (Fig. 9). Nodules in sarcoidosis have more
peribronchovascular and central distribution.
7 8

CT/HRCT typically shows patchy reticular, honeycomb, large nodular opacities (diameter, i cm), simple silicosis
and ground-glass opacities. Subpleural honeycombing is a transforms into complicated silicosis. Radiologic progression
frequent finding. The infiltrative pattern tends to have a dis- ofsimple silicosis to complicated silicosis is mirrored by clinical
tinctive basilar and peripheral subpleural distribution [18-20] deterioration of the patient, who has increasing dyspnea and
(Fig. 7). There is generally minimal involvement of the interlob- functional impairment [29].
ular septa [20]. lntralobular bands may be present. Enlarge- CT is of value because it can detect the development of
ment of mediastinal lymph nodes is common in UIP and complicated disease early [27, 28]. Large nodular opacities
presumably is part of the inflammatory process [2i]. can progress to form even larger conglomerate masses or
CT/HRCT can assess response to steroid therapy in UIP progressive massive fibrosis, which is accompanied by the
[1 8]. Patients with UIP who are found to have areas of ground- development of cicatricial emphysema. This further reduces
glass opacity or air-space consolidation are more likely to lung function. The extent of emphysema correlates more
have a response to steroid therapy than are those with only closely with functional impairment than does the degree of
honeycombing or linear or nodular opacities [i 8]. nodular profusion (27, 30]. CT/HRCT clearly shows fibrosis
and emphysema [27]. CT can monitor disease progression
and evaluate for potentially curable superimposed disease,
Asbestosis
such as tuberculosis and lung cancer [26-28].
HRCT can depict early pulmonary fibrosis due to asbestos Recently, HRCT was found to differentiate focal dust em-
exposure [22]. The subpleural parenchyma of the lower lobes physema, which is most commonly associated with tiny p-
is the initial site of detectable abnormality by HRCT [22, 23]. type nodular opacities, from centrilobular emphysema [31].
Parenchymal features of asbestosis, like those of UIP, include
thickened intralobular and intenlobular (septal) lines, sub-
Sarcoidosis
pleural curvilinear opacities, subpleural nodular irregularities,
honeycombing, and hazy patches of increased attenuation. Sarcoidosis is characterized by nonnecrotizing granulomas
The distribution of the parenchymal abnormalities has a bas- distributed along the lymphatic pathways of the bronchovas-
ilar and peripheral predominance [22-25]. Occasionally, cular bundles and interlobular septa. The opacities tend to be
HRCT examinations with the patient both prone and supine nodular and predominate in upper and middle lung zones. The
are necessary to differentiate gravity-dependent subpleural nodules often are clustered in the perihilar, peribronchovas-
opacities from fibrosis (Fig. 3). CT/HRCT is also sensitive in cular region, with relative sparing of the lung periphery [i 3]
the detection of calcified and uncalcified pleural plaques in (Fig. 9).
patients exposed to asbestos. In later stages of sarcoidosis, cicatricial changes result in
architectural distortion and fibrotic areas of consolidation [32]
(Fig. iO). Sarcoidosis may occasionally be difficult to differ-
Sillcosis and Coal Worker’s Pneumoconiosis
entiate from lymphatic carcinomatosis because both can have
The characteristic CT finding in silicosis and coal worker’s lymphadenopathy and nodular peribronchovascular and sep-
pneumoconiosis is multiple small nodules with predominant tal thickening [1 3]. Cicatricial lung distortion and traction
distribution in the upper lung zones, especially posteriorly [5, bronchiectasis are seen in sarcoidosis and can be useful in
14, 26-28] (Fig. 8). Although silicosis and coal worker’s differential diagnosis. Also, nodules may be more numerous
pneumoconiosis are pathologically distinct entities, their radio- with sarcoidosis than with lymphatic carcinomatosis.
logic findings are similar.
As simple silicosis and coal worker’s pneumoconiosis pro-
Lymphatic Carcinomatosis
gress and the number of nodules increases, nodules coalesce
and the adjacent lung architecture becomes contracted and CT/HRCT of lymphatic carcinomatosis is characterized by
distorted. At the stage of coalescence of small nodules into nodular thickening of the interlobular septa without cicatnicial
 AJR:158, May 1992 HIGH-RESOLUTION CT OF LUNG 975

Fig. 9.-Typical high-resolution CT findings of

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stage II sarcoidosis. Note central penbronchovas-

cular distribution of small nodules. Lung periphery
is relatively spared.

Fig. 10.-Stage IV sarcoidosis. High-resolution

CT scan shows bilateral midlung regions of con-
solidation due to sarcoid granulomatous reaction
and fibrosis. Secondary traction bronchiectasis
and cicatricial parenchymal distortion are present.
Typical small nodular changes are present in an-
terior segment of right upper lobe and superior
segment of left lower lobe.

Fig. 11.-Lymphatic carcinomatosis. High-res-

olution CT scan shows typical nodular thickening
of interiobular septa (arrows) and bronchovascular
bundles (arrowheads).

Fig. 12.-Pigeon breeder’s hypersensitivity

pneumonitis. High-resolution CT scan shows
patchy areas of ground-glass opacity (white ar-
rows). By definition, ground-glass opacity doss
not obscure bronchovascular shadows. Scattered
small focal nodular opacities (black arrows) are
present also. These high-resolution CT findings
are compatible with hypersensitivity pneumonitis.

11 12

distortion of polygonal architecture. Distribution tends to be to be characteristic enough to suggest the diagnosis [35].
basilar. Peribronchovascular nodularity also is often evident Chest radiography has shown upper zone predominance of
[33, 34] (Fig. i i). CT/HRCT may locate an area of involvement fibrotic changes in chronic hypersensitivity pneumonitis [36].
that is suggestive of lymphatic carcinomatosis early in the This finding has not yet been confirmed by CT/HRCT [35].
course of the disease.

Cardiogenic Pulmonary Edema

Hypersensitivity Pneumonitis (Extrinsic Allergic Alveolitis)
Smooth subpleural and peribronchovascular thickening as
Acute hypersensitivity pneumonitis is characterized prirnar-
well as increased thickness and number of visible interlobular
ily by ground-glass and air-space opacification. Small (i .5 mm
septal lines without nodularity are characteristics of the inter-
or less) or medium (i .5-3.0 mm) nodular opacities are also
stitial abnormalities seen in pulmonary edema. The diffuse
seen. Subacute hypersensitivity pneumonitis with disease
infiltrate may be dependently distributed. Various degrees of
duration measured in days or months shows both small
alveolar opacification representing air-space edema may also
rounded opacities and ground-glass opacity that do not ob-
be present. The left ventricle and atrium may be enlarged.
scure the underlying bronchovascular shadows (Fig. i 2).
Small pleural effusions are frequently present [37].
Chronic hypersensitivity pneumonitis of greater than i year’s
duration has irregular fibrotic linear opacities associated with
the findings of subacute disease [35].
Emphysema
Abnormalities are found predominantly in the middle lung
zones, and the lung bases are relatively spared. No axial CT/HRCT of emphysema is characterized by bullae or small
predilection has been noted. In the appropriate clinical setting lucent areas (or both) without the well-defined walls one would
with a history of exposure, the CT/HRCT findings in the expect to see with lung cysts or honeycombing. CT/HRCT
subacute phase of hypersensitivity pneumonitis are thought can show changes of centrilobular, panacinar, irregular, and
 976 SWENSEN ET AL. AJA:158, May 1992

Fig. 13.-Emphysema.
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A, Chest radiograph shows left hilar broncho-

genic carcinoma. Linear interstitial pattern with
Kerley’s B lines suggested lymphatic carcinoma-
tosis.
B, High-resolution CT scan shows central lung
cancer but no evidence of lymphatic carcinoma-
tosis. Interstitial pattern seen on chest radiograph
(A) was due to paraseptal emphysema (arrows).
This pattern was symmetric with contralateral lung
and subsequentiy shown to be unchanged over
several years.

A B

Fig. 14.-High-resolution CT scan of early stage

of Iymphangioleiomyomatosis. Small air-filled,
thin-walled cysts (solid arrows) were uniformly
distributed throughout lungs. Patients with this dis-
ease are predisposed to pneumothorax (open ar-
row).

Fig. 15.-High-resolution CT scan of eosino-

philic granuloma (histiocytosis X) shows numerous
small air-filled, thin-walled cysts (arrows). These
cysts are spherical, not tubular, and should not be
confused with signet ring sign of bronchiectasis.

paraseptal emphysema [38]. There is a significant correlation Eosinophilic Granuloma (Histiocytosis X)

between HRCT grading and pathologic grading of emphy-
The parenchymal disease of eosinophibic granuboma (histio-
sema [39, 40]. CT/HRCT may show that apparent diffuse
cytosis X) tends to have an upper lung predominance [47-
infiltrative lung disease on chest radiographs is due to a
50]. Cystic changes and nodules are the predominant CT/
pleural process or a type of emphysematous lung disease
HRCT finding [48]. Usually, small thin-walled, air-fibbed cysts
(Fig. i3).
or nodules are present [47, 48] (Fig. i 5). Nodules may pro-
gress to cavitated nodules to cysts to confluent cysts [48].
The patients are prone to pneumothorax, probably from cyst
Lvmnhanoioleiomvomatosis and Tuberous Sclerosis
rupture. Mild interbobular septab thickening also may occur.
Lymphangioleiomyomatosis and pulmonary involvement in The cysts found in Iymphangioleiomyomatosis have a sim-
tuberous sclerosis are radiologically and pathologically iden- ilar appearance but are not associated with nodular changes
tical. Both are characterized by haphazard proliferation of or an upper lung distribution [48]. The CT/HRCT cystic find-
smooth muscle cells along bronchovascular bundles, lym- ings in eosinophilic granuboma may also resemble bronchiec-
phatics, and pulmonary veins. Numerous small parenchymal tasis, but examination of serial sections can differentiate
cysts are uniformly distributed throughout the lungs and are tubular from spherical structures. The cysts in both bymphan-
a characteristic finding on CT/HRCT [4i -46] (Fig. 1 4). Al- gioleiomyomatosis and eosinophilic granuboma do not have a
though not a prominent feature, septal thickening results from peripheral distribution like honeycomb cysts of UIP.
lymphatic engorgement, smooth muscle proliferation, and
fibrosis. Additional CT/HRCT findings that may not be evident
Chronic Eosinophilic Pneumonia
on conventional radiographs are small pneumothoraces, chy-
bus effusions, mediastinal lymphangiomyomatous ad- Fewer than 50% of patients with chronic eosinophilic pneu-
enopathy, and renal or hepatic angiomyolipomata [4i-46]. monia have the classic pattern of peripheral air-space disease
 AJA:158, May 1992 HbGH-RESOLUTION CT OF LUNG 977
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Fig. 16.-CT scan of bronchiolitis obliterans

with organizing pneumonia. Although nonspecific,
focal areas of air-space infiltrate (arrows) may be
present, often involving outer third of lung.

Fig. 17.-Unenhanced CT scan shows high-

attenuation region of lung consolidation (arrows).
Findings are characteristic of amiodarone toxicity.
*
Air-space infiltrate was shown to be due to bron-
chiolitis obliterans with organizing pneumonia.
16 17

Fig. 18.-Obliterative bronchiolitis. CT scan

shows confluent regions of hyperiucency due to
hyperinflation that are primarily in lung periphery.
More central regions of higher attenuation are ac-
centuated on this expiration scan.

Fig. 19.-High-resolution CT scan of alveolar

proteinosis shows predominant pattern of air-
space filling. Multiple fluffy, approximately 2-cm
areas of confluence (arrows) correspond to sec-
ondary pulmonary lobules.

involving the middle and upper lung zones on the chest pneumonia; however, the disease can also be restricted to
radiograph [5i 52]. In patients who lack these classic find-
, more central areas without subpleurab disease [55, 57]. Bron-
ings, diagnosis and therapy can be delayed. bn some cases, chiab wall thickening and dilatation are frequently found within
the absence of classic findings may even lead to unnecessary the areas of consolidation.
open lung biopsy. CT/HRCT can display the peripheral posi- The CT/HRCT findings of idiopathic BOOP are acknowl-
tion of air-space infiltrates in this disorder by eliminating edged to be nonspecific; however, in the proper clinical set-
superimposition [53]. In the appropriate clinical setting, the ting, they can support the diagnosis. CT/HRCT can evaluate
diagnosis of chronic eosinophilic pneumonia can be strongly the extent of disease and its distribution. CT/HRCT may help
supported by the CT/HRCT findings [53]. LOffler’s syndrome differentiate BOOP from UIP [57].
has a similar distribution of eosinophilic infiltrates, but they BOOP may be a manifestation of toxicity from certain
are more fleeting [54]. drugs, including amiodarone and bleomycin [58]. Amiodarone-
induced BOOP can cause characteristic high-attenuation pa-
renchymal-pleural abnormalities. The high attenuation is
Bronchiolitis Obliterans with Organizing Pneumonia (BOOP)
thought to be from the iodinated composition of the drug [59]
BOOP is a relatively nonspecific pattern of intraluminal (Fig. i7).
fibrosis that can be seen in various clinical contexts. In some
patients, BOOP represents a primary idiopathic form of fi-
Obliterative Bronchiolitis
brosing lung disease (“idiopathic BOOP”). CT findings in pa-
tients with idiopathic BOOP include patchy areas of air-space Obliterative bronchiolitis is a form of small-airways disease
consolidation and nodular opacities 1 0 mm or less in diameter that results in chronic obstructive airways resistance. It has
(Fig. i6). Air-space consolidation and nodular opacities can been associated with viral infection, exposure to toxic fumes,
be seen either alone or in combination. Air-space consolida- bone marrow transplantation, and rheumatoid arthritis [60-
tion is usually and asymmetric
bilateral but can be unilateral 62]. BOOP is a distinct clinical and pathologic entity that
[55, 56]. It is common for the areas of consolidation to be usually has associated parenchymal infiltrates. Obliterative
subpleural, similar to the distribution with chronic eosinophilic bronchiolitis, on the other hand, is not associated with paren-
 978 SWENSEN ET AL. AJA:158, May 1992

chymal infiltrates, although there is widespread inhomogene-

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Disease activity in idiopathic pulmonary fibrosis: CT and pathologic corre-

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