醫(yī)學(xué)影像診斷學(xué)課件：呼吸系統(tǒng)影像診斷學(xué)

1、呼吸系統(tǒng)影像診斷學(xué)Radiology of Respiratory system目 的 要 求熟悉呼吸系統(tǒng)疾病的影像學(xué)檢查方法。掌握肺與縱隔的正常X線、CT表現(xiàn)。掌握肺、胸膜與縱隔基本病變的X線、CT表現(xiàn)。掌握支氣管擴(kuò)張癥、各型肺炎、肺膿腫、肺結(jié)核、原發(fā)性肺癌的典型X線及CT表現(xiàn)。了解縱隔腫瘤及腫瘤樣病變的影像診斷原則及常見縱隔腫瘤的影像表現(xiàn)。Part I Imaging methods and normal imaging anatomy Section I Common imaging techniques 1. chest fluoroscopy (透視)Advantages: real

2、-time fast imagelive moving pictures cheap price Disadvantages: lower resolution and sensitivitycan not stored not applied in lung but more in digestive tract, interventional radiologyCommon imaging techniques2. chest radiography (攝片) routine position：posterior-anterior P, PAlateral P(left/right P,

3、pathological side close to film) Ad：cheap pricegood natural contrastLow radiation Disad: overlapping imageCommon imaging techniques chest radiography 3. DSA （Digital subtractive angiography） Bronchial arteriography (支氣管動脈造影) Pulmonary artery angiography (肺動脈造影)Angiographyprecontrast CT and contrast

4、enhanced CT(平掃+增強(qiáng)) mediastinum window and lung window (縱隔窗+肺窗) 4. Computer Tomography (CT) Computer Tomography (CT)HRCT（High resolution computed tomography） very thinning slice (1-2mm）+ high resolution reconstruction image of lung value：small nodule, diffuse interstitial lung diseases(DILD,彌漫性肺間質(zhì)病變

5、) and bronchiectasis (支氣管擴(kuò)張)Computer Tomography (CT)Multiple Slice Computer Tomography (MSCT) post-processing techniques-3D ReconstructionMultiple plane reconstruction（MPR）-coronal Minimalintensityprojection (MinP)surfaceshaded displays (SSD)Computer Tomography (CT)Computed tomography angiography (C

6、TA)Fusion CT images of bronchial arteriography and bronchographyComputer Tomography (CT)Computed tomographic virtual endoscopy （CT虛擬內(nèi)窺鏡檢查）Computer Tomography (CT)Dual energy CT and spectral CT (能譜CT)Has been widely used in clinicSpectral curve analysis- identifying benign and malignant lymph nodules

7、Iodine based imaging - find early abnormal blood perfusion caused by pulmonary embolismspectral CT lung perfusion diagnose early pulmonary embolism Computer Tomography (CT)5. Magnetic Resonance Imaging (MRI) multiple plane and multiple sequence image rarely used in lung because long scan time and br

8、eathy artifact useful to mediastinum mass5. MRI Artwhat are these？ Section IIThe normal X-ray featuresComparison of normal chest anatomy and X-ray film（1）Thoracic cage (胸 廓)Soft tissue of chest wallUnable to differentiate soft tissue of chest wall, just totally overlapping image pectoralis major (胸大

9、肌)sternocleidomastoid muscle (胸鎖乳突肌)supraclavicular skin fold (鎖骨上皮膚皺褶 ) 1. Soft tissue of chest wall female breast shadows: the lower lung fields increase the density and curve marginNipple shadows （乳頭影）: look like pulmonary nodules（1）Thoracic cage (胸 廓)2. Skeleton scapula；thoracic vertebrae； clavi

10、cle；sternum(胸骨) ribs and costal cartilage anterior rib and posterior rib（location marker） calcification of costal cartilage（1）Thoracic cage (胸 廓)2.Congenital rib anomaliescervical rib(頸肋)bifid rib(叉狀肋)fusion of rib(肋骨聯(lián)合）（1）Thoracic cage (胸 廓)（2） Pleura (胸膜)partial pleura（PP）and visceral pleura（VP）Pl

11、eural cavity：vacuum, negative pressureoblique fissure and horizontal fissure:doublelayerofvisceralpleura between lunglobesNormally invisible on X-ray film, fissure can be showed linear white shadow（2） Pleura (胸膜)Interlobular fissures Interlobular fissures（3） Lung (肺)trachea and bronchuslung fieldslu

12、ng hilarlung markingslobe, segment, lobules, alveolustrachea and bronchus (氣管、支氣管 )Trachea: in the midline up to the thoracic inletTracheal bifurcation: T5-6 level, acute angle(60-80)R/L main bronchi （3） Lung (肺)normal lungs filling with air appear dark areas on PA X-ray film divided into zones：inne

13、r, middle and the outer zone upper, middle and lower fields lung fields (肺野)（3） Lung (肺) Consists of pulmonary arteries, veins and major bronchi The left hilar is usually slightly higher than the rightlung hilar (肺門)（3） Lung (肺)Composition: Lung artery, vein, bronchial walls, lymphatics and some fib

14、rotic tissueRadiated distribution from hilar to distal lung arealung markings(肺紋理 )（3） Lung (肺)Right Lung: three lobes-upper, middle, lower lobe left lung: two lobes-upper ,lower lobe Right lobe Left lobe Right lateral left lateral Pulmonary lobe (肺葉)（3） Lung (肺)Lobes of right lungLobes of left lung

15、Right lung: upper (S1-3), middle(S4-5), lower lobe (S6-10)- -10SLeft lung: upper (S1+2,3,4,5), lower lobe (S6,7+8,9,10)-8Sunable to identify lung segment on X-ray film but CTPulmonary segment (肺段)（3） Lung (肺)Lung lobe lung segment lobules terminal bronchioles alveoli（3） Lung (肺)Normally invisible on

16、 image smallest fundamental unit of lung structuremeasures between 1 and 2.5 cm across; polyhedral in shape bounded by interlobular septasupplied by aterminal bronchiole and apulmonary artery branch. Secondary pulmonary lobule（次級肺小葉）Pulmonary parenchyma (肺實(shí)質(zhì)): portion of thelunginvolved in gas trans

17、ferthealveoli,alveolar ducts andrespiratory bronchiole.Pulmonary interstitium (肺間質(zhì)): a collection of support tissues within thelung that incluces the alveolar epithelium, pulmonary capillary endothelium, peri-vascular and peri-lymphatic tissues.（3） Lung (肺)（4）Diaphragm (膈肌)The upper surfaces of the

18、diaphragm should be clearly visibleThe right side higher than left.the level of the right hemidiaphragm: the anterior end of the 6th rib or the posterior segment of the 10th ribmade of the chest wall and the diaphragm must be sharpthe lowest position in the chest cavity（4）Diaphragm (膈肌)Costophrenic

19、Angles(肋膈角)Cardiophrenic Angles(心膈角)（5） Mediastinum (縱隔)extends from the sternum anteriorly to the vertebral column posteriorly The upper limit is formed by the thoracic inlet and the lower border is the diaphragm Divide 6 zones:Upper and lower M: the lower border of T4 vertebraAnterior, middle and

20、posterior M: CT cross-sectional anatomyHow to know lung structures on CT:R/L hilarInterlobular fissure: the marker of identifying lung lobeLung segment: according to the positioning of bronchi and vessels for identification T：TracheaE：esophagusS1：apical segmentChest inlet planeTracheal bifurcation p

21、lane2022/9/22022/9/22022/9/2Part IICommon abnormal imaging signsObstruction of the bronchus Consolidation or exudative lesionCavity and air containing spaceSingle or multiple nodules and massReticulatar shadow, leptonema shadow and stripe-like opacitiesCalcification Lung basic pathologic changesObst

22、ruction of the bronchusObstructive emphysemaObstructive atelectasis Obstructive pneumonia Obstructive emphysema阻塞性肺氣腫 Definition: is referred to the increased expansion of the lungs with air, is characterized by permanent enlargement of alveoli and is companied by destruction of alveolar walls (肺內(nèi)含氣

23、組織的擴(kuò)張，伴有永久性肺泡擴(kuò)大和肺泡的破壞)It may be diffuse or localized and bullous emphysema(分為彌漫性或局灶性)Causes: chronic lung disease, such as chronic bronchiolitis, asthma and pneumonoconiosis (慢支炎、哮喘和塵肺)55Obstructive emphysemaX-ray features:Increased translucency of the overinflation areas 肺野透光度升高Lung markings thinne

24、r, fine, straight 肺紋理稀疏、細(xì)、直barrel-shaped thorax 桶狀胸intercostal space is increaseddiaphragm is flattened膈肌低平bulla (1cm) 肺大泡heart shadow becomes long and narrow心影狹長Pulmonary collapse/ obstructive atelectasis (肺不張)Definition ：Complete bronchial obstruction, the air is absorbed by the blood within 18-24

25、 hr, lung lobe shows collapse ( increased density in involved lung accompanying with the volume loss )Include:Complete collapse of a lung（一側(cè)肺不張）Lobar collapse（肺葉性肺不張）segmental atelectasis（肺段性肺不張）Lobular atelectasis(小葉肺不張)Radiological signs of a lung collapse （一側(cè)肺不張）Xrays features:Loss of aeration: i

26、ncreased attenuation（肺內(nèi)空氣消失、密度升高）Vascular and bronchial signs-crowdedElevation of the diaphragmDisplacement of adjacent fissure Shift of trachea, hilus, mediastinumObstructive atelectasis 58Complete collapse of left lung-Narrowing intercostal space 肋間隙-Compensatory emphysema in the unaffected lung（健

27、側(cè)肺代償性氣腫） and may herniate (疝入)across the midlineshrink/contractionObstructive atelectasis Right upper lobe collapseThe right upper lobe appears as a dense triangular shadowThe apex of the triangular shadow at the hilar and its base at the outsideThe horizontal fissure(水平裂) shift to the upperObstruct

28、ive atelectasis PALObstructive atelectasis Middle lobe collapseConsolidation 肺 實(shí) 變 Definition: gas in the alveoli are replaced by pathological fluid or tissues. Acute inflammation called exudation 滲出）Common diseases: pneumonia, pulmonary tuberculosis, pulmonary edema, pulmonary hemorrhage of the lun

29、g 肺炎、肺結(jié)核、肺水腫、肺出血In the earliest form, small focal areas of exudative lesion may appear as ill-defined nodules 1cm in diameter.Then high density of consolidations（高密度實(shí)變影）fog-like opacity（云霧狀）; opacities areas （不透光區(qū)）ill-defined border (reaching fissure- clear borderConsolidation 肺 實(shí) 變 Air bronchogram

30、含氣支氣管征：the visualization of air-filled bronchi, can be seen on radiography or CT because surrounding lung hilar is of increased attenuation, but the remain gas in the bronchi is seen. Consolidation 肺 實(shí) 變 Air bronchogramConsolidation 肺 實(shí) 變 Lobar consolidation肺 葉 的實(shí) 變X-ray features:Lobar homogenous de

31、nsityAir bronchogram (支氣管氣像)well-defined edge , No change of lobar shape，no fissures displacementConsolidation 肺 實(shí) 變 cavity and air containing space空洞與空腔Definition:Cavity : necrotic lung tissues are drained out through bronchi, leaving a chamber containing air or fluid air/gas-fluid levelThe wall co

32、nsists of necrosis, granulation tissue, fibrous tissue, tumor tissueCommon Diseases: lung abscess，tuberculosis, tumorx-ray appearance:a radiolucent shadow with a definite thin or thick ring wallThe inner part of the cavity may be smooth or irregularThere may be an air-fluid level in the cavity cavit

33、y and air containing space空洞與空腔Important features of Cavity Thin wall (3mm thick)TBThick wallTumorabscessMoth eaten cavityTBAccording to the size and thickness of wall: Mouth-eating cavity蟲蝕樣空洞 Thin-wall cavity薄壁空洞 Thick-wall cavity 厚壁空洞Thin-wall cavity（薄壁空洞）: thickness of the wall is less than 3mmn

34、o air-fluid level in the cavity洞內(nèi)無液平No consolidation around it 洞周無實(shí)變Cavitythick-wall cavity 厚壁空洞: thickness of wall is more than 3mm ill-regular transparent area不規(guī)則透光區(qū) inner wall may be ill-regular or smooth內(nèi)壁不規(guī)則或光滑Common diseases: lung abscess and lung cancer (carcinoma cavity ）CavityThin walled ca

35、vityThick walled cavityCavityAbscess cavity-lung abscessThick wall 厚壁空洞Surrounding consolidation 周圍實(shí)變Become smooth and thinner when consolidation resolves and necrotic material is coughed up.抗炎治療后壁變薄，周圍實(shí)變吸收好轉(zhuǎn)CavityCavityIntrapulmonary air containing space (空腔)Definition: pathological distention of i

36、ntrapulmonary space (肺內(nèi)生理性腔隙出現(xiàn)病理性擴(kuò)大) Air space enlargementPossessing an epithelialized wall (保留肺泡上皮壁)X-ray :less than 3mm in wall thicknessno air-fluid level no consolidation around itconcurrent infection may be seen the air-fluid level and consolidation around it Common diseases:bullae（wall is very

37、 thinner and uniformity ）contain air lung cysts cystic bronchiectasisIntrapulmonary air containing space (空腔)Bronchiectasis 支氣管擴(kuò)張Definition:Localized (局灶性) irreversible bronchial dilationBronchial wall thickeningCauses:Chronic infectionAirway obstruction: tumor, stricture(狹窄)Inherited abnormalitiesI

38、ntrapulmonary air containing space (空腔)Bronchiectasis Classification Cylindrical（柱狀）Varicose（曲張型）Cystic（囊狀）Cylindrical (tubular)Saccular (cystic)VaricoseIntrapulmonary air containing space (空腔)Bronchiectasis支氣管擴(kuò)張 The internal diameter of bronchus is greater than that of accompanying arteryBronchiect

39、asis支氣管擴(kuò)張NoduleDefinition: A rounded opacity, at least moderately well defined, no more than()3 cm in diameter.Common diseases: lung cancer, tuberculoma, metastatic carcinoma of lung, hamartoma, inflammatory pseudotumor(炎性假瘤)Single or multiple nodules and mass 結(jié)節(jié)與腫塊 Alveolar nodular sign: proliferat

40、ion lesion x-ray appearance: Nodule about less than 10mm in diameter well-defined border without fusionDiseases: tuberculosis, chronic inflammationSingle or multiple nodules and mass 結(jié)節(jié)與腫塊 Miliary nodules 粟粒狀結(jié)節(jié) X-ray appearances:size：less than 4mmshowing as spots shadowsdiffuse distribution Common d

41、iseases: Miliary tuberculosisMiliary fungal真菌） infectionHematogenous metastasisPneumosilicosis（矽肺）Single or multiple nodules and mass 結(jié)節(jié)與腫塊 Hematogenous miliary nodules: TB。Single or multiple nodules shadow and mass Mass：Definition：round or round-like shadow more than 3cm in diameterX-ray appearance

42、s： benign mass -round or round-like opacity -clear and regular border -Diffuse or central calcification -Doubling time over 18 months -Complete encapsule Single or multiple nodules and mass Solitary pulmonary massSingle or multiple nodules and mass Female , 43 years old, health exam:a mass in the ri

43、ght upper lobeSclerosing hemangiomaSingle or multiple nodules and mass Malignant massX-ray appearances：-Irregular or spiculated edge 棘狀突起 or lobular 分葉-Notch sign 臍凹征-Doubling time: 16 months-Invasion of adjacent structures-Metastasis-Thick-wall cavitySingle or multiple nodules and mass Malignant ma

44、ssSolitary pulmonary massSolitary pulmonary massSolitary pulmonary massReticulate, leptonema, stripe-like opacities間質(zhì)性改變 Definition：pathological features of interstitial disease, including exudation, infiltration, fibrous connective tissue desmoplasia (adhesion粘連), diffuse or localization.Causes:Lym

45、phangitis carcinomatosis LymphomaLeukemiaLymphoproliferative disease(淋巴組織增生)Pulmonary edema（肺水腫）Nonspecific interstitial pneumonia silicosis （非特異性間質(zhì)性矽肺SLE (systemic lupus erythematosus )Reticulate, leptonema, stripe-like opacities間質(zhì)性改變X-rays:lung marking increased, disorder, blurdiffuse reticulate,

46、leptonemaa, stripe shadows or honeycomb appearance (蜂窩狀)Fibrous: irregular stripe shadows, thickness or fineness, increasing density, stiffness, blur Suggesting a repair of inflammationHoneycombing in idiopathic pulmonary fibrosis特發(fā)性肺纖維化表現(xiàn)為蜂窩肺Reticulate, leptonema, stripe-like opacities間質(zhì)性改變Interlob

47、ular septum thickeningHoneycombing in idiopathic pulmonary fibrosis特發(fā)性肺纖維化: 表現(xiàn)為蜂窩肺Reticulate, leptonema, stripe-like opacities間質(zhì)性改變Calcification 鈣化Definition:cataplasia (組織退化) or necrosis and tumor may be occurs calcificationX -ray： -high-density shadow -clear border -varying in shape and sizeCommon

48、 diseases：TB, pulmonary hamartoma錯構(gòu)瘤 (Popcorn) Female，44 years old, health exam: nodule in left lower lobeHamartoma 錯構(gòu)瘤Calcification Pleura lesionsPleural effusion/fluid -Free fluid (游離性胸腔積液) -Localized fluid(局灶性胸腔積液) -Empyema(膿胸)Hydropneumothorax - 液/氣胸Pleural thickening, conglutination(adhesion) &

49、 calcificationPleural tumorsPleural effusionNormal: a free pleural effusion, very small amount, 20ml 250ml: bluntness in the lateral costophrenic angleDue toTransudation 漏出液Exudation滲出物Pus 膿BloodChyle 乳糜 Small amount Little (少量) -Collection in posterior costophrenic angle -Bluntness of the lateral c

50、ostophrenic angle -Below the 4th anterior ribSmall pleural effusionsBoth costophrenic angles are bluntedPleural effusionMiddle（中量）-Homogenous opacity extends upward and obscure the diaphragm and lung base-The upper edge is concave and higher laterally-Extend into the pleural fissure-Below the 2nd an

51、terior rib-Showing a concave upper margin with a highest point laterally and lowest point medially (a reverse parabola) (外高內(nèi)低的斜形弧線（滲液曲線, 反相拋物線）Pleural effusionMassive（大量）-Complete opacification of the hemithorax-Contralateral displacement of the mediastinum-Large pleural fluid usually resulted in lo

52、wer lobe collapse with upward displacement of the collapsed lobePleural effusionPneumothorax 氣胸 Definition：free air into the pleural cavityTwo ways：-the rupture of the parietal pleural, due to the trauma -the rupture of the visceral pleura, usually occurs with no penetrating wound, called spontaneou

53、s（自發(fā)性） pneumothoraxPneumothorax 氣胸 X-rays： collapsed lung with higher density ，well-defined border in the laterala belt without lung markingsother changes: such as mediastiunm shift to the contralateral , the rib-costal space enlargement, diaphragmatic muscle decreasePneumothorax 氣胸Hydropneumothorax

54、液氣胸 Airfluid levelPleural thickening, adhesions, calcification 胸膜肥厚、粘連、鈣化Definition: pleuritis causes cellulose deposition(纖維素沉積)，granulation tissue hyperplasia (肉芽組織增生)，haemorrhage (出血), organization(機(jī)化) X-ray appearances: Pleural thickening: -zone-like opacity alone the inner surface of thorax Ple

55、ural thickening, adhesions, calcification 胸膜肥厚、粘連、鈣化X-ray appearances: Pleural adhesion: -tent-shaped adhesion(幕狀) -bluntness of costophrenic angle -limitation of diaphragm movement Pleural calcification: -patch-shaped high density with well-defined border 第五節(jié) 常見肺部疾病的X線表現(xiàn) The X-ray presentations of

56、common diseases in the respiratory system肺炎（Pneumonia）肺結(jié)核（pulmonary tuberculosis ）肺癌（Lung cancer）縱隔病變（Mediastinal tumors/mass）按照解剖部位分類：大葉性肺炎 （Lobar pneumonia）小葉性肺炎 （Lobular pneumonia）間質(zhì)性肺炎 （Interstitial pneumonia）臨床常按照病因分類：感染性、理化性、免疫和變態(tài)反應(yīng)性等（一）肺炎 (Pneumonia)1.大葉性肺炎 （the lobar pneumonia）概念：大葉性肺炎是肺炎雙球菌

57、所致，以肺葉和肺段分布的，實(shí)變?yōu)橹鞯募毙苑窝住ＥR床：發(fā)生于青壯年；起病急，以突然高熱惡寒，胸痛，咳鐵銹色痰為特征；WBC總數(shù)及中性粒細(xì)胞明顯増高。X線表現(xiàn)晚于臨床3-12小時（一）肺炎 (Pneumonia)1.大葉性肺炎 （the lobar pneumonia）（一）肺炎 (Pneumonia)病理分期與 X線表現(xiàn) ： 充血期(Congestion）: X線可無陽性發(fā)現(xiàn)，或?yàn)椴∽儏^(qū)肺紋理增多，透明度降低。（12小時潛伏期）1.大葉性肺炎 （the lobar pneumonia）（一）肺炎 (Pneumonia)病理分期與 X線表現(xiàn) ： 實(shí)變期（Consolidation，Red and

58、Gray hepatization，紅肝期及灰肝期）: X線表現(xiàn)為以肺葉或肺段為分布的大片實(shí)變均勻致密影，實(shí)變內(nèi)可見支氣管氣像，以葉間裂為界，邊界清楚，形狀與肺葉或肺段的輪廓一致。1.大葉性肺炎 （the lobar pneumonia）（一）肺炎 (Pneumonia)病理分期與 X線表現(xiàn) ： 消散期(Resolution) : 實(shí)變先從邊緣開始密度逐漸減低，可表現(xiàn)為散在，大小不等和分布不規(guī)則的斑片狀致密影，最后可有少量索條狀影或完全消散。兩周吸收、少數(shù)1-2月或成為機(jī)化性肺炎。與肺不張的鑒別 ：肺不張伴有肺壓縮和葉間裂的移位 （一）肺炎 (Pneumonia)2.支氣管肺炎（broncho

59、pneumonia，lobular pneumonia)概念：是多種致病菌所致以小葉滲出和實(shí)變?yōu)橹鞯陌橛兄夤鼙诔溲?，水腫，肺間質(zhì)內(nèi)炎性浸潤的混合性肺炎。病灶在小葉支氣管和肺泡內(nèi)產(chǎn)生滲出物，呈小葉性，又稱小葉性肺炎，兩肺散在分布，可融合成片。臨床：因是混合菌感染，臨床表現(xiàn)較重，多有高熱，咳嗽，咳泡沫粘液膿性痰，并伴有呼吸困難，紫紺及胸痛。多見老、弱及幼兒。（一）肺炎 (Pneumonia)X線表現(xiàn)：位置：兩肺中下野內(nèi)中帶肺實(shí)質(zhì)和間質(zhì)受累沿肺紋理增多、粗、模糊，分布的小斑片狀模糊的密度不均勻致密影密集的病變可融合成較大的片狀，可伴有小葉性局限性肺氣腫和肺不張支氣管壁增厚呈軌道征（一）肺炎 (Pn

60、eumonia)2.支氣管肺炎（bronchopneumonia，lobular pneumonia)（一）肺炎 (Pneumonia)3.間質(zhì)性肺炎（the interstitial pneumonia） 概念：以肺間質(zhì)炎癥為主，為小支氣管壁及肺間質(zhì)的炎性細(xì)胞浸潤，炎癥可沿淋巴管擴(kuò)散引起淋巴管炎和淋巴結(jié)炎，臨床發(fā)熱、咳嗽及紫紺等。X線表現(xiàn)為：中下肺野，肺紋理的增多和模糊，呈網(wǎng)狀或小斑片影伴發(fā)彌漫性肺氣腫及肺門密度增加（一）肺炎 (Pneumonia)3.間質(zhì)性肺炎（the interstitial pneumonia） （一）肺炎 (Pneumonia)3.間質(zhì)性肺炎（the interst