Thoracic Radiology
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Transcript of Thoracic Radiology
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Thoracic Radiology
Wendy Blount, DVMNacogdoches TX
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Thoracic Rads - Normal
Review of thoracic radiographs - Steps• Skeletal
– Spine, front limbs, ribs, sternum• Cranial abdomen• Airways, Lung fields• Great vessels
– Aorta, pulmonary arteries, cranial & caudal vena cava• Smaller vessels
– Internal thoracic arteries, pulmonary lobar a & v, brachiocephalic trunk, left subclavian artery
• Cardiac silhouette– Vertebral heart score, bulge
• Left Heart Failure? Right Heart Failure?
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Thoracic Rads - Normal
Why is it so difficult to evaluate cardiac and chamber size on radiographs?
• Comparing heart size to lung field size doesn’t work– Dogs of different conformation have different
ratios of heart size to lung size
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Thoracic Rads - Normal
Why is it so difficult to evaluate cardiac and chamber size on radiographs?
• Comparing heart size to lung field size doesn’t work– Dogs of different conformation have different
ratios of heart size to lung size
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Why is it so difficult to evaluate cardiac and chamber size on radiographs?
• Comparing heart size to lung field size doesn’t work– Dogs of different conformation have different
ratios of heart size to lung size
Thoracic Rads - Normal
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Thoracic Rads - Normal
Why is it so difficult to evaluate cardiac and chamber size on radiographs?
• Comparing heart size to lung field size doesn’t work– Dogs of different conformation have different
ratios of heart size to lung size– Lung field size changes with the breathing cycle– Abdominal fat pushes the diaphragm cranially– Thoracic fat makes lung fields appear smaller
• Comparing heart size to vertebral size works better– Vertebral heart score
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Thoracic Rads - Normal
Why is it so difficult to evaluate cardiac and chamber size on radiographs?
• Things can make the heart look bigger
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Thoracic Rads - Normal
Why is it so difficult to evaluate cardiac and chamber size on radiographs?
• Things can make the heart look bigger
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Why is it so difficult to evaluate cardiac and chamber size on radiographs?
• Things can make the heart look bigger
Thoracic Rads - Normal
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Thoracic Rads - Normal
Why is it so difficult to evaluate cardiac and chamber size on radiographs?
• Things can make the heart look bigger– Pericardial fat– Pericardial effusion– Peritoneopericardial diaphragmatic hernia
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Thoracic Rads - Normal
Why is it so difficult to evaluate cardiac and chamber size on radiographs?
• Things can make the heart look bigger– Pericardial fat– Pericardial effusion– Peritoneopericardial diaphragmatic hernia
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Thoracic Rads - Normal
Why is it so difficult to evaluate cardiac and chamber size on radiographs?
• Things can make the heart look bigger– Pericardial fat– Pericardial effusion– Peritoneopericardial diaphragmatic hernia– Oblique positioning on VD/DV can make right
heart look bigger• MYTH - “increased sternal contact”
means right heart enlargement
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Thoracic Rads - Normal
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Thoracic Rads - Normal
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Thoracic Rads - Normal
Normal cats change with age• Long axis of the heart is more
horizontal in old cats (40%)• Aortic bulge develops (30%)
– Not due to hypertension or hyperthyroidism– At the aortic isthmus– Cardiac measurements in young & old cats are
the same, despite these conformational changes in the thorax
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Thoracic Rads - Normal
5.0 + 4.8 = 9.8 Vertebral Heart Score
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Thoracic Rads - Normal
Vertebral Heart Score• Measure heart long axis
– carina to the apex• Measure heart short axis
– Widest perpendicular to length• Count vertebrae from cranial aspect T4• Add together• Dogs – normal 8.5-10.5• Cats – normal 7-8
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Heart Chambers – VD/DV - Left
Thoracic Rads - Normal
LV - Left Ventricle
AV - Aortic Valve
AA - Ascending Aorta
DA - Descending Aorta
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Heart Chambers – VD/DV - Left
Thoracic Rads - Normal
LV - Left Ventricle
AV - Aortic Valve
AA - Ascending Aorta
DA - Descending Aorta
LA – Left Atrium
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Heart Chambers – VD/DV - Left
Thoracic Rads - Normal
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Heart Chambers – VD/DV - Right
Thoracic Rads - Normal
Right Ventricle
Pulmonic Valve
Main Pulmonary Artery
Right Pulmonary Artery
Left Pulmonary Artery
PV
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Heart Chambers – VD/DV - Right
Thoracic Rads - Normal
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Thoracic Rads - Normal
Heart Chambers – VD/DV – Clock Face• Aorta 12-1 o’clock
• LV 3-6 o’clock
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Thoracic Rads - Normal
Heart Chambers – VD/DV – Clock Face• Aorta 12-1 o’clock• MPA 1-2 o’clock• LV 3-6 o’clock• RV 7-9 o’clock
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Thoracic Rads - Normal
Heart Chambers – VD/DV – Clock Face• Aorta 12-1 o’clock• MPA 1-2 o’clock• LV 3-6 o’clock• RV 7-9 o’clock• LA has to be really big to see on VD
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Thoracic Rads - Normal
Heart Chambers – VD/DV – Clock Face• Aorta 12-1 o’clock• MPA 1-2 o’clock• LV 3-6 o’clock• RV 7-9 o’clock• LA has to be really big to see on VD• RA 9-12 o’clock
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Thoracic Rads - Normal
Heart Chambers – Lateral – Left
• LA – Left Atrium• MV – Mitral Valve• LV – Left Ventricle• AV – Aortic Valve• SV – Sinus of Valsalva• AAo – Ascending Aorta• BCT – Brachiocephalic Trunk• LS – Left Subclavian a.
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Thoracic Rads - Normal
Heart Chambers – Lateral – Right
• RA – Right Atrium• Raur – R Auricle• RV – Right Ventricle• MPA – Pulmonary a.
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Thoracic Rads - Normal
Heart Chambers – Lateral – Right
• RA – Right Atrium• Raur – R Auricle• RV – Right Ventricle• MPA – Pulmonary a.• RVOT – RV Outflow• PV – Pulmonic Valve• RPA – R Pulmonary a.• LPA – L Pulmonary a.
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Thoracic Rads - Normal
Heart Chambers – Lateral – Clock Face• LA (caudal waist) – 12-3 o’clock
• LV - 2-6 o’clock
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Thoracic Rads - Normal
Heart Chambers – Lateral – Clock Face• LA (caudal waist) – 12-3 o’clock
• LV - 2-6 o’clock• RV - 6-9 o’clock
• MPA – 10-11 o’clock – bulge at 1-2 o’clock
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Thoracic Rads - Normal
Heart Chambers – Lateral – Clock Face• LA (caudal waist) – 12-3 o’clock• CdVC – 2 o’clock• LV - 2-6 o’clock• RV - 6-9 o’clock• Raur – 9 o‘clock• RA not easily seen on the lateral view• CrVC – 10 o’clock• MPA – 10-11 o’clock – bulge at 1-2 o’clock
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Thoracic Rads - Abnormal
Case #1 – 8 year old neutered male cocker spaniel – coughing
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Case #1 – 8 year old neutered male cocker spaniel – coughing
Thoracic Rads - Abnormal
6.2 + 5.9 = 12.1
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Thoracic Rads - Abnormal
Case #1 – 8 year old neutered male cocker spaniel - coughing
• Skeletal, Cranial abdomen– No abnormalities noted
• Airways, Lung fields– Mild perihilar edema
• Great vessels– enlarged caudal vena cava
• Smaller vessels– enlarged pulmonary lobar veins
• Cardiac silhouette– Generalized cardiomegaly, enlarged LA
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Thoracic Rads - Abnormal
Case #1 – 8 year old neutered male cocker spaniel - coughing
• Skeletal, Cranial abdomen– No abnormalities noted
• Airways, Lung fields– Mild perihilar edema
• Great vessels– enlarged caudal vena cava
• Smaller vessels– enlarged pulmonary lobar veins
• Cardiac silhouette– Generalized cardiomegaly, enlarged LA
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Thoracic Rads - Abnormal
Case #1 – 8 year old neutered male cocker spaniel – coughing
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Thoracic Rads - Abnormal
Case #1 – 8 year old neutered male cocker spaniel – coughing
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Thoracic Rads - Abnormal
Case #1 – 8 year old neutered male cocker spaniel – coughing
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Thoracic Rads - Abnormal
Case #1 – 8 year old neutered male cocker spaniel - coughing
• Left Congestive Heart Failure– Mild perihilar edema– enlarged pulmonary lobar veins– enlarged LA (generalized cardiomegaly)– Enlarged LV (elevated trachea)
• Right Congestive Heart Failure– enlarged caudal vena cava– Generalized cardiomegaly (RV enlargement)– (ascites, pleural effusion)
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Thoracic Rads - Abnormal
Case #1 – 8 year old neutered male cocker spaniel - coughing
• Diagnosis by echo - DCM
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Thoracic Rads - Abnormal
Are rads or echo better for detecting congestive heart failure?
• radiographs
Are rads or echo better for detecting enlarged heart chambers?
• echo
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Thoracic Rads - Abnormal
Generalized cardiomegaly (all 4 heart chambers enlarged)Dogs• Dilated Cardiomyopathy• Mitral regurgitation• Tricuspid regurgitationCats• Dilated cardiomyopathy• anemia
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Thoracic Rads - Abnormal
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Thoracic Rads - Abnormal
Pseudocardiomegaly • No significantly enlarged heart chambers• Significantly enlarged cardiac silhouette• Pericardial effusion
– Hemorrhage – HBT or ruptured LA– Right heart failure – modified transudate– Infectious pericarditis– Idiopathic pericarditis
• Peritoneopericardial Diaphragmatic Hernia
• Pericardial fat
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Case #2 – 15 month Maine coon cat – tachypnea, lethargy
Thoracic Rads - Abnormal
5.1 + 3.8 = 8.9
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Thoracic Rads - Abnormal
Case #2 – 15 month Maine coon cat – tachypnea, lethargy• Skeletal & cranial abdomen• Airways, Lung fields
– No abnormalities noted• Great vessels
– caudal vena cava somewhat enlarged• Smaller vessels
– No abnormalities noted• Cardiac silhouette
– Generalized cardiomegaly, apex shifted right
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Thoracic Rads - Abnormal
Case #2 – 15 month Maine coon cat – tachypnea, lethargy• Skeletal & cranial abdomen• Airways, Lung fields
– No abnormalities noted• Great vessels
– caudal vena cava somewhat enlarged• Smaller vessels
– No abnormalities noted• Cardiac silhouette
– Generalized cardiomegaly, apex shifted right
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Thoracic Rads - Abnormal
Case #2 – 15 month Maine coon cat – tachypnea, lethargy
• Heart Failure??– Probably not
• Diagnosis– Echo showed dilation of LV and RV– Flea Anemia (PCV 10%)
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Case #3 – 5 year old Maltese • honking cough• holosystolic murmur loudest L apex
Thoracic Rads - Abnormal
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Case #3 – 5 year old Maltese • honking cough• holosystolic murmur loudest L apex
Thoracic Rads - Abnormal
6.0 + 7.1 = 13.1
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Thoracic Rads - Abnormal
Case #3 – 5 year old Maltese • continuous murmur is heard loudest at
the left axilla• Left Heart Failure
– pulmonary edema, LA enl, tracheal elevation• Airway Cough – enlarged LA
– compression of left bronchus and trachea• Bulge at 1:30 on VD, apex shifted right
– cardiomegaly (R or L or both?)
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Thoracic Rads - Abnormal
Heart Chambers – VD/DV – Clock Face• Aorta 12-1 o’clock
• MPA 1-2 o’clock• LV 3-6 o’clock• RV 7-9 o’clock
• LA has to be really big to see on VD• RA 9-12 o’clock
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Thoracic Rads - Abnormal
Case #3 – 5 year old Maltese • Diagnosis by echo - PDA
– Right heart normal
LISTEN TO THE LEFT ARMPIT!!
When the left heart is markedly enlarged, right heart size can be difficult to evaluate on radiographs
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Thoracic Rads - Abnormal
Case #4 – 12 year old Mini Poodle- holosystolic murmur L apex• Skeletal, cranial abdomen, airways,
Lung fields, Great vessels, small vessels– No abnormalities noted
• Cardiac silhouette– VHS high if you include LA– VHS normal if you exclude LA– Huge LA
• No signs of congestive heart failure
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Thoracic Rads - Abnormal
Case #4 – 12 year old Mini Poodle- holosystolic murmur L apex• Diagnosis
– Mitral regurgitation• Treatment
– Cough suppressants• Monitoring
– Chest rads every 6 months – Sooner if respiratory rate while sleeping >40
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Thoracic Rads - Abnormal
Case #4 – 12 year old Mini Poodle- holosystolic murmur L apex
You can have a Huge LA and even LV without CHF
CHF is rarely present without enlarged LA
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Thoracic Rads - Abnormal
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Thoracic Rads - Abnormal
3 Most Common Causes of L Heart Enlargement1.MR2.PDA3.SAS
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Case #5 – 4 year old DSH- Murmur heard on annual – left sternum
Thoracic Rads - Abnormal
4 + 3.5 = 7.5
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Thoracic Rads - Abnormal
Case #5 – 4 year old DSH- Murmur heard on annual – left sternum• Skeletal, cranial abdomen, Lung fields,
airways, Great vessels, small vessels– No abnormalities noted
• Cardiac silhouette– VHS normal– Enlarged LA on VD
• No signs of congestive heart failureDiagnosis by echo - HCM
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Thoracic Rads - Abnormal
Case #5 – 4 year old DSH- Murmur heard on annual – left sternum
LA is seen more easily on the VD in cats• LA sits more cranial in the catLA is seen more easily on lateral in dogsVHS usually does not include LA in cats• Other chambers need to be enlarged to perceive
cardiomegaly on the lateral in cats
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Case #6 – 10 year old mixed dog- Gagging up white foamy fluid, mitral murmur
Thoracic Rads - Abnormal
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Thoracic Rads - Abnormal
Case #6 – 10 year old mixed dog- Gagging up white foamy fluid, mitral murmur• Skeletal, Cranial abdomen, Great vessels
– No abnormalities• Airways, Lung fields
– Elevated trachea, compressed left bronchus– Perihilar edema
• Smaller vessels– enlarged pulmonary lobar veins
• Cardiac silhouette– VHS 11.5, generalized cardiomegaly, enlarged LA
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Thoracic Rads - Abnormal
Case #6 – 10 year old mixed dog- Gagging up white foamy fluid, mitral murmur
• Left Heart Failure
• Echo diagnosis – severe mitral regurgitation
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Case #7 – 1 yr old Golden Retriever- Episodes of collapse with exercise
Thoracic Rads - Abnormal
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Case #7 – 1 yr old Golden Retriever- Episodes of collapse with exercise• Skeletal, Cranial abdomen, Airways,
Lung fields, small vessels– No abnormalities
• Cardiac silhouette– VHS 9.5– aortic bulge & enlarged LA on lateral
• No signs of congestive heart failure• Echo diagnosis – severe SAS
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Thoracic Rads - Abnormal
Loss of Cranial Waste1.Dilated Aortic Arch
• SAS• PDA• Tetralogy of Fallot
2.Enlarged RAuricle• TR• Heartworm Disease
3.Heart Base Tumor (RA, Aortic Body)• HSA, chemodectoma, myxosarcoma
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Case #7 – 12 yr old Mixed Terrier- Chronic cough and cyanosis
Thoracic Rads - Abnormal
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Thoracic Rads - Abnormal
Case #7 – 12 yr old Mixed Terrier- Chronic cough and cyanosis• Skeletal, Cranial abdomen, Vessels
– No abnormalities• Airways, Lung fields
– Pronounced airway pattern• Cardiac silhouette
– VHS 10-10.5, RV enlargement, apex shifted L• No heart failure
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Thoracic Rads - Abnormal
Case #7 – 12 yr old Mixed Terrier- Chronic cough and cyanosis
• Echo diagnosis– RV thickening– Suspect pulmonary hypertension
• Clinical Diagnosis– Severe chronic pulmonary disease
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Thoracic Rads - Abnormal
Case #7 – 12 yr old Mixed Terrier- Chronic cough and cyanosisWhat does it mean when the apex is
shifted right?– LV enlargement or generalized cardiomegaly
What does it mean when the apex is shifted left?– RV enlargement
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Thoracic Rads - Abnormal
Case #7 – 12 yr old Mixed Terrier- Chronic cough and cyanosisRV enlargement must be moderate to
severe to see on radsRA enlargement difficult to appreciate on
rads unless severe (cause)– TR
Lifting of the apex off the sternum on lateral view means RV enlargement
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Measuring RV enlargement on Lateral View of the Thorax
Thoracic Rads - Abnormal3.75 / 1 = 3.75
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Thoracic Rads - Abnormal
Measuring RV enlargement on Lateral View of the Thorax
1. Measure heart long axis• Carina to apex
2. Measure heart short axis• Widest point perpendicular to long axis
3. Short Axis - Divide Cranial part by Caudal part• Cranial is <2.5x Caudal in normal dogs• (Cr >2.5x Cd) means RV enlargement
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Thoracic Rads - Abnormal
Case #8 – 10 month old English PointerEjection murmur loudest at heart base on
left side
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Thoracic Rads - Abnormal
Case #8 – 10 month old English PointerEjection murmur loudest at heart base on
left side• Skeletal, Cranial Abdomen, Airways,
Lung fields, small vessels– normal
• Great vessels– pulmonary artery enlarged
• No signs of Congestive Heart Failure
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Thoracic Rads - Abnormal
Case #8 – 10 month old English PointerEjection murmur loudest at heart base on left• Causes of enlarged MPA (dogs)
– PS (RPA, LPA, lobar aa/vv not enlarged)– PDA (lungs overcirculated – lobar aa and vv enlarged, but
not tortuous)– Pulmonary hypertension (RPA, LPA lobar aa enlarged)
• MPA enlargement– Not easily seen on lateral in dogs– not readily seen in cats
• This case – echo diagnosis– PS – need spectral Doppler to measure gradient across– RV thickening
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Thoracic Rads - Abnormal
LPA, RPA, lobar aa enlarged and tortuous• Pulmonary Hypertension1.HW Disease2.Primary PH3.Chronic Respiratory Disease
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Case #9 – 6 month old poodle with murmur found on physical exam
Thoracic Rads - Abnormal
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Thoracic Rads - Abnormal
Case #9 – 6 month old poodle with murmur found on physical exam
Dx – PDA with no CHF
Measuring pulmonary lobar arteries1.Caudal lobar aa should be same width as a rib
– Seen best on the VD/DV view 2.cranial lobar aa 0.75x 3rd or 4th rib
– Seen best on the lateral view
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Thoracic Rads - Abnormal
Case #9 – 6 month old poodle with murmur found on physical exam
Dx – PDA with no CHF
Measuring pulmonary lobar arteries1.Caudal lobar aa should be same width as a rib
– Seen best on the VD/DV view 2.cranial lobar aa 0.75x 3rd or 4th rib
– Seen best on the lateral view
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Thoracic Rads - Abnormal
Case #10 – 5 yr old DSH catTachypnea
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Thoracic Rads - Abnormal
Case #10 – 5 yr old DSH cattachypnea• Ascites in the cranial abdomen• Perihilar edema• HUGE Caudal Vena Cava• Enlarged pulmonary lobar veins• Elevated trachea (LV enlargement)• Enlarged Lauricle on VD• Marked generalized cardiomegaly (VHS
10.5)
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Thoracic Rads - Abnormal
Case #10 – 5 yr old DSH catTachypneaEnlarged Caudal vena cava-size varies with respiratory cycle-only severe enlargement is reliably detected-maximum width < length T5 or T6Causes• Right heart failure• Mass obstructing Caudal Vena Cava
– Thrombus, tumor
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Thoracic Rads - Abnormal
Case #10 – 5 yr old DSH catTachypnea
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Thoracic Rads - Abnormal
Case #11 – 2 yr old DSH catTachypnea
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Thoracic Rads - Abnormal
Case #11 – 2 yr old DSH catTachypnea• VHS 8.75• Left Heart Failure
– Patchy pulmonary edema (caudal)– Enlarged pulmonary lobar vv
• Right Heart failure– Pleural effusion
• Echo diagnosis – hypertrophic cardiomyopathy
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Case #12 – 6 yr old WestieADR
Thoracic Rads - Abnormal
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Thoracic Rads - Abnormal
Case #12 – 6 yr old WestieADRVHS 8.5 (low normal)• Clinical diagnosis – severe dehydration• Causes of microcardia
– Severe dehydration– Addison’s Disease– Pneumothorax (heart lifted off the sternum)
• Should also see collapsed lung lobes
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Thoracic Rads - Review
Left Heart Failure• Pulmonary edema (alveolar if severe)• Pleural effusion in cats• Pulmonary lobar veins much larger than
arteries• Enlarged LA + compression of L bronchus
– Not a sign of heart failure per se– But LHF is rarely present without LA enlargement
• + Enlarged LV– Tracheal elevation– Cardiomegaly (increased VHS)
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Thoracic Rads - Review
Right Heart Failure• Pleural effusion
– Can obscure evaluation of the heart, lungs and great vessels
• Enlarged caudal vena cava• Ascites
– Modified transudate• Often concurrent with left heart failure
– Generalized cardiomegaly (increased VHS)• RHF alone:
– HWDz, Chaga's Disease, pericardial disease
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Thoracic Rads - Review
Chronic Bronchitis• Increased or mineralized airway pattern• Peribronchiolar infiltrates
– May progress to bronchopneumonia– Interstitial pattern– Alveolar pattern (air bronchograms) if severe
• Signs of pulmonary hypertension– Enlarged pulmonary artery and lobar aa
• No signs of heart failure
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Thoracic Rads - Review
Patent Ductus Arteriosus-left to right shunt (aorta to MPA)-volume expansion• + Enlarged pulmonary artery• + Pulmonary overcirculation
– Enlarged pulmonary lobar aa & vv• Enlarged descending aorta• Enlarged LV
– Tracheal elevation– Increased VHS
• Enlarged LA – + compression left bronchus
• + pulmonary edema
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Thoracic Rads - Review
Sub-Aortic Stenosis-pressure overload left side• + Enlarged LV on rads
– Increased VHS– Not as marked as volume overload
• Enlarged ascending aorta• Left Heart Failure due to aortic
insufficiency is rare• Death more often due to arrhythmia
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Thoracic Rads - Review
Pulmonic Stenosis-pressure overload right side• + Enlarged RV on rads
– Not as marked as volume overload• Enlarged MPA• Right Heart Failure due to pulmonic
insufficiency is rare• Death more often due to arrhythmia
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Thoracic Rads - Review
Ventricular Septal Defect-left to right shunt (LV to RV)-volume expansion• + RV enlargement• + Pulmonary overcirculation
– Enlarged pulmonary lobar aa & vv• Enlarged LV
– Tracheal elevation– Increased VHS
• Enlarged LA – + compression left bronchus
• + pulmonary edema
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Thoracic Rads - Review
Atrial Septal Defect-left to right shunt (LA to RA)-lower pressure differential, so no
significant volume expansion• + RV enlargement• + RA enlargement
– Enlarged pulmonary lobar aa & vv• Heart failure is rare
(handout)