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RADIOLOGICAL SIGN OF CHEST DISEASE
BY:Dr.Deepak Adhikari,MBBS
1st Year Resident
Department of Radiology
JRRMMC
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Increased Lung density
1.Air space disease /Parenchymal air space
2.Interstitial Disease
3.Combined air space and interstitial
disease
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Predominantly air space disease
Radiological Findings:Margins of the opacities are poorly outlined expect when
consolidation abuts the pleura.
Air containing bronchi /Air bronchogram are evident
Air space nodule :A localized are of consolidaton measuring
10 mm in diameter or less may also be identified.
Tendency to coalesce
On HRCT scan area of airspace consolidation are often
marginated by interlobular septa.
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Air Bronchogram Sign This sign refers to a branching, linear, tubular
lucency representing a bronchus or bronchiole
passing through airless lung parenchyma .
Indicates that the underlying opacity must beparenchymal rather than pleural or mediastinal in
location.
Does not differentiate nonobstructive
atelectasis from other abnormal parenchymal
opacities such as pneumonia.
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Distribution characteristics
1.Focal /Nonsegmental/Lobar
2.Patchy /Segmental/
Lobular/Broncho
3.Extensive or diffuse bilateral
consolidation
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Segmental consolidation
Pneumonia
Endobronchial obstruction
Pulmonary infraction
Aspiration
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Patchy/ Lobular/Nonsegmental
Broncho pneumonia
Focal hemorrhage
Neoplasm
Irradiation
Lofflers syndrome
Chronic eosinophilic pneumonia
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DIFFUSE BILATERAL CONSOLIDATION
Causes:
Hydrostatic pulmonary edema
Acute respiratory distress syndrome
Diffuse pulmonary hemorrhage
Pneumocystic Pneumonia
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PREDOMINANTLY INTERSTITIAL DISEASE
5 radiological pattern
Septal
Reticular
Nodular
Reticulonodular
Ground glass
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SEPTAL/LINEAR
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Septal Pattern
Effectively restrict diagnosis :1.Hydrostatic Pulmonary edema
2.Malignancy-either lymphangitic spread of carcinoma orlymphoma
Not as main abnormality1.Idiopathic pulmonary fibrosis
2.Sarcoidosis
3.Asbestosis
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Fine Reticular Pattern
Acute Hydrostatic pulmonary edema
Viral pneumonia
Mycoplasm pneumonia
Chronic Interstitail pulmonary edema associated with
mitral stenosis
Idiopathic pulmonary fibrosis
pulmonary fibrosis associated with connectivetissue disease
Asbestosis
Sarcoidosis
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Medium reticulation/HoneycombingRefers to reticular interstitial opacities where the
intervening spaces are 3 to 10 mm in diameter.
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Honeycomb Pattern
Honeycombing is characterized by the
presence of cystic airspaces with thick, clearly
definable fibrous walls lined by bronchiolarepithelium.
It results from destruction of alveoli and
loss of acinar architecture and is associated
with pulmonary fibrosis.
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Causes Usual interstitial pneumonitis (UIP)(idiopathic pulmonary fibrosis,
cryptogenic alveolitis) asbestosis
Collagen vascular disease
Hypersensitivity pneumonic (chronic)
Pneumonia or pneumonitis (chronic)
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Coarse reticular opacitiesRefers to spaces greater than 1
cm in diameter are seen most
commonly in diseases that
produce cystic spaces as a result
of parenchymal destruction.
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Cystic Pattern
The term cyst is nonspecific and refers to athin-walled (usually less than 3 mm thick),
well-defined, well-circumscribed, air- or fluid-
containing lesion, 1 cm or more in diameter,
that has an epithelial or fibrous wall. A cystic pattern results from a
heterogeneous group of diseases that have in
common the presence of focal, multifocal, ordiffuse parenchymal lucencies and lung
destruction
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CYSTIC Vs HONEYCOMB
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Nodular pattern
Miliary (
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Micro Nodules (Synonym:miliary nodules)
Tiny, sharp, discreet nodules (
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Macro Nodules (Synonym: small nodules)
Causes:Metastatic cancer
Septic emboli
Diffuse granulomatous infections
Langerhans histiocytosis (eosinophilic granuloma)
Vasculitis
Sarcoidosis
Silicosis
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Nodular Pattern in CT
A nodular pattern refers to multiple round opacities,generally ranging in diameter from 1 mm to 1 cm.
Nodular opacities may be described as miliary , small,
medium, or large as the diameter of the opacity
increases. Nodules can be further characterized according to
their margins (e.g., smooth or irregular),
Presence or absence of cavitation,
Attenuation characteristics (such as ground-glassopacity [GGO] or calcification),
Distribution (e.g., centrilobular, perilymphatic, or
random)
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Peribronchial (also known as Perilymphatic)
Peribronchial nodules are usually well defined and
have a patchy or asymmetric distribution. They caninvolve parahilar areas, interlobular septa, and pleural
surfaces and fissures
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Centrilobular Nodules
Centrilobular nodules are distributed predominantlywithin the center of the secondary pulmonary
lobule.
They spare the pleural surfaces, usually being
centered 5 to 10 mm away from the pleural surfaceand interlobar fissures.
They can range in size from a few millimeters to
>1 cm
May be well defined or ill defined.
They tend to be evenly spaced and of similar size.
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Tree-in-Bud Pattern The CT pattern of centrilobular nodular and
branching linear opacities has been likened to
the appearance of a budding tree.
All processes producing the tree-in-bud
pattern are (a)bronchiolar dilatation and (b)impaction of bronchioles with mucus, pus, or
other material
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Random Nodules
Random nodules show no definite
relationship to the secondary lobule or other
structures of the lung (i.e., interlobular septa,small vessels, pleura).
They usually are well defined, diffuse, and
symmetric in distribution. Subpleural nodulesare common.
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i l d l
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The presence of interconnecting linear opacities result
in a reticular pattern. Orientation of some linear
opacities parallel to the x-ray beam causes additional
nodular component that result in reticulonodular
pattern.
Reticulonodular pattern
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Ground-Glass Opacification/ foggy/hazy/semiopaque
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Ground Glass Pattern
A ground glass pattern is considered to bepresent when there is a hazy increase in opacity
unassociated with obscuration of the underlying
vascular markings.(If vessel are obscured theterm consolidation is used)
Acute
1.Pneumocystis Jiroveci pneumonia
2.Pulmonary hemorrhage3.Acute interstitial pneumonia
Subacute
Extrinsic allergic alveolitis
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Crazy paving patternThe abnormality consists mainly of filling
of airspaces with proteinaceous material,
interlobular septal thickening is frequentlyidentified on CT in the areas of GGO,
creating a crazy paving pattern
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Fibrosis (Synonym: scarring)
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Causes: scarring from any cause
Sarcoidosis
Tuberculosis
Silicosis
Radiation
Pneumonitis
late stage ARDS
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Cavitation
A cavity is defined radiographically as agas containing space within the lung
surrounded by a wall whose thickness is
greater than 1 mm.
There is necrosis of centaral portion of a
lesion an drainage of the resultant partially
liquefied material via a communicating
airway.
Cavity Vs Abscess
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B ll
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Bullae
A bullae is a sharplydemarcated air
containing space that
measures 1 cm ormore in diameter
and possesses a
smooth wall 1mm orless in thickness.
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Belbs
A belb is a localized collection of air in the
immediate subpleural lung or within the
pleura.It develops maost commonly inlung apices and seldom exceeds 1 cm in
diameter.
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Pneumatocele
A pneumatocele is a thin walled gas
filled space within the lung that
characteristically increases in the size
over a period of days to week and
almost invariably resolves , typically
occurs in association with infection.
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Silhouette Sign Felson and Felson popularized the term
silhouette sign to indicate an obliteration of
the borders of the heart, other mediastinal
structures, or diaphragm by an adjacent
opacity of similar density.
An intrathoracic lesion not anatomically
contiguous with a border of one of these
structures will not obliterate that border.
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Air Crescent SignA mass growing within a pre-existing
cavity, or an area of pneumonia that
undergoes necrosis and cavitates, may
form a peripheral crescent of air
between the intracavitary mass and the
cavity wall, resulting in the air crescent
sign.
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Bulging Fissure SignHistorically, the bulging fissure sign wasseen as a result of pneumonia caused by
Klebsiella pneumoniae involving the
right upper lobe.The disease is often confined to one
lobe, with consolidation spreading
rapidly, causing lobar expansion andbulging of the adjacent fissure inferiorly.
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Continuous Diaphragm Sign
This sign is seen as a continuous
lucency outlining the base of the heart,
representing pneumomediastinum.Air in the mediastinum tracks
extrapleurally, between the heart and
diaphragm .
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Deep Sulcus Sign This sign refers to a deep, sometimesfingerlike collection of intrapleural air
(pneumothorax) in the costophrenic sulcus
as seen on the supine chest radiograph.
When present, this sign may represent a
pneumothorax that is much larger thaninitially expected.
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Fallen Lung Sign
This sign refers to the appearance of the
collapsed lung occurring with a fractured
bronchus.
The bronchial fracture results in the lung
falling away from the hilum, either inferiorly
and laterally in an upright patient orposteriorly, as seen on CT in a supine patient.
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Flat Waist Sign
This sign refers to flattening of the
contours of the aortic knob and adjacent
main pulmonary artery .
It is seen in severe collapse of the left
lower lobe and is caused by leftwarddisplacement and rotation of the heart.
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Finger-in-Glove Sign In allergic bronchopulmonary aspergillosis, aclinical disorder secondary to Aspergillus
hypersensitivity, the bronchi become impacted
with mucus, cellular debris, eosinophils, andfungal hyphae.
The impacted bronchi appear radiographically
as opacities with distinctive shapes ,variouslydescribed as gloved finger.
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Golden S Sign
When a lobe collapses around a large central
mass, the peripheral lung collapses and the
central portion of lung is prevented from
collapsing by the presence of the mass.
The relevant fissure is concave toward the lung
peripherally but convex centrally, and the shapeof the fissure resembles an S or a reverse S.
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L ft i h l Si
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Luftsichel Sign
In left upper lobe collapse, the superiorsegment of the left lower lobe, which is
positioned between the aortic arch and the
collapsed left upper lobe, is hyperinflated. This
aerated segment of left lower lobe is hyperlucent
and shaped like a sickle, where it outlines the
aortic arch on the frontal chest radiograph.
This peri-aortic lucency has been termed theluftsichel sign, derived from the German words
luft (air) and sichel (sickle) .
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Halo Sign
This sign refers to ground-glassattenuation on CT scanning that
surrounds, or forms a halo around, a
denser nodule or area of consolidation.
Most hemorrhagic pulmonary nodules
produce this sign.
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Hampton Hump Sign
Pulmonary infarction secondary to pulmonary
embolism produces an abnormal area of
opacification on the chest radiograph, which is
always in contact with the pleural surface.
The opacification may assume a variety of
shapes. When the central margin is rounded, ahump is produced.
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Westermark Sign
This sign refers to oligemia of the lung
beyond an occluded vessel in a patient
with pulmonary embolism.
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M lti I C b Si
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Melting Ice Cube Sign
This sign refers to the appearance of a
resolving pulmonary infarct on a chest
radiograph or CT scan, which looks like an ice
cube that is melting peripherally to internally.
This is distinguished from the pattern of
resolving pneumonia, where the opacification
disappears in a patchy fashion .
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h i k Si
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Juxtaphrenic Peak Sign
This sign refers to a small triangular shadow
that obscures the dome of the diaphragm,
secondary to upper lobe atelectasis.
The shadow is caused by traction on the
lower end of the major fissure, the inferior
accessory fissure, or the inferior pulmonaryligament.
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S i Si
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Spine Sign
Lower lobe pneumonia may be poorly
visualized on a posteroanterior (PA)
chest radiograph. Spine sign, which is progressive
increase in lucency of the vertebral
bodies from superior to inferior.
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PLEURAL EFFUSION Vs ASCITES
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PLEURAL EFFUSION Vs ASCITES
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Mediastinal mass
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Mediastinal mass
A mediastinal mass displaces the medialpleura toward the lung.The interface with the
lung has sharp Margin & Convex Margin.
May also displace,compress or invase adjacentstructure i.e trachea
May obscure a adjacent structure of same
density,the silhouette sign.
Absence of air bronchogram
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Pleural/Extrapleural mass
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Pleural/Extrapleural mass
The borders are generally sharp andconvex.
The margin forms an obtuse anglewith the chest wall.
Air bronchgram is absent.
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