醫(yī)學(xué)影像學(xué)教學(xué)課件：呼吸系統(tǒng)（一）胸部1

ImagingDiagnosisofRespiratorySystem

(1)

呼吸系統(tǒng)（一）ContentPreface(前言）Methodsofchestexamination（檢查方法）Normalradiologicalanatomy（正常X線表現(xiàn)）Abnormalchestradiograph（基本病變的X線表現(xiàn)）Preface前言

Goodcontrast,Mostpulmonary,diseasecanbeviewed,Focalofchestcanbelocatedanddefined.病例男，61歲，咳嗽咳痰氣促20年，加重伴痰血1月就診。問題：1.該患者需做什么影像學(xué)檢查？2.該患者影像學(xué)檢查是否有病變？3.該患者影像學(xué)顯示病變的部位在哪里？屬于哪種基本病變？4.初步診斷是什么？病變的部位在哪里？1.胸廓？2.肺部？3.胸膜？4.縱膈？----右肺下葉屬于哪種基本病變？1.支氣管阻塞？2.滲出與實(shí)變？3.空洞與空腔？4.結(jié)節(jié)與腫塊？5.線狀、網(wǎng)格狀級(jí)索條狀影？6.鈣化？初步診斷？1.感染？2.良性腫瘤？3.惡性腫瘤？ExaminationtechniqueX-rayexaminationofchest:1.Chestfluoroscopy2.Chestradiography3.Bronchography

CT

MR

DSA---AngiographyChestfluoroscopy透視

AdvantageSimple,assistedmeans

Multipositionanddynamicview

Diaphragmmovement—

Paralysis膈麻痹

Mediastinummovement—

Obstructiveemphysema阻塞性肺氣腫

LocateabnormalityDisadvantage

Hardtodetectsmalllesion

Norecord

HightdoseChestradiography

胸部攝影

Routineexaminationforpatients

Excludeseriouschestdisease;

Provideevidenceofthepreoperativeconditionoflungandheartbeforesurgery;

Findoutthepostoperativecomplications:Lunginfections,Pulmonaryembolus(肺栓塞）.Positionincommonusing:

Postero-anteriorview(PA-view)

Standard:ErectpositionAnteriorchestwallagainstthefilmScapulaerotateforwardEnd-inspirationShortexposuretimeCASSETTEChestradiography

胸部攝影Chestradiography

胸部攝影Positionincommonusing:

Lateralview----Leftlateralview----RightlateralviewBronchography

支氣管造影

Radiographicexaminationofthebronchialtreebyinstillationofcontrastmediumdirectlyintothetracheaorbronchi.

Evaluationofbronchiectasis(支氣管擴(kuò)張）

ReplacedbyCT,andespecially

highresolutionCT(HRCT)

ComputedTomography

Advantage

Excellentanatomicdetail(chestwall,pleura,lungs,mediastinum)

Contrastenhancement—greatvessels

Indication適應(yīng)癥

Staginglungcancerandothermalignanttumors

Diffuselungdisease—high-resolutionCT

Pleuraldisease

MediastinaldiseaseComputedTomography1.PlainCTscan2.Contrastenhancement：3.HighResolutionCT（HRCT）①鑒別良惡性病變；②了解病變的血供情況；③了解縱隔病變與大血管的關(guān)系；④鑒別病變?yōu)檠苄曰蚍茄苄?。ComputedTomography4.MSCT(多層面螺旋CT掃描)：X線管一次旋轉(zhuǎn)過程中同時(shí)獲得多個(gè)層面圖象數(shù)據(jù)的成像。掃描時(shí)間短、提高空間分辨力等。標(biāo)準(zhǔn)圖像

多方位重建圖像MagneticResonanceImaging(MRI)

MoresensitivethanCTindetectingHilarandMediastinalLymphadenopathy（淋巴結(jié)病變）.Lessvalueinlungdiseases.MultipleImaging;HighResolutionInsofttissue;Flowvoideffect;displayheartandarotaluncontracte

Characteristic:Angiography

血管造影

Pulmonaryarteriography（肺動(dòng)脈造影）

Pulmonaryembolism肺動(dòng)脈栓塞

Vascularabnormalities血管畸形

Bronchialarteriography（支氣管動(dòng)脈造影）

Hemoptysis咯血

腫瘤NormalRadiologicalAnatomy

Normalchestimagingisthethree-dimensionalofallofthethoracicviscera.NormalRadiologicalAnatomy

inspirationexpirationNormalRadiologicalAnatomy

1.

Thoraciccage（胸廓）2.Tracheaandbronchu氣管與支氣管

3.Lung（肺）4.Pleura胸膜5.Mediastinum（縱隔）6.Diaphragm

（膈）NormalRadiologicalAnatomy

1.Thoraciccage------SofttissuesBoneNormalRadiologicalAnatomy

Thoraciccage----Softtissues

1.Sternocleidomastoid(胸鎖乳突肌)ClavicleSkinrumple(鎖骨上皮膚皺折)Thoraciccage----Softtissues

3.Pectoralismajor(胸大肌)Breastandnipple

乳房一般重疊于兩肺下野呈半圓形密度高,下緣清楚,上緣模糊.NormalRadiologicalAnatomy

NormalRadiologicalAnatomy

Thoraciccage--boneRibs:markingthechangeofchest.Scapula（肩胛骨）3.Clavicle（鎖骨）Thoracicvertebrae（胸椎）2.TracheaandbronchusTracheaisconnectedwithcricoidcartilage(環(huán)狀軟骨）,about11~13cmlength,1.5~2cmwidth.Tracheaisdividedinrightandleftmainbronchion5~6thoracicvertebraplane.Tracheamainbronchus3.LungNormalRadiologicalAnatomy

Lungfields肺野

Lungmarkings肺紋理

Hilumoflung肺門Lobeoflung肺葉Lungfields肺野uppermiddlelowerlateralmiddleinternalzoneHilaofthelungsComposition(組成）:

PulmonaryarteryPulmonaryveinBronchi

LymphThelateralviewofthechest上肺靜脈干左肺動(dòng)脈弓兩下肺動(dòng)脈干Bilateralhilumoflungoverlap；Appearto‘comma’.兩側(cè)肺門大部分重疊;右肺門略偏前；肺門表現(xiàn)：似“逗號(hào)”。HilaofthelungsPosition:

MiddlezoneInternalstriplungmarkingsComposition：PulmonaryarteryPulmonaryveinLymphaticCharacteristic:

Branchingandtaperingfromthepulmonaryhilaintotheperipherallung.

（從肺門向肺外周呈樹枝狀分布、逐漸變細(xì))Thelobesofthelung、segmentand

pulmonarylobule

（肺葉、肺段和肺小葉）Thelobesoflung:differentwithlungfield.Lobesareseparatedbyfissures.----Therightlunghas3lobes;----Theleftlunghas2lobes;Interlobarfissure(葉間裂)

----Majorfissure----Minor(horizontal)fissure

majorfissureminor(horizontal)fissureFissuresandlobesofthelungsInterlobarfissure(葉間裂)Interlobarfissure(葉間裂)MajorfissureMinor(horizontal)fissure

右肺上葉示圖右肺中葉示圖右肺下葉示圖

左肺上葉示圖Thelobesoflung、segmentand

pulmonarylobule

（肺葉、肺段和肺小葉）Segment:Onelobeoflungiscomposedof2~5Segment.Pulmonarylobule:MuchpulmonarylobulearecomposedoftheSegment.

Pulmonaryparenchyma&mesenchyme

肺實(shí)質(zhì)與肺間質(zhì)LungiscomposedofpulmonaryparenchymaandmesenchymeNormalRadiologicalAnatomy

Fissure:

Horizontalfissure水平裂Obliquefissure斜裂4.PleuraPartialpleura壁層胸膜Visceralpleura臟層胸膜PleuralcavityItsnegativepressuremaintainsthelunginflatedNormalRadiologicalAnatomy

Thenormalpleura

isinvisible,onlyshowedalamellarorstriationinitsdirectionparallelingwithX-Ray

Position

Posteroanterior(PA):BetweenthelungsLateral:BetweenthesternumandthoracicvertebraeMediastinumRegion（分區(qū)）RuleofsixornineT4EdgebetweenthemanubriumandbodyofthesternumLinethroughthelowermarginofthe4ththoracicvertebra

SuperiormediastinumInferiormediastinumAnteriormediastinum

MiddlemediastinumPosteriormediastinum

Horizontalline水平線ordinate

line縱線Mediastinum----ruleofsixornineT8Diaphragm膈Shape:---2lobe---DomePosition:---ForPAfilm9thor10thposteriorrib.AbnormalchestradiographPulmonarylesions肺部病變Pleuralesions胸膜病變Mediastinal

lesions縱隔病變Bronchialobstruction

（支氣管阻塞）InfiltrateandConsolidationoflungCavityandintrapulmonaryaircontainingspaceNoduleandMassReticulate、leptonemaaandtrabsshadowCalcificationPulmonarylesions肺部病變Bronchialobstruction支氣管阻塞

Incompletebronchialobstruction(不完全阻塞)

--Obstructiveemphysema(阻塞性肺氣腫)Completebronchialobstruction（完全阻塞）

--Obstructiveatelectasis(肺不張)CausesBronchialcarcinomaEndobronchialbenigntumor（支氣管內(nèi)的良性腫瘤）Mucoidimpaction（粘液嵌塞）Postinfectionbronchialnarrow（炎癥后的支氣管狹窄）Extrabronchialcompression(支氣管外的病變壓迫)

Bronchialobstruction--Localobstructiveemphysema(局限性阻塞性肺氣腫)--Chronicdiffuseobstructiveemphysema(慢性彌漫性阻塞性肺氣腫)Obstructiveemphysema

(阻塞性肺氣腫)Localobstructiveemphysema(局限性阻塞性肺氣腫)

Obstructionoccurinlargebronchisuchasmainbronchi;lobebronchi;segmentbronchi;…Radiologicalappearance:Translucentlocallungfields局部肺野的透亮度增高Localobstructiveemphysema(局限性阻塞性肺氣腫)

Pneumonoresection（肺葉切除）orPulmonaryatelectasis（肺不張）increasethenegativepressure ofthoraciccavity;theadjacentorcontralateral

lungpassivehyperinflationChronicdiffuseobstructiveemphysema

(慢性彌漫性阻塞性肺氣腫)Obstructioninbronchiole（細(xì)支氣管的阻塞）

Secondary

chronicobstructiveairwaysdiseases.Radiologicalappearance

Reductionofperipheralpulmonaryvascularity(外周肺血管紋理的減少):FewerlungmarkingsPulmonaryhyperinflationBarrel-shapedchestFlatteneddiaphragmTranslucentlungfields

Alterationofthecentralpulmonaryarteriesandheart(心臟及中心肺動(dòng)脈的改變):PulmonaryarteryenlargeHeartelongated(心影狹長）Chronicdiffuseobstructiveemphysema(慢性彌漫性阻塞性肺氣腫)Obstructiveatelectasis(阻塞性肺不張)Completebronchialobstruction,gradualresorptionofair.Include:Completecollapseofalung一側(cè)肺不張

Lobarcollapse肺葉不張Roundedatelectasis圓形肺不張

Lobularatelectasis肺小葉不張Characteristic：Opacificationofallorawholelobeorseveralsegmentsofalobe肺葉或肺段的密度增高volumeloss體積縮小Radiologicalsignsofobstructiveatelectasis

(肺不張的影像學(xué)表現(xiàn))CrowdingofvesselsCrowdingofribsShiftofstructuressuchasinterlobarfissuresorthehilumtowardsareasoflungvolumeloss(葉間裂及肺門向不張的肺組織移位，即向心性移位）Elevationofthehomo-diaphragm（患側(cè)膈上抬）Compensatoryhyperinflationofadjoininglung（鄰近肺過度充氣）Completeatelectasisofalung一側(cè)肺不張ObstructionoccurredinmainbronchiOpacificationofthehemithoraxMediastinumshifttothesideofcollapseofalungDiaphragmraisesThecontralaterallungishyperinflatedandevenherniatedacrossthemidline(對(duì)側(cè)肺過度充氣，甚至超過中線）.CT---lungwindowCT–MediastinumwindowLobaratelectasis肺葉不張

---ObstructionoccurinlobebronchiOpacificationofawholelobe,associatedwithvolumeloss.Shiftofstructuressuchasinterlobarfissuresorthehilumtowardsareasoflungvolumeloss葉間裂及肺門向心性移位Elevationofthehomo-diaphragm患側(cè)膈肌抬高Compensatoryhyperinflationofadjoininglung鄰近肺組織過度充氣RightupperlobeatelectasisRightupperlobeatelectasismajorfissuremajorfissureminorfissureminorfissureRightupperlobeatelectasismassRightmiddlelobeatelectasis

minorfissureminorfissuremajorfissuremajorfissureminorfissuremajorfissureminorfissuremassRightmiddlelobeatelectasis

massLeftupperlobeatelectasismajorfissuremajorfissureLeftupperlobeatelectasisRightlowerlobeatelectasisRightlowerlobeatelectasisLeftlowerlobeatelectasisLeftlowerlobeatelectasisLeftlowerlobeatelectasisLeftlowerlobeatelectasis86bronchialobstruction（支氣管阻塞）InfiltrateandConsolidationoflungCavityandintrapulmonaryaircontainingspaceNoduleandMassReticulate、leptonemaaandtrabsshadowCalcificationPulmonarylesions肺部病變Exudation

andConsolidation

滲出與實(shí)變Exudation

isacuteinflammatoryreactionoftheorganism.Involvesthealveoli,whichfilledwithfluidorexudatethatdisplacestheairinthem.Lobarhomogenousdensity---Largeareasofhomogeneousshadowingwithfluffy,marginsismisty,

obscuredlungmarkings.Airbronchogram(支氣管氣像)---Airfilledbronchi,normallyinvisible,willbecontrastbyinfiltratecreatingairbronchogram.

NochangeoflobarshapeRadiologicalappearance:Exudation

andConsolidation

滲出與實(shí)變AirbronchogramCauses:

Pneumonia肺炎

Pulmonaryedema(肺水腫）

Hemorrhage肺出血

Aspirationpneumonitis吸入性肺炎

AlveolarcellcarcinomaExudation

andConsolidation

滲出與實(shí)變Lobularpneumonia

bronchopneumonia

支氣管肺炎MultifocalbronchocentricinfectionbasedonthepulmonarylobuleExudation

andConsolidation

滲出與實(shí)變Exudation

andConsolidation

滲出與實(shí)變Exudation

andConsolidation

滲出與實(shí)變Exudation

andConsolidation

滲出與實(shí)變Exudation

andConsolidation

滲出與實(shí)變MajordifferentiatingfactorsbetweenAtelectasisandPneumoniaAtelectasis肺不張

Pneumonia

肺炎--Lossoflungvolume--Anatomyshiftstowardsatelectasis--Linear,smooth,wedge-shaped--Apexofopacitystartsathilum--Normallungvolume--Noanatomicalshift--Consolidation--Airbronchogramsbronchialobstruction（支氣管阻塞）InfiltrateandConsolidationoflungCavityandintrapulmonaryaircontainingspaceNoduleandMassReticulate、leptonemaaandtrabsshadowCalcificationPulmonarylesions肺部病變

Cavityandintrapulmonaryaircontainingspace空洞與空腔Cavity:Necrotictissueventoutthroughbronchi,leavingachambercontainingairorfluid.Groupingdependonpathologicalchange

Mouth-eatencavityThinwalledcavity

ThickwalledcavityCavityandintrapulmonaryaircontainingspace空洞與空腔Cavitywallisnecrotictissue.Radiologicappearance：Manysmalllucentareainconsolidatedlungfiled,irregular;likemouth-eaten.

Causes:Caseouspneumonia干酪性肺炎

Mouth-eatencavity

Cavitywallisamellarfibroustissueandgranulationtissue;

cavitywall≤3mm。Radiologicappearance：cavitywithroundlucentarae,boundaryclearly,innerwallsmoothlyandwithoutfluidsurface;seldomconsolidationaroundit.Causes:

pulmonarytuberculosis(TB)

ThinwalledcavityPulmonarytuberculosiscavityRadiologicappearance:Cavitywithirregularlucentarae,innerwallunevenly;andhigh-densityconsolidationaroundit.

Causes:

①Pulmonarytuberculosis

(withoutorseldomfluidsurfaceinit.)②Pulmonaryabsces

(havingobviouslyfluidlevel.)③Pulmonarycarcinoma

(innerwallwithnodusirregularly.)Thickwalledcavity

--Cavitywall>3mm

Thickwalledcavity----TB

Thickwalledcavity----TB

Thickwalledcavity----lungabscess

Thickwalledcavity----lungabscess

Thickwalledcavity

----lungcancerbronchialobstruction（支氣管阻塞）InfiltrateandConsolidationoflungCavityandintrapulmonaryaircontainingspaceNoduleandMassReticulate、leptonemaaandtrabsshadowCalcificationPulmonarylesions肺部病變Radiologicappearance:

Diameterlessthan1cm，marginclear；likeaplumblossompetal.Causes:Pulmonarytuberculosis肺結(jié)核;Chronicinflammation慢性炎癥.Nodule----glandalveolusnodosityshadowPulmonarytuberculosis肺結(jié)核GlandalveolusnodosityshadowRadiologicappearance：diameterlessthan4mm，diffuseddistribution

。Causes:acutehematogenous[disseminated]pulmonarytuberculosis急性血行播散型肺結(jié)核，noduledisease結(jié)節(jié)病,lymphangitiscarcinomatosa癌性淋巴管炎等，Nodule----MiliarynoduleshadowNodule---MiliarynoduleshadowMass①Benigntumor：hamartoma(錯(cuò)構(gòu)瘤)②Malignanttumor：lungcancer③Nontumorousdisease:Tuberculoma(結(jié)核瘤）,Inflammatorypseudotumor(炎性假瘤)。DifferentiatebetweenbenignandmalignanttumorBenigntumorMalignanttumor

ShapeGlobularIrregularityPeplosornotYesNoMarginSharp,smoothandglossyNosharp,shortandfinesentus,sublobeorhilumnotchNeoplasmnecrosisNoYes，partmayformcavityGrowthSlowly,noperipheryinfiltratingFast，infiltrativegrowthContrastCTscanningLightornopotentializeObviouslypotentialize，CTvalueaddedmorethan20HU。Mass----LungcarcinomaMass—LungcarcinomaMass—LungcarcinomaMass--Peripherallungcancer

Mass--Peripherallungcancer

Mass--Metastatictumor

Mass--Peripherallungcancer

Mass--Peripherallungcancer

Mass----Hamartomabronchialobstruction（支氣管阻塞）InfiltrateandConsolidationoflungCavityandintrapulmonaryaircontainingspaceNoduleandMassReticulate、leptonemaaandtrabsshadowCalcificationPulmonarylesions肺部病變Responseforthepulmonaryinterstitialinpathologicalchanges.肺的網(wǎng)狀、細(xì)線狀及條索狀陰影在病理上是肺間質(zhì)性病變的反應(yīng)。

Reticulate、leptonemaaandtrabsshadow

肺的網(wǎng)狀、細(xì)線狀及條索狀陰影Radiologialappearance:1.Lungmarkingthickening,edgeunsharpness,bronchialwallthickening（大支氣管、血管周圍）2.Trabs、Reticulate、Honeycombshadowing（小支氣管、血管周圍）3.Diffusereticulate、Septallines、

Miliaryshadows、Groundglasspattern

（沿肺間質(zhì)分布）Reticulate、leptonemaaandtrabsshadow

肺的網(wǎng)狀、細(xì)線狀及條索狀陰影Reticulate、leptonemaaandtrabsshadow

肺的網(wǎng)狀、細(xì)線狀及條索狀陰影peribronchovascularinterstitialthickeningintralobularinterstitialthickeningReticulate、leptonemaaandtrabsshadow

肺的網(wǎng)狀、細(xì)線狀及條索狀陰影bronchialobstruction（支氣管阻塞）InfiltrateandConsolidationoflungCavityandintrapulmonaryaircontainingspaceNoduleandMassReticulate、leptonemaaandtrabsshadowCalcificationPulmonarylesions肺部病變CalcificationAppeartocataplasiaornecrosistissue,especiallyinhealingphaseofCaseoustubercle(干酪性結(jié)節(jié)）

inLungorlymphaden.Calcification鈣化Radiologicappearance:Highdensityshadow;

Marginclear;kindsofSizeandshape,suchasmottling,lumporglobular.AbnormalchestradiographPulmonarylesions肺部病變Pleuralesions胸膜病變Mediastinallesions縱隔病變Pleuraleffusion胸腔積液PneumatothoraxandHydropneumothorax氣胸及液氣胸PleuralesionsPleuraleffusion胸腔積液FreepleuraleffusionEncapsulatedeffusion包裹性積液

Interlobareffusion葉間積液

Infrapulmonaryeffusion肺下積液

FreepleuraleffusionLittlepleuraleffusion:>250ml,Costophrenicangleflatten、blunting;Belowthe4thanteriorrob.FreepleuraleffusionMiddlepleuraleffusion:Superiormarginisconcaveandhigherlaterally,Belowthe2ndanteriorribFreepleuraleffusion

Massivepleuraleffusion:

Completeopacificationofthehemithorax

ContralateraldisplacementofthemediastinumEncapsulatedeffusionNotalteritsappearancewithchangeofpatient’sposition

Fusiformshape

shadowncloseneighbor

chestwall.

Interlobareffusion葉間積液Pneumatothorax（氣胸）

Pathwayofairenteringpleuralcavity：①partialpleurabroken壁層胸膜破裂②visceralpleurabroken臟層胸膜破裂Radiologicappearance：Visceralpleurabevisibleasasharpwhitelineseparatefromthechestwall.Thelungretractstowardsthehilum.Pulmonaryvascularmarkingsarenotvisibleperipheraltothevisceralpleura.Pneumatothorax（氣胸）Pneumatothorax（氣胸）