Patients with Sjogren syndrome are at increased risk
for developing what diffuse lung diseases
Lymphocytic interstitial pneumonitis (LIP). Non-
Hodgkin pulmonary lymphoma.
Ankylosing spondylitis lung involvement
Young to middle-aged man with spine changes
(kyphosis, spinal ankylosis). Increased lung volumes.
Upper lobe fibrobullous disease. Simulates
postprimary fibrocavitary Tb or mycetoma formation.
These histologic terms provide the most precise
method of classifying the idiopathic interstitial
UIP. Acute interstitial pneumonia (AIP). COP.
Respiratory bronchiolitis-associated interstitial lung
disease (RB-ILD). DIP. Nonspecific interstitial
Usual Interstitial Pneumonia
Most common of the idiopathic interstitial pneumonias.
Most cases are sporadic. 30% of cases associated
with collagen vascular or immunologic disorder.
Findings: Irregular septal or subpleural thickening.
Intralobular lines. Honeycombing. Traction
bronchiectasis. Typically most severe in peripheral and
Acute Interstitial Pneumonia
Diffuse ground-glass opacity and consolidation with air
bronchograms. Linear opacities, honeycombing, and
traction bronchiectasis are uncommon.
Conditions associated with BOOP, organizing
Viral infection (influenza, adenovirus, measles). Toxic
fume inhalation (sulfur dioxide, chlorine). Collagen
vascular disease (rheumatoid arthritis and SLE). Organ
transplantation (bone marrow, lung, and heart-lung).
Drug reactions. Chronic aspiration.
Cryptogenic Organizing Pneumonia
Idiopathic form of organizing pneumonia. Most
common finding: Patchy consolidation or ground-glass
opacity with subpleural or peribronchial distribution.
Scattered nodular opacities may be present.
Respiratory Bronchiolitis-Associated Interstitial Lung
Typically young, heavy smokers. Scattered ground-
glass opacities. Small centrilobular nodules with upper
Desquamative Interstitial Pneumonia
95% are cigarette smokers. Cannot be radiologically
distinguished from UIP. Bibasilar reticular opacities.
Normal or midly decreased lung volumes. May have
ground-glass opacities. Honeycombing is rare.
Generally asymmetric upper lung bullae. Generally
symmetric lower lung interstitial fibrosis.
Tuberous Sclerosis (TS) ILD
Indistinguishable from LAM. Symmetric bilateral
reticular or reticulonodular opacities. Scattered lung
cysts. Normal to increased lung volumes.
Pneumothorax is common
Exclusively in women. Lung cysts separated by
interlacing bundles of smooth muscle. May obstruct
lymphatics causing chylothorax. Poor prognosis.
Alveolar Septal Amyloidosis
Simulates silicosis or lung sarcoidosis. Upper lung
Chronic Aspiration Pneumonia
Irregular reticular interstitial opacities.
3 major pneumoconioses
Asbestosis. Silicosis. CWP.
Pleura: Parietal pleural plaques. Pleural effusion.
Localized visceral pleural fibrosis. Diffuse pleural
fibrosis. Mesothelioma. Lung parenchyma: Interlobular
septal thickening. Interstitial fibrosis (asbestosis).
Rounded atelectasis. Bronchogenic carcinoma. Lower
Mining, ceramic work, and sandblasting. Upper lobe
and parahilar nodules. Nodule calcification may occur.
Egg shell calcification of hilar lymph nodes.
Silicoproteinosis like alveolar proteinosis has increased
susceptibility to TB.
Coal Worker's Pneumoconiosis
Predominantly upper lung reticulonodular or small
Berylliosis. Aluminum. Hard metal (cobalt, tungsten).
Inhaled antigenic organic dusts: Farmer's lung (moldy
hay). Humidifier lung (thermophilic bacteria). Bird-
fancier's lung (avian proteins). Acute and chronic forms.
Chronic disease findings: Interlobular and intralobular
interstitial thickening. Honeycombing, Traction
bronchiectasis. May spare costophrenic angles.
Lung Sarcoidosis staging
0 Normal chest radiograph. 1 Bilateral hilar lymph node
enlargement. 2 Bilateral hilar lymph node enlargement
and parenchymal disease 3. Parenchymal disease only.
4 Pulmonary fibrosis.
Common findings: Symmetric hilar adenopathy allows
distinction from malignancy and TB. Symmetric mid
and upper lung reticulonodular opacities.
Perilymphatic interstitial nodules, 3 to 10 mm.
Langerhans Cell Histiocytosis of Lung
Very high association with cigarette smoking. Mid and
upper lung centrilobular small nodules. In late stages
may develop cysts or bullae. Risk of pneumothorax.
Nodule-cyst evolution: Nodule to Cavitated nodule to
Thick-walled cyst to Thin-walled cyst.
Necrotizing granulomatous vasculitis involving upper
and lower respiratory tracts and kidneys. Discrete
nodules or masses with central necrosis and cavitation.
May mimic Goodpasture syndrome and idiopathic
pulmonary hemorrhage. Tracheal or bronchial lesions
may be present. c-ANCA positive.
Chronic Eosinophilic Pneumonia
Symptoms and radiographic abnormalities last longer
than 1 month. Predilection for women. Responds to
corticosteroid therapy, improving within 4 to 7 days.
Peripheral, homogeneous, ill-defined areas of
consolidation that may parallel the chest wall
Male predominance. Blood eosinophilia. Cardiomegaly.
Pulmonary edema. Pleural effusions. Pulmonary
parenchymal infiltration with eosinophils may produce
interstitial or airspace opacities.
Eosinophilic Lung Disease Associated With
Wegener granulomatosis. Sarcoidosis. Rheumatoid
lung disease. Polyarteritis nodosa. Allergic angiitis and
Eosinophilic Lung Disease of Identifiable Etiology
Drugs (Nitrofurantoin and Penicillins). Parasites
(Ascaris lumbricoides, Strongyloides stercoralis).
Pulmonary alveolar proteinosis
Lipoproteinaceous material deposits within alveoli.
Predilection for males in their 20s to 40s. Bilateral
symmetric perihilar airspace opacification. Crazy
paving CT finding: Geographic ground-glass opacities
with thickened interlobular and intralobular septa.
Prone to superinfection with Nocardia, Aspergillus,
Cryptococcus, and atypical mycobacteria.
Deposition of minute calculi within alveolar spaces.
Confluent bilateral dense micronodular opacities. So-
called black pleura sign. Apical bullous disease is
Diffuse pulmonary ossification
Formation of bone within lung parenchyma.
Associations: Mitral stenosis. UIP. Amyloidosis.
Paratracheal air cysts. True diverticula. Occur at
weakened posterior membrane of cervical trachea.
Bronchus suis. Accessory bronchus to all or a portion
of right upper lobe. Arises from right lateral tracheal
wall within 2 cm of tracheal carina. Associated with
congenital tracheal stenosis and aberrant left
Primary neoplasms of trachea
Malignant: Squamous cell carcinoma. Adenoid cystic
carcinoma (cylindroma). Benign:
Saber-sheath trachea. Amyloidosis.
Relapsing polychondritis. Wegener granulomatosis.
Tracheobronchomegaly (Mounier-Kuhn syndrome).
Tracheomalacia. Interstitial pulmonary fibrosis.
Coronal diameter is less than two thirds of sagittal
diameter. Affects older men with chronic obstructive
pulmonary disease (COPD).
Multiple submucosal osseous and cartilaginous
deposits within trachea and central bronchi of elderly
men. Spares membranous posterior wall of trachea.
Systemic autoimmune disorder. Affects cartilage of
earlobes, nose, larynx, tracheobronchial tree, joints,
and large elastic arteries. Diffuse smooth wall
thickening of the wall of trachea and central bronchi
with luminal narrowing.
Tracheobronchomegaly (Mounier-Kuhn syndrome)
Congenital. Associated with Ehlers-Danlos syndrome.
Men under age 50. Trachea and central bronchi
measure greater than 3.0 cm and 2.5 cm.
Diffuse tracheal and central bronchial dilation.
Congenital or acquired (COPD, Chronic bronchitis,
Cystic fibrosis, Relapsing polychondritis).
Fallen lung sign
Subtended lung remains collapsed against lateral
chest wall. Secondary to bronchial injury. Responds
poorly to chest tube evacuation.
Calcified material within bronchus. Usually from
eroding calcified lymph nodes (Histoplasmosis or TB).
Transient bronchial narrowing. Peribronchial cuffing
and tram tracking. Air trapping: Hyperinflation,
Flattening or inversion of diaphragm, Attenuation of
peripheral vascular markings. Prominence of the
retrosternal airspace. Complications:
Pneumomediastinum. Pneumothorax, Subpleural
blebs from expiratory air dissection.
Excess production of sputum on most days for at least
3 months in 2 consecutive years. 50% have normal
chest radiographs. Some patients show peribronchial
cuffing or tram tracks.
Permanent dilation of bronchi. Cylindric bronchiectasis:
mild diffuse dilation. Varicose bronchiectasis: cystic
dilation interrupted by focal areas of narrowing. Cystic
bronchiectasis: localized saccular dilation. Caused by
chronic inflammation with cartilage damage and
dilation. Localized bronchiectasis is most commonly a
result of prior TB. Generalized bronchiectasis is seen
in cystic fibrosis. Central bronchiectasis: Allergic
bronchopulmonary aspergillosis. Cystic fibrosis.
Bronchial atresia. Acquired central bronchial
Production of abnormally thick, tenacious mucus.
Recurrent infection commonly with Pseudomonas
aeruginosa or Staphylococcus aureus. Severe
bronchiectasis. Hyperinflation with predominantly
upper lobe bronchiectasis and mucus plugging.
Dysmotile cilia syndrome
May result in Rhinitis. Sinusitis. Bronchiectasis.
Dysmotile spermatozoa and sterility. Situs inversus.
Kartagener syndrome triad
Sinusitis. Situs inversus.. Bronchiectasis.
Allergic bronchopulmonary aspergillosis
Hypersensitivity reaction to Aspergillus. Asthma, blood
eosinophilia, bronchiectasis with mucus plugging, and
circulating antibodies to Aspergillus antigen. Proximal
upper lobe bronchiectasis with mucoid impaction.
Finger in glove appearance.
Permanent enlargement of airspaces distal to terminal
bronchiole. Destruction of alveolar walls without
Airspace distention in central portion of lobule. Spares
distal portions of the lobule. Upper lobe predominance.
Associated with cigarette smoking.
Distention of airspaces throughout lobule. Destruction
of central respiratory bronchioles and peripheral
alveolar sacs and alveoli. Predilection of lower lobes.
Associated with alpha-1 antitrypsin deficiency.
Distention of peripheral airspaces adjacent to
interlobular septa. Spares centrilobular region.
Generally involves subpleural regions of upper lobes.
Paracicatricial or irregular emphysema
Lung destruction associated with fibrosis. No
consistent relationship to a given portion of the lobule.
Commonly associated with old granulomatous
Diffuse hyperlucency (panlobular). Flattening and
depression of hemidiaphragms. Increased retrosternal
airspace (panlobular > centrilobular). Bulla. Enlarged
central pulmonary arteries. Right heart enlargement
(centrilobular). Loss of pulmonary capillary bed.
Arterial deficiency emphysema versus increased
Arterial deficiency: Predominantly panlobular
emphysema. Hyperinflated lungs with peripheral
vascular attenuation and bullae. Pink Puffers.
Increased markings: Increased linear parenchymal
markings. Small airways thickening of chronic
bronchitis. Bullae uncommon. Blue Bloaters.
Thin-walled cystic space > 1 cm in diameter. Found
within lung parenchyma.
Bullae may be seen in diseases that cause chronic
upper lobe fibrosis, such as
Sarcoidosis. Pulmonary Langerhans cell histiocytosis.
Primary bullous disease
Isolated bullae without intervening emphysema or
interstitial lung disease. Associated with: Marfan or
Ehlers-Danlos syndromes. Intravenous drug use. HIV
infection. Vanishing lung syndrome.
CT findings and associations of infectious bronchiolitis
Tree-in-bud opacities. Generally due to infection: Viral.
CT findings of diffuse panbronchiolitis
Tree-in-bud opacities. Bronchial dilation and thickening.
CT findings and associations of Respiratory
bronchiolitis–associated interstitial lung disease
Centrilobular and geographic ground-glass opacities.
CT findings and associations of Hypersensitivity
Centrilobular ground-glass nodules. Air trapping on
expiratory scans. Inhaled organic antigen.
CT findings and associations of Follicular bronchiolitis
Centrilobular ground-glass nodules. Rheumatoid
arthritis. Sj?gren syndrome.
CT findings and associations of Constrictive
Mosaic attenuation with air trapping on expiratory
scans. Bronchial dilation (late). Transplant patients.
Drug reactions. Inhalation injury.
Transudative pleural effusion lab values
Pleural/serum protein ratio less than 0.5. Pleural/serum
LDH ratio less than 0.6. Pleural LDH less than 200
Infectious causes of pleural effusion?
Bacterial/mycobacterial. Viral. Fungal. Parasitic.
Cardiovascular causes of pleural effusion?
Heart failure. Pericarditis. Superior vena cava
obstruction. Postcardiac surgery. Myocardial infarction.
Neoplastic causes of pleural effusion?
Bronchogenic carcinoma. Metastases. Lymphoma.
Pleural or chest wall neoplasms (mesothelioma).
Immunologic causes of pleural effusion?
Systemic lupus erythematosus. Rheumatoid arthritis.
Sarcoidosis (rare). Wegener granulomatosis.
Inhalational cause of pleural effusion?
Trauma causes of pleural effusion?
Blunt or penetrating chest trauma.
Abdominal disease causes of pleural effusion?
Cirrhosis (hepatic hydrothorax). Pancreatitis.
Subphrenic abscess. Acute pyelonephritis. Ascites
(from any cause). Splenic vein thrombosis.
Miscellaneous causes of pleural effusion?
Drugs. Myxedema. Ovarian tumor.
Pleural effusion from congestive heart failure features
Transudative. Bilateral, right larger than left. Isolated
right effusion twice as common as isolated left effusion.
Findings on CT that are fairly specific for the presence
of an exudative pleural effusion
Thickening and enhancement of parietal pleura.
Loculations. Soft tissue lesions along parietal pleura
outlined by pleural fluid.
Tumors most commonly associated with pleural
effusion are, in order of frequency,
Lung carcinoma. Breast carcinoma. Pelvic tumors
(ovarian fibroma = Meigs syndrome). Gastric
Lung abscess versus empyema?
Empyema: Oval. Oriented longitudinally. Thin. Smooth
(split pleura sign). Obtuse chest wall angle.
Compresses lung. Requires drainage. Abscess:
Round. Thick and irregular wall. Acute chest wall angle.
Consumes lung. Antibiotics and postural drainage to
Most common intrathoracic manifestation of
Most common causes of chylothorax are
Malignancy. Iatrogenic trauma. TB
Left chylothorax versus right chylothorax?
Left chylothorax: Injury to upper duct. Right
chylothorax: Injury to lower duct.
Communication between lung and pleural space. If
bronchus involved, may result in empyema. If
peripheral airspace (bronchiole) involved, may result
in intractable pneumothorax.
Primary spontaneous pneumothorax
Often occurs in young or middle-aged men.
Predilection of taller individuals. Results from bleb or
bulla rupture, usually within upper lungs.
Secondary Spontaneous Pneumothorax
COPD. Asthma. Valsalva (cocaine, marijuana, labor).
Sarcoidosis. Langerhans cell histiocytosis.
Lymphangioleiomyomatosis. Necrotizing pneumonia.
Abscess. Mechanically ventilated patients.
Rare recurrent pneumothoraces. Occurs with menses.
Pleural endometrial implants. Treated with OCPs.
Most common cause of tension pneumothorax
Iatragenic trauma in mechanically ventilated patients.
Causes of pleural thickening
Pneumonia. Pulmonary infarct. Trauma. Asbestos
Causes of pleural calcification
(tuberculosis). Parietal pleura:??Asbestos exposure
Causes of pleural/extrapleural masses
?Metastases (usually multiple).??Mesothelioma
(usually diffuse pleural thickening). Other: Loculated
pleural effusion/empyema. Hematoma.
Fluid within calcified pleural layers seen on CT
Active empyema. Most commonly within patients with
Pleural thickening extending over more than one fourth
of the costal pleural surface. Commonly results from
resolution of an exudative pleural effusion (including
asbestos-related effusions), Empyema, or Hemothorax.
Pleurectomy (decortication) may be necessary to
Malignant pleural disease is most often caused by one
of four conditions:
Metastatic adenocarcinoma (lung, breast, ovary, kidney,
GI tract). Invasive thymoma or thymic carcinoma.
Mesothelioma. Rarely non-Hodgkin lymphoma.
Benign and malignant Asbestos-Related Pleural
Benign: Pleural plaques. Pleural effusions. Diffuse
pleural fibrosis. Malignant: Mesothelioma.
When viewed en face, calcified pleural plaques appear
Geographic opacities. Llikened to a holly leaf.
Autosomal recessive disorder. Unilateral absence of
sternocostal head of pectoralis major. Ipsilateral
syndactyly. Rib anomalies.
Most common benign neoplasm of chest wall
Most common malignant soft tissue neoplasms of the
chest wall in adults.
A rare malignant neoplasm arising from the chest wall
of children and young adults
Askin tumor. Arises from primitive neuroectodermal
rests. Very aggressive with a poor prognosis.
Benign chest wall lesions
Abscess. Hematoma. Lipoma. Hemangioma. Desmoid
Inferior rib notching causes
Coarctation of aorta. Aortic thrombus. Takayasu
arteritis. SVC syndrome. Neurofibromatosis.
Suprior rib notching cause
Benign rib neoplasms, most common first
Osteochondroma. Enchondroma. Osteoblastoma.
Most common primary rib malignancy
Most common: Myeloma. Metastatic carcinoma.
Primary malignancies: Chondrosarcoma. Osteogenic
Most common metastatic lesions to ribs
Breast cancer. Lung cancer.
Expansile lytic rib metastases are seen most
Renal cell carcinoma. Thyroid carcinoma.
Sclerotic rib metastases are most commonly seen in
Breast cancer. Prostate cancer.
Pleuropulmonary infections that may traverse the
pleural space and produce a chest wall infection
TB. Actinomycosis. Nocardiosis.
Congenital hypoplastic and elevated scapula.
Sprengel deformity (hypoplastic, elevated scapula).
Omovertebral bone. Fused cervical vertebrae.
Hemivertebrae. Kyphoscoliosis. Rib anomalies.
Erosion of the distal clavicles
Rheumatoid arthritis: Well-defined pointed distal
clavicle. Hyperparathyroidism: Irregular and wide
H-shaped or Lincoln log vertebrae on lateral chest
Sickle cell anemia.
Rugger jersey appearance to thoracic spine on lateral
Pectus excavatum is commonly associated with
congenital connective tissue disorders, such as
Marfan syndrome. Poland syndrome. Osteogenesis
imperfecta. Congenital scoliosis.
Outward bowing of sternum. May be congenital or
Eventration of the diaphragm
Congenital absence or underdevelopment of
diaphragmatic musculature. Localized elevation of
anteromedial hemidiaphragm in older individuals.
Unilateral diaphragmatic paralysis is usually caused by
Surgical injury or neoplastic involvement of phrenic
Bilateral Diaphragmatic Elevation that is not effort
related may be caused by
Neuromuscular disturbance. Intrathoracic or intra-
Herniation through embryonic pleuroperitoneal canal.
Neonates present with large hernias with lung
hypoplasia and respiratory distress. Adults present with
small hernias, mostly on the left side (liver thought to
Parasternal diaphragm defect. Invariably right sided.
Asymptomatic cardiophrenic angle mass.
Primary diaphragmatic tumors
Benign: Lipomas. Fibromas. Schwannomas.
Neurofibromas. Leiomyomas. Echinococcal cysts and
extralobar sequestrations may be found within the
diaphragm. Metastatic invasion more common than
primary malignancy (Fibrosarcoma): Lower lobe
bronchogenic carcinoma. Mesothelioma.
Cystic adenomatoid malformation
Usually seen in infancy. One or several large cysts
lined with respiratory epithelium with scattered mucous
glands, smooth muscle, and elastic tissue. Round, air-
filled masses that compress adjacent lung and
Bronchial atresia presentation
Central bronchial mucocele with peripheral
hyperlucency in a young, asymptomatic patient.
Intralobar and extralobar sequestration blood supply
Intralobar sequestration: Single large artery from
infradiaphragmatic aorta. Pulmonary vein drainage.
Extralobar sequestration: Small branches systemic
arteries and occasionally pulmonary arteries. Systemic
venous drainage (inferior vena cava, azygos, or
Hypogenetic lung-scimitar syndrome
Variant of hypoplastic lung with abnormal venous
drainage to the IVC just above or below right
hemidiaphragm. Small right hemithorax with
diaphragmatic elevation or eventration. Dextroposition
of heart. Herniation of left lung anteriorly into right
Three radiographic patterns of aspiration pneumonitis
Extensive bilateral airspace opacification. Diffuse but
discrete airspace nodular opacities. Irregular
parenchymal opacities that are not obviously airspace.
Exogenous lipoid pneumonia
Older patients with swallowing disorders or
gastroesophageal reflux. Use mineral oil as a laxative
or inhale oily nose drops. Fat density opacity.
Drug that cause drug induced chest diseases
Lupus-like syndrome (procainamide, isoniazid,
hydralazine). Nitrofurantoin. Bleomycin. Methotrexate.
A confident diagnosis of hamartoma can be made
when HRCT shows
Nodule less than 2.5 cm with a smooth or lobulated
border and containing focal fat. May have popcorn
Benign neoplasm arising from neural elements in the
central airways or lung parenchyma. The skin is the
most common site for these tumors.
Granular cell myoblastoma.
Bronchogenic adenocarcinoma features
Most common type of lung cancer (nonsmokers, too).
Arise from bronchiolar or alveolar epithelium. Irregular
or spiculated appearance. ccur in the lung periphery.
Bronchioloalveolar cell carcinoma (BAC)
Grows along bronchiolar and alveolar walls (lepidic
growth). May appear as: Solitary nodule. Focal ground-
glass opacity. May mimic pneumonia or bilateral
nodular airpsace processes.
Squamous cell carcinoma features
Arises centrally within lobar or segmental bronchi.
Central necrosis with cavitation may be seen.
Generally presents as hilar mass and atelectasis.
Small cell carcinoma features
Arises centrally within main or lobar bronchi from
bronchial neuroendocrine (Kulchitsky) cells.
Hematogenous dissemination. Hilar/mediastinal mass.
Large cell bronchogenic carcinoma radiographic
Large peripheral mass.
In addition to cigarette smoke, well-recognized risk
factors for the development of bronchogenic carcinoma
Asbestos exposure. Previous Hodgkin lymphoma.
Radon exposure. Viral infection. Diffuse interstitial or
localized lung fibrosis.
Most common radiographic findings from
endobronchial tumor obstruction.
Resorptive atelectasis. Obstructive pneumonitis.
Majority of pancoast tumors, histology type
Pancoast tumor symptoms
Arm pain and muscular atrophy due to brachial plexus
involvement. Horner syndrome (ptosis, anhydrosis,
miosis) from involvement of sympathetic chain.
Shoulder pain from chest wall invasion.
CT angiogram sign and BAC
Filling of airspaces with mucoid material produced by
malignant cells creates low-density airspace
opacification surrounding enhanced pulmonary arteries.
Typical radiologic findings of lymphangitic
Linear and reticulonodular opacities. Peribronchial
cuffing. Subpleural edema or pleural effusion.
Helps distinguish lymphangitic carcinomatosis due to
lung cancer from other metastases
Unilateral or asymmetric involvement of lungs suggests
lung cancer rather than an extrapulmonary site.
Two patient groups of small cell lung cancer
Disease limited to one hemithorax (limited disease).
Contralateral lung or extrathoracic spread (extensive
Two most common primary tracheal malignancies
SCC > Adenoid cystic carcinoma
Tracheal mass size and malignancy
Masses > 2 cm are likely to be malignant. Less than 2
cm are more likely benign.
Other, less common primary tracheal malignancies
Mucoepidermoid carcinoma. Carcinoid tumor.
Adenocarcinoma. Lymphoma. Small cell carcinoma.
Leiomyosarcoma. Fibrosarcoma. Chondrosarcoma.
Primary malignant neoplasms of the central bronchi
Squamous cell carcinoma. Small cell carcinoma.
Carcinoid tumor. Bronchial gland tumors (adenoid
cystic carcinoma, mucoepidermoid carcinoma).
Carcinoid radiologic features
Prefers right upper and middle lobes. Well-defined
smooth or lobulated nodules or masses. Iceberg tumor:
small intrabronchial and large extraluminal soft tissue
A benign neoplasm comprised of disorganized
epithelial and mesenchymal elements normally found
in the bronchus or lung.
A feature that helps distinguish lymphangitic
carcinomatosis from interstitial fibrosis,
Thickened septal lines of lymphangiti carcinomatosis
do not distort the pulmonary lobule.
Lymphocytic interstitial pneumonitis
Infiltration of pulmonary interstitium by mature
lymphocytes. CT findings: Diffuse ground-glass opacity.
Poorly defined centrilobular nodules. Thin-walled cysts.
Associations: Sjogren syndrome.
Hypogammaglobulinemia. Multicentric Castleman
Posttransplant lymphoproliferative disorder (PTLD)
Spectrum of entities. Ranging from benign polyclonal
lymphoid proliferation to aggressive non-Hodgkin
Rare malignant tumor affecting children and young
adults. Histology simulates fetal lung at 10 to 16 weeks’
gestation. Tend to be extremely large at presentation.
Lobar pneumonia features
Typical of pneumococcal pulmonary infection.
Inflammatory process spreads via pores of Kohn and
canals of Lambert to produce nonsegmental
consolidation. Air bronchograms are common.
Most common pattern of pneumonia. Typical of
staphylococcal pneumonia. Inflammation centered
around lobular bronchi. Multifocal opacities produce
patchwork quilt of scattered normal and diseased
lobules. No air bronchograms due to exudate within
Interstitial pneumonia features
Viral and mycoplasma infection. Inflammatory
thickening of bronchial and bronchiolar walls and
pulmonary interstitium. Peribronchial cuffing and
Pneumatoceles may be distinguished from abscesses
Thin walls. Rapid change in size. Generally develop
during late phase of infection.
Calcified parenchymal focus (Ghon lesion) and lymph
nodel calcification. Primary TB.
Reactivation occurs in apical and posterior segments
of upper lobes and superior segments of lower lobes.
Ill-defined patchy and nodular opacities. Cavitation
usually indicates active and transmissible disease.
Erosion of cavitary focus into pulmonary artery branch
can produce an aneurysm.
May complicate primary or reactivation disease.
Hematogenous dissemination. Diffuse bilateral 2- to 3-
mm pulmonary nodules.
Opportunistic fungal lung pathogens
Aspergillus. Candida. Cryptococcus.
Aspergillus lung involvement
Aspergilloma or mycetoma within preexisting cavities.
Semi-invasive (chronic necrotizing) aspergillosis in
mildly impaired immunity. Invasive pulmonary
aspergillosis in neutropenia. Allergic
bronchopulmonary aspergillosis in hyperimmunity.
Pulmonary echinococcal cysts are composed of three
Inside out: Endocyst, produces daughter cyts. Exocyst
(chitinous layer), protective membrane. Pericyst,
surrounding compressed, fibrotic lung.
CT halo sign
Decreased attenuation surrounding a dense, mass-like
opacity. Relatively specific for invasive aspergillosis in
a neutropenic patient.
Most common AIDS-defining opportunistic infection.
Interlobular (Septal) Lines
Thin, short, 1- to 2-cm lines oriented perpendicular to
and intersecting costal pleura.
Interlobular (septal) lines DDx:
Interstitial edema. ? Lymphangitic carcinomatosis. ?
Sarcoidosis. ? Idiopathic pulmonary fibrosis (IPF)
(other forms of usual interstitial pneumonia UIP).
Intralobular lines ILD DDx
IPF (UIP). Asbestosis. Alveolar proteinosis.
Thickened fissures ILD DDx
Pulmonary edema. ? Sarcoidosis. ? Lymphangitic
Peribronchovascular interstitial thickening
Pulmonary edema (smooth). ? Sarcoidosis (nodular). ?
Lymphangitic carcinomatosis (smooth or nodular).
Centrilobular nodules ILD DDx
Hypersensitivity pneumonitis.? Bronchiolitis obliterans
with organizing pneumonia (BOOP)/cryptogenic
organizing pneumonia (COP).? Respiratory
bronchiolitis-associated interstitial lung disease (RB-
Subpleural lines ILD DDx
Asbestosis. ? IPF (UIP).
Parenchymal bands ILD DDx
Asbestosis. ? IPF (UIP). ? Sarcoidosis.
IPF (UIP). ? Asbestosis.? Hypersensitivity pneumonitis
Thin-walled cysts ILD DDx
Eosinophilic granuloma (EG).
Lymphangioleiomyomatosis.? Tuberous sclerosis.?
Neurofibromatosis (pneumatocele). (emphysema).
Micronodules, random distribution ILD DDx
Miliary tuberculosis or histoplasmosis.? Hematogenous
metastases.? Silicosis/coal worker's pneumoconiosis
Micronodules, perilymphatic distribution ILD DDx
Sarcoidosis. ? Lymphangitic carcinomatosis.?
Ground-glass opacities ILD DDx
Desquamative interstitial pneumonia.? Acute interstitial
pneumonia (AIP).? Hypersensitivity pneumonitis.
BOOP/COP.? RB-ILD.? Hemorrhage.? Pneumocystis
jiroveci pneumonia.? Cytomegalovirus pneumonia.?
Traction bronchiectasis ILD DDx
Sarcoidosis. ? Silicosis/CWP.
Conglomerate mass ILD DDx
Sarcoidosis.? Silicosis.? CWP.? Radiation fibrosis.
5- to 10-cm-long curvilinear opacities are found within
1 cm of the pleura and parallel the chest wall. Most
often seen in patients with asbestosis and, less
Nontapering linear opacities, 2 to 5 cm in length.
Extend from lung to contact pleural surface. Asbestosis.
Small (6 to 10 mm) cystic spaces with thick (1 to 3 mm)
walls. usually have shared walls . Usually in posterior
subpleural regions. End-stage pulmonary fibrosis: IPF
(UIP). Chronic hypersensitivity pneumonitis.
Slightly larger in diameter (10 mm) than honeycomb
cysts. Uniform in size. Thinner walls. Do not share
walls with adjacent cysts. Cysts of LCH and LAM are
usually evenly distributed from central to peripheral
portions of upper lobes
1- to 3-mm. Sharply marginated. Round opacities seen
on HRCT. Represent conglomerates of granulomas or
tumor cells within the interstitium.
Ground-Glass or Hazy Increased Density
Granular appearance with maintained visibility of
pulmonary vessels. Absence of air bronchograms.
Desquamative interstitial pneumonia (DIP).
Pneumocystis jiroveci (formerly P carinii) pneumonia.
Acute hypersensitivity pneumonitis. Nonspecific
interstitial pneumonia (NSIP). Interstitial pulmonary
Fibrosis causes traction on the walls of bronchi,
resulting in irregular dilation.
ILDs Upper zone distribution
Tuberculosis (postprimary). Chronic fungal infection
(Histoplasmosis,?Coccidioidomycosis). ?Sarcoidosis. ?
Eosinophilic granuloma.? Silicosis.? Ankylosing
spondylitis.? Hypersensitivity pneumonitis (chronic).
Radiation fibrosis from treatment of head and neck
ILDs Lower zone distribution
Idiopathic pulmonary fibrosis.? Asbestosis.?
Rheumatoid lung.? Scleroderma.? Neurofibromatosis.?
Dermatomyositis/polymyositis.? Chronic aspiration.
ILDs normal or increased lung volumes
Sarcoidosis.? Eosinophilic granuloma.?
Lymphangioleiomyomatosis.? Tuberous sclerosis.?
Interstitial disease superimposed on emphysema.
Idiopathic pulmonary fibrosis.? Sarcoidosis.?
Eosinophilic granuloma.? Rheumatoid lung.?
Scleroderma.? Pneumoconiosis.? Hypersensitivity
pneumonitis.? Chronic aspiration.? Radiation fibrosis.
ILDs miliary nodules
). Silicosis.? Metastases (Thyroid carcinoma, Renal
Sarcoidosis.? Eosinophilic granuloma.
Hilar/mediastinal lymph node enlargement
Sarcoidosis.? Lymphangitic carcinomatosis.?
Lymphoma.? Hematogenous metastases.?
Tuberculosis. Fungal infection.? Silicosis.
ILDs Pleural disease
Asbestosis (plaques).? Lymphangitic carcinomatosis
(effusion).? Rheumatoid lung disease
Manifestations of Rheumatoid Lung Disease
Pleural effusion. Pleural thickening. Pericarditis.
Pericardial effusion. Pulmonary fibrosis (basilar
predominance). Necrobiotic nodules (peripheral
cavitating nodules, Caplan syndrome). Bronchiolitis
obliterans (Hyperinflation) Pulmonary arteritis.
Pulmonary arterial hypertension. Right heart
enlargement. Pulmonary hemorrhage
Thick walled cavitating lung nodules. Rheumatoid
arthritis patients with hypersensitivity to inhaled dust
particles (coal, silica, asbestos).
Scleroderma ILD findings
Interlobular septal thickening. Ground-glass opacities.
Honeycombing. Lower lung predominance. Patulous
Interstitial pulmonary edema CXR findings?
Intrapulmonary vascular shadows. Peribronchial
cuffing. Tram tracking.
Kerley A and B lines?
Kerley A lines thickening of central connective tissue
septa. Kerley B lines thickening of peripheral
Alveolar pulmonary edema localized to the right upper
lung may be seen in patients with
Severe mitral regurgitation.
Causes of Pulmonary Venous Hypertension and
LV failure. Mitral valve disease (Mitral stenosis, Mitral
insufficiency). LA myxoma. Cor triatriatum. Obstruction
of central pulmonary veins (fibrosing mediastinitis,
pulmonary vein stenosis, pulmonary venous
thrombosis). Obstruction of intrapulmonary veins
(pulmonary venoocclusive disease).
Radiographic findings of pulmonary venous
Enlargement of pulmonary veins (progressive dilation
of horizontally oriented pulmonary veins).
Redistribution of pulmonary blood flow to upper lungs.
Respiratory failure due to increased capillary
permeability edema. Associated with increased lung
Common causes of ARDS
Shock. Severe trauma. Burns. Sepsis. Narcotic
ARDS radiographic findings
Patchy peripheral airspace opacities (12-24 hrs).
Confluent bilateral airspace opacities with air
bronchograms (days). Coarse reticulonodular pattern
(week) that may resolve.
Causes of neurogenic pulmonary edema
Head trauma. Seizure. Increased intracranial pressure.
Hemorrhage or hemorrhagic edema of the lung can
Trauma. Bleeding diathesis. Infections (invasive
aspergillosis, mucormycosis, Pseudomonas, influenza).
Drugs (penicillamine). Pulmonary embolism. Fat
embolism. ARDS. Autoimmune diseases
(Goodpasture syndrome, idiopathic pulmonary
hemorrhage, Wegener granulomatosis, systemic lupus
erythematosus, rheumatoid arthritis, and polyarteritis
Damage to alveolar and renal glomerular basement
membranes by cytotoxic antibody.
Idiopathic Pulmonary Hemorrhage
Indistinguishable from Goodpasture syndrome.
Pulmonary hemorrhage and anemia in patient with
normal renal function and urinalysis. No
antiglomerular basement membrane antibodies.
Vasculitides that can cause pulmonary hemorrhage
Wegener granulomatosis. Systemic lupus
erythematosus. Rheumatoid arthritis. Polyarteritis
Sensitive, but not specific marker of venous
Most common radiographic findings in PE without
Localized peripheral oligemia with or without distended
proximal vessels (Westermark sign). Peripheral
airspace opacification. Linear atelectasis.
Radiographic features that suggest infarction in PE
Small pleural effusion and pleura-based wedge-
shaped opacity (Hampton hump).
Nonthrombotic pulmonary embolism causes
Air embolism. Macroscopic fat embolism.
Methylmethacrlate embolization from vertebroplasty.
Radioactive seed embolization from prostate
PAH is defined as a systolic pressure in the pulmonary
30 mm Hg.
Typical radiographic findings of PAH are
Enlarged main and hilar pulmonary arteries that taper
rapidly toward lung periphery. RV enlargement.
PAH measurements of proximal interlobar pulmonary
artery (CXR) and main pulmonary artery (CT)
Interlobar pulmonary artery > 16 mm. Main pulmonary
artery > 28.6 mm.
In addition to PAH, enlargement of the central
pulmonary arteries may be seen in
High cardiac output (anemia, thyrotoxicosis). Left-to-
right shunts (ASD, VSD, PDA, PAPVR).
Shunt vascularity on chest radiographs
Enlargement of both central and peripheral pulmonary
Disorders of the pulmonary arteries that produce PAH
Chronic PEs. Vasculitis. Pulmonary arteriopathy
resulting from long-standing increased pulmonary
blood flow from left-to-right shunt.
Multiple pulmonary nodules of similar size and
appearance are almost always
Pulmonary nodule is defined as
Round or oval opacity 4 to 30 mm in diameter.
Pulmonary mass is defined as
Round opacity greater than 3 cm.
Differential in a patient under the age of 35, particularly
a nonsmoker without a history of malignancy,
Granuloma. Hamartoma, Inflammatory lesion.
An SPN in a patient over 35 years of age should never
be followed radiographically without tissue confirmation
unless the lesion contains
Benign pattern of calcification. Presence of
Studies have shown that bronchogenic carcinoma has
a doubling time of
Between 1 month and 2 years.
Presence of small satellite nodules around the
periphery of a dominant pulmonary nodule is strongly
Benign disease, particularly granulomatous infection.
Presence of a halo of ground-glass opacity encircling
an SPN in an immunocompromised, neutropenic
patient should suggest the diagnosis of
Invasive pulmonary aspergillosis.
Comet tail of bronchi and vessels entering the hilar
aspect of the mass, and associated with lobar volume
loss is characteristic of
Complete or central calcification within an SPN is
Healed granuloma from tuberculosis or histoplasmosis.
Concentric or laminated calcification of an SPN
Granuloma and allows confident exclusion of
Popcorn calcification within a pulmonary nodule is
Fat within an SPN is diagnostic of a
Enhancement of malignant SPNs
Most common thoracic inlet masses?
Thyroid masses. Lymphomatous nodes.
Intrathoracic thyroid goiter CT findings?
Well-defined margins. Continuity of mass with cervical
thyroid. Coarse calcifications. Cystic or necrotic areas.
Baseline high CT attenuation (intrinsic iodine content).
Intense enhancement (>25 H).
Tumor of dilated lymphatic channels. Cystic or
cavernous form (cystic hygroma) is commonly
discovered in infancy and is often associated with :
Turner syndrome and trisomies 13, 18, and 21.
Anterior mediastinal masses?
Thymic neoplasms. Lymphoma. Germ cell neoplasms.
Primary mesenchymal tumors.
Thymoma versus thymic carcinoma
Thymomas may be encapsulated (noninvasive) or
invasive. Thymic carcinomas, epithelial component
shows signs of frank malignancy.
Thymoma-associated autoimmune diseases
Myasthenia gravis. Pure red cell aplasia. Graves
disease. Sjogren syndrome. Hypogammaglobulinemia.
Congenital: Remnants of thymopharyngeal duct.
Contain thin or gelatinous fluid. Acquired:
Postinflammatory. Associations: AIDS, Prior radiation
or surgery, Autoimmune conditions (Sj?gren syndrome,
Myasthenia gravis, Aplastic anemia).
Thymoma. Thymic cyst. Thymolipoma. Thymic
hyperplasia. Thymic neuroendocrine tumors. Thymic
carcinoma. Thymic lymphoma.
Germ cell neoplasms
Teratoma (benign and malignant). Seminoma.
Embryonal cell carcinoma. Endodermal sinus tumor.
Mesenchymal anterior mediastinal tumors
Lipoma. Hemangioma. Leiomyoma. Liposarcoma.
_________ is the most frequent site of a localized
nodal mass in patients with Hodgkin disease.
A key in distinguishing primary from metastatic
mediastinal germ cell neoplasm is the presence of
Retroperitoneal lymph node involvement in metastatic
Benign and malignant teratoma features on CT
Benign: round or oval and smooth in contour.
Malignant: irregular, lobulated, or ill-defined margin.
Middle mediastinal masses
Foregut and mesothelial cysts. Tracheal and central
bronchial neoplasms. Diaphragmatic hernias. Vascular
Differential for central calcification of mediastinal/hilar
lymph nodes on CT?
Differential for peripheral (eggshell)l calcification of
mediastinal/hilar lymph nodes on CT?
Differential for hypervascular mediastinal/hilar lymph
nodes on CT?
Carcinoid tumor/small cell carcinoma. Kaposi sarcoma.
Metastases (RCC. Thyroid carcinoma). Castleman
Differential for necrotic mediastinal/hilar lymph nodes
Mycobacteria. Fungus. Metastases (SCC. Seminoma.
Differences in lymph nodes of sarcoidosis and
Sarcoidosis: Lobular lymph nodes that do not
coalesce. Lymphoma/mets: May form conglomerate
enlarged nodal masses.
Castleman disease also known as
Angiofollicular lymph node hyperplasia.
Pericardial cysts most commonly arise in the
Anterior cardiophrenic angles. Right-sided lesions
being twice as common as left-sided lesions.
Three groups of neurogenic tumors of the posterior
Intercostal nerves: Neurofibroma. Schwannoma.
Sympathetic ganglia: Ganglioneuroma.
Paraganglionic cells: Chemodectoma.
Most common posterior mediastinal neurogenic tumors
Most common posterior mediastinal neurogenic tumors
Multiple lesions in the mediastinum, particularly
bilateral apicoposterior masses, are virtually diagnostic
Posterior mediastinal masses
Esophageal lesions. Foregut cysts. Vertebral lesion.
Lateral thoracic meningocele. Pancreatic pseudocyst.
Causes of chronic sclerosing (fibrosing) mediastinitis
Histoplasmosis (most common). TB. Radiation therapy.
Drugs (methysergide). Idiopathic (autoimmune).
SVC syndrome manifestations
Headache. Epistaxis. Cyanosis. Jugular venous
Ludwig angina describes
Substernal chest pain caused by intramediastinal
extension of infection.
Causes of unilateral pulmonary artery enlargement
Poststenotic dilation from valvular or postvalvular
pulmonic stenosis. Pulmonary artery aneurysms.
Distension of pulmonary artery by thrombus or tumor.
Rare vasculitides that may present with pulmonary
Beh?et disease and Hughes-Stovins syndrome
Sarcoidosis 1-2-3 sign
1: Right paratracheal. 2. Right hilar. 3. Left hilar lymph
Coronary calcification is detected at angiography in
____% of patients with 50% diameter stenosis.
A_____% diameter narrowing is the physiologic point
at which flow is restricted enough to result in ischemia
under stress conditions.
50% diameter narrowing. Roughly predicts a 75%
cross-sectional area reduction.
Cardiac MR uses?
Define location and size of previous myocardial
infarctions. Demonstrate complications of previous
infarctions. Establish presence of viable myocardium
for possible revascularization. Differentiate acute
versus chronic myocardial infarction. Evaluate regional
myocardial wall motion and systolic wall thickening.
Demonstrate global myocardial function with right
ventricular and left ventricular ejection fractions.
Demonstrate regional myocardial perfusion. Evaluate
papillary muscle and valvular abnormalities.
Myocardial rupture (may occur ______ days after
3 to 14 days.
Onset is typically 1 week to 3 months postinjury. Fever,
chest pain, pericarditis, pericardial effusion, and
pleuritis, with pleural effusion usually more prominent
on the left. Dressler syndrome responds well to anti-
Hibernating myocardium versus stunned myocardium?
Hibernating: High-grade stenosis resulting in
chronically ischemic myocardium. May act like
postinfarction scar. Improved function with
revascularization. At risk for acute infarction. Stunned
myocardium: Postischemic, dysfunctional myocardium
without complete necrosis. Potentially salvageable.
Causes of dilated cardiomyopathies
Ischemic cardiomyopathy (most common cause):
Chronic ischemia. Prior infarction. Anomalous coronary
arteries. Long-term sequelae of myocarditis: Coxsackie
virus. Toxins: Ethanol, Adriamycin, Doxorubicin.
Metabolic conditions: Mucolipidosis.
Mucopolysaccharidosis. Glycogen storage disease.
Nutritional deficiencies: Thiamin. Selenium). Infants of
diabetic mothers. Muscular dystrophies.
Ventricular Wall. Ventricular Cavity. Contractility.
Compliance features of dilated cardiomyopathy?
LV thin. LV dilated. Decreased contractility. Normal to
Ventricular Wall. Ventricular Cavity. Contractility.
Compliance features of hypertrophic cardiomyopathy?
LV thick. LV normal to decreased. Increased
contractility. Decreased compliance.
Ventricular Wall. Ventricular Cavity. Contractility.
Compliance features of restrivice cardiomyopathy?
Normal LV wall. Normal LV cavity. Normal to
decreased contractility. Severely decreased
Ventricular Wall. Ventricular Cavity. Contractility.
Compliance features of Uhl anomaly?
RV thin. RV dilated. Decreased contractility. Normal to
Hypertrophic cardiomyopathies are divided into two
Concentric hypertrophy: may be diffuse, midventricular,
or apical in distribution. Asymmetrical septal
hypertrophy (ASH), also known as idiopathic
hypertrophic subaortic stenosis (IHSS).
Hypertrophic cardiomyopathy causes?
May be familial (60%). Autosomal dominant with
variable penetrance. Associated with
neurofibromatosis and Noonan syndrome. Secondary
to pressure overload.
Features of ASH (asymmetric septal hypertrophy)?
Hypertrophy of the interventricular septum (>12 to 13
mm). Abnormal ratio of thickness of interventricular
septum to left ventricular posterior wall (>1.3:1).
Narrowing of left ventricular outflow tract during systole.
Restrictive cardiomyopathy causes
Infiltrative disorders: Amyloid. Glycogen storage
disease. Mucopolysaccharidosis. Hemochromatosis.
Sarcoidosis. Myocardial tumor infiltration.
What other disease should be ruled out when
considering restrictive cardiomyopathy?
MR finding in restrictive cardiomyopathy caused by
amyloidosis or sarcoidosis?
high signal in the myocardium on T2WIs.
Defined as right ventricular failure secondary to
pulmonary parenchymal or pulmonary arterial disease.
Etiologies of cor pulmonale include
destructive pulmonary disease (pulmonary fibrosis and
chronic obstructive pulmonary disease). hypoxic
pulmonary vasoconstriction resulting from chronic
bronchitis, asthma, CNS hypoxia, upper airway
obstruction. Acute and chronic pulmonary embolism.
Idiopathic pulmonary hypertension. Extrapulmonary
diseases affecting pulmonary mechanics such as chest
deformities, morbid obesity (pickwickian syndrome),
Acquired disorder in infants or adults. Also called
arrhythmogenic right ventricular dysplasia. Dilation of
RV with marked thinning of anterior right ventricular
wall. MR may show fatty infiltration of anterior RV free
wall. Premature death from early congestive failure or
Enlargement of pulmonary outflow tract causes
Left-to-right shunts. Poststenotic dilation secondary to
pulmonary stenosis. Pulmonary arterial hypertension.
Marfan syndrome. Takayasu arteritis. Idiopathic dilation
of pulmonary artery.
Differential diagnosis for pulmonary arterial
Long-standing pulmonary venous hypertension (mitral
stenosis). Eisenmenger physiology (long-standing left-
to-right shunts). Pulmonary emboli. Vasculitides
(rheumatoid arthritis or polyarteritis nodosa). Primary
Increased pulmonary blood flow is caused by
Left-to-right shunts. High output states: Volume loading.
Pregnancy. Peripheral shunt lesions (arteriovenous
malformations). Hyperthyroidism. Anemia. Leukemia.
Decreased pulmonary blood flow with a small heart is
Chronic obstructive pulmonary disease. Hypovolemia.
Malnourishment. Addison disease.
Mitral stenosis in the adult is usually caused by
Rheumatic heart disease.
Causes of Pulmonary Venous Hypertension
Left ventricular failure. Mitral stenosis. Mitral
regurgitation. Aortic stenosis. Aortic regurgitation.
Pulmonary veno-occlusive disease. Congenital heart
Left atrial enlargement, left ventricular enlargement,
and bulging of the atrial septum to the right.
Cardiac thrombus features
Intra-atrial thrombi are usually associated with atrial
fibrillation, often secondary to rheumatic heart disease.
Commonly occurs along posterior wall of LA. Left
ventricular thrombi are usually secondary to recent
infarction or ventricular aneurysm. Clots typically have
low MR GRE signal, whereas tumors have
intermediate signal. Clots will not enhance.
Intracardiac lipomas or lipomatous hypertrophy
High T1 signal and fat suppression. Second most
common benign cardiac tumor.
Atrial myxoma features
50% of primary cardiac tumors. Most common primary
benign cardiac tumor. Most (75% to 80%) are in LA.
May mimic rheumatic valvular disease clinically.
Benign cardiac tumors
Atrial myxoma. Lipoma. Rhabdomyoma (50% to 85%
of tuberous sclerosis). Fibromas (12% may calcify).
Metastatic cardiac tumor features
10 to 20 times more common than primary cardiac
tumors. Breast. Lung. Melanoma. Lymphoma.
Primary malignant cardiac tumors
Angiosarcoma (most common). Rhabdosarcoma.
Liposarcoma. Other sarcomas.
Constrictive pericardial disease features
Fibrous or calcific thickening of pericardium.
Compromises ventricular filling through restriction of
cardiac motion. Most common cause is
postpericardiotomy. Other causes: Coxsackie B.
Tuberculosis. Chronic renal failure. Rheumatoid
arthritis. Neoplastic involvement. Radiation pericarditis.
Differential diagnosis for a cardiophrenic angle mass
Pericardial cyst. Fat pad. Lipoma. Enlarged lymph
nodes. Diaphragmatic hernia. Ventricular aneurysm.
Congenital absence of pericardium features
Complete left-sided absence (55%). Foraminal defects
(35%). Total absence (10%). M > F. Complete absence:
Heart is shifted toward the left, with prominent bulge of
right ventricular outflow tract, main pulmonary artery,
and left atrial appendage. Partial absence of the
pericardium risks strangulation of cardiac structures.
Surgical closure of partial defects is usually
Noninfectious causes of miliary pattern
Pneumoconioises (silicosis). Eosinophilic granuloma.
Sarcoidosis. Metastases (Thyroid. Melanoma.)
Minimal pleural effusion volume visible on frontal,
lateral, and decubitus chest radiographs
Frontal (200 mL). Lateral (75 mL). Decubitus (5 mL)
Which junction line, anterior or posterior, extends
above the clavicles
Posterior junction line.
Define pulmonary cavity
Refers to a lucency located wtihin a nodule, mass, or
focus of consolidation.
Order of the left lower lobe basilar segments (from
lateral to medial) on a frontal radiograph
Anteromedial, Lateral, Posterior (ALP).
DDx of subcarinal mass on radiograph
Lymph node enlargement. Bronchogenic cyst. Left
Classic primary TB chest radiograph findings
Parenchymal consolidation with mediastinal and hilar
lymph node enlargement.
Combination of calcified lung nodule and calcified
Lung nodule that is a residum of primary TB. Usually is
At what pulmonary venous wedge pressures do Kerley
lines, effusions, and airspace opacities occur?
Normal 12 mm Hg. Kerley lines 17 mm Hg. Effusion 20
mm Hg. Airspace opacity 25 mm Hg.
Complications of bronchiectasis
Recurrent infections. Hemoptysis. Mucoid impaction.
Hereditary hemorrhagic telangiectasia (Osler-Weber-
Telangiectasias. AVMs. Aneurysms in multiple organ
systems (Pulmonary. GI. Cutaneous. CNS)
Parenchymal findings associated with acute PE
Wedge-shaped peripheral foci of consolidation. Linear
Focal areas of chronic consolidation may be seen in
Lipoid pneumonia. Bronchoalveolar cell carcinoma.
Diffuse chronic consolidation can be seen in
Bronchoalveolar cell carcinoma. Alveolar proteinosis.
Sarcoid. Lipoid pneumonia.
Kartagener's syndrome (dyskinetic cilia syndrome)
Situs invertus. Bronchiectasis. Sinusitis.
Wegener's granulomatosis lung findings
Multiple lung nodules or masses. Cavitation occurs
50%. Local or diffuse consolidation due to hemorrhage.
Help distinguish LCH from LAM
LCH: Usually associated with nodules and variable
appearing cysts. Spares costophrenic angles.
Extensive ground glass opacities in a patchy or
geographic pattern. 1/3 have upper lobe predominant
cysts of varying sizes and wall thicknesses
Bronchopleural fistula, postpneumonectomy should be
Pneumonectomy space fails to fill with fluid. Abrupt
decrease in air-fluid level in the pneumonectomy space.
New collection of air in previously opacified
pneumectomy space. Contralateral mediastinal shift.
Superior sulcus tumor symptoms
Shoulder pain. Horner's syndrome (ptosis, miosis,
anhidrosis). Weakness and atrophy of hand muscles.
Deems a superior sulcus tumor unresectable
Any involvement of vertebral body, brachial plexus,
Smaller nodules adjacent to a lung mass. Suggests an
Mediastinal lipomatosis causes
Cushing's syndrome. Steroid therapy. Obesity.
Form of peripheral lobar atelectasis that develops with
pleural disease (commonly asbestosis). Volume loss.
Comet tail (whorled bronchovascular structures).
Diameter of ascending aorta aneurysm
4 cm. 6 cm significant risk of rupture.
Bulla versus bleb
Bulla, sharply demarcated area of emphysema greater
than 1 cm. Bleb, gas-containing space within visceral
Chest radiograph finding in healed varicella pneumonia
Diffuse discrete pulmonary calcifications.
Nodal status and stage in NSCLC
N0, No metastatic lymph nodes. N1, Metastatic
ipsilateral hilar lymph nodes. N2, Metastatic ipsilateral
mediastinal and subcarinal lymph nodes. N3,
Metastatic contralateral mediastinal or hilar lymph
Causes of SVC syndrome
Neoplastic: Lung cancer (especially small cell
carcinoma). Lymphoma. Metastatic carcinoma. Benign:
Long-term IV devices (catheters. pacemakers).
Fibrosing mediastinitis (Histoplasmosis).
Neoplastic and nonneoplastic causes of hypertrophic
90% Malignant lung neoplasms. Nonneoplastic: Cystic
fibrosis. IPF. Localized fibrous lesions of the pleura
Epicardial fat pad sign
Double lucency sign. Displacement (>4 mm) of anterior
and posterior (epicardial) pericardial fat by pericardial
What obvious structures should be avoided while
planning a TTNB (transthoracic needle biopsy)
Interlobar fissures. Pulmonary vessels. Bullae. Areas
of severe emphysema.
Peripheral consolidation (photographic negative of
Chronic eosinophilic pneumonia.
Sloughed lung within a cavity
Pulmonary gangrene. Closely associated with
Mosaic lung attenuation causes
Small airways disease. Chronic pulmonary embolism.
Distinguishes small airways disease of chronic PE in
setting of mosaic attenuation
Expiratory images demonstrate air-trapping in small
Allergic bronchopulmonary aspergillosis radiographic
Central bronchiectasis. Mucous plugging (finger-in-
glove). Atelectasis. Patchy migratory foci of
Pulmonary alveolar proteinosis susceptible infections
Nocardia. Aspergillus. Mucormycetes.
Localized fibrous tumor of the pleura enhancement
Intense and homogeneous contrast enhancement.
Calcified fine lung nodules differential
Healed varicella. Healed histoplasmosis. Silicosis.
CT findings of Swyer-James syndrome
Areas of decreased lung attenuation with associated
reducting in number and size of vessels.
Bronchiectasis. Air trapping on expiratory images.
Blind-ending diverticulum arising from medial wall of
bronchus intermedius. Rarely presents with recurrent
infections, hemoptysis, cough, and or dyspnea.
Bronchiolitis obliterans organizing pneumonia CT
Patchy bilateral airspace consolidation with peripheral,
subpleural distribution. Poorly defined lung nodules in
a peribronchiolar distribution.
Triad of pulmonary veno-occlusive disease
Severe pulmonary artery hypertension. Evidence of
pulmonary edema. Normal wedge pressure.
Water lily sign
Echinococcus cysts: Endocyst ruptures its contents
within the ectocyst, floating on top of debris, like a
Differential diagnosis for wall-to-wall heart?
Tricuspid regurgitation. Pericardial effusion. Dilated
Common predisposing factors for aortic dissection
Hypertension. Annuloaortic ectasia: Marfan or Ehlers-
Danlos syndrome. Bicuspid aortic valve. Aortic
Anatomic structure separating Type A from Type B
(Stanford) aortic dissections
Left subclavian artery. Distal type B. Proximal type A.
Chest bone findings associated with Marfan syndrome
Pectus excavatum. Scoliosis.
Pectus excavatum associations
Marfan syndrome. Ehlers-Danlos syndrome. Mitral
valve prolapse. Homocystinuria. Hunter-Hurler
4 life threatening complications of type A aortic
Coronary artery dissection (myocardial infarction).
Carotid artery dissection (stroke). Pericardial
hemorrhage (tamponade). Aortic valve rupture (aortic
Helps distinguish ventricle true aneurysms from
Pseudoaneurysm: Inferoposterior location. Narrow
neck (less than 50%). Aneurysm: Anteroapical
location. Wide neck.
Which aberrant subclavian artery (right or left) is a
Right aortic arch with aberrant left subclavian artery.
Left-sided ligamentum arteriosum completes the ring.
Causes of SVC syndrome
Neoplastic: Bronchogenic carcinoma. Metastases.
Lymphoma. Infectious: Fungal infection
(histoplasmosis, fibrosing mediastinitis).
Persistent left superior vena cava associations
ASD. Tetralogy of Fallot. P(T)APVR.
Tetralogy of Fallot. 4 primary lesions
Overriding aorta. VSD. Pulmonar infundibular stenosis.
Right ventricular hypertrophy.
Thoracic vessels. Takayasu arteritis involvement
Aorta. Right common carotid.Subclavian arteries.
Causes of constritive pericarditis
Cardiac surgery. Radiation therapy. Uremic
pericarditis. Viral pericarditis (coxsackie). Tuberculous
Treatment of intramural hematoma of aorta
Similar to aorta dissections: type A (surgically) type B
Sinus of valsalva aneurysm versus aortic root dilation
Sinus of valsalva aneurysm is focal dilation of one
sinus of Valsalva, not entire root.
Type I: Supracardiac drainage. Snowman heart. Type
II: Cardiac. Coronary sinus or right atrium drainage.
Type III: Infracardiac. Portal vein, hepatic vein, or
ductus venosus drainage (pulmonary edema due to
Aortic pseudoaneurysm causes
Atherosclerosis (penetrating ulcer). Infection. Trauma.
Mirror-image right aortic arch congential heart disease
Tetralogy of Fallot. Truncus arteriosus.
4 components of scimitar syndrome
Right lung hypoplasia. Hypoplastic right pulmonary
artery. Right lower lobe systemic arterial supply.
PAPVR from right lung.
Partial congenital absence of the pericardium findings:
Leftward deviation of the heart without deviation of
mediastinum. Prominent left atrial appendage. Lung
located between aorta and pulmonary artery confirms
Heterotaxy syndrome associated with interruption of
IVC with Azygous continuation
Bilateral left-sidedness/polysplenia syndrome.
Features that suggest a primary malignant cardiac
Invasiveness. Extension outside of heart. Involvement
of more than one chamber. Central necrosis or
cavitation. Large pericardial effusion.
Pulmonary sling aberrant course
Left pulmonary artery arises from right pulmonary
artery and courses between esophagus and trachea.