CT skanning af Lunger

Transkript

1 CT skanning af Lunger Billeddiagnostisk kursus i Pædiatrisk Pulmonologi Onsdag den 14. april 2010 Gratien Andersen, overlæge Billeddiagnostisk Afdeling Århus Universitetshospital, Skejby

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3 Bronkiektasier Definition: Bronko-artieriel ratio >1.2 Bronkier, der er større end den ledsagende arterier (praktisk definition) 3 typer: Cylindriske, varikøse og cystiske Diagnostisk nøjagtighed ved HRCT: 95%

4 Cylindriske

5 Varikøse

6 Cystiske

7 Atelektaser

8 Atelektase

9 Kongenitte forandringer Anomalier med normal vaskulatur Kongenit lobært emfysem Bronkogen cyste CCAM (Congenital Cystic Adenomatoid Malformation) Pulmonal agenesi og hypoplasi Segmentær bronkial atresi Anomalier med abnorm vaskulatur Pulmonal sekvester Pulmonale arteriovenøse malformationer Pulmonary Varix

10 Kongenit lobært emfysem

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12 Bronkogen cyste

13 CCAM (Congenital Cystic Adenomatoid Malformation) Type I: 50% Type II: En eller flere cyster >2cm 40% Multiple cyster 1-10 mm i diameter Type III: 10% Multiple mikroskopiske cyster (Ø<2mm)

14 CCAM (Congenital Cystic Adenomatoid Malformation)

15 CCAM (Congenital Cystic Adenomatoid Malformation)

16 CCAM (Congenital Cystic Adenomatoid Malformation) Persisterende interstitiel emfysem

17 Segmentær bronkial atresi Kongenit bronkocele/mykocele

18 Pulmonal sekvester Intralobær: 70% Erhvervet sekvestrering? (Kroniske infektioner) Arterie fra aorta Vene drænage til lungevene / ve. Atrium Ekstralobær Kongenit sekvestrering Arterie fra aorta Vene drænage til cava inf., azygous, portae, Ledsagende anomalier: Diafrgma eventration/hernia, fistler til GI system,

19 Pulmonal sekvester

20 Pulmonal sekvester

21 Pulmonal varix

22 AVM Multiple 35 50% Bilat % I 60% associeret med Osler-Weber-Rendu syndrom (Hereditær hæmoragisk telangiektasi)

23 Benign tumor: Pulmonale tumorer Laryngotrakeal papilom Hamartom Malign tumor Primær Hæmangiom, Leiomyom, lipom Bronkial carcinom Pulmonal blastom Rabdomyosarkom Leiomyosarcom, hæmangiopericytom, bronkogen sarkom etc Sekundær (Metastaser): F.eks. fra Wilms tumor, osteogen sarkom, rabdomyosarkom, lymfom etc

24 Diffuse infiltrative lungeforandringer Interstitielle lungeforandringer HRCT

25 Interstitial lung disease Chest HRCT radigraphy Accuracy 34% 61% Confidence in diagnosis 18% 42%

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28 Diagram shows anatomy and dimensions of secondary lobule and pulmonary acinus. Webb W R Radiology 2006;239: by Radiological Society of North America

29 Røntgen af 1 mm snit Centrilobulær B=Bronkiole A=Arterie V=Vene S=Interlobær septum

30 Interlobær septal fortykkelse Interstitiel pulmonal ødem

31 Interlobær septal fortykkelse Lymfangiektasi: Nodulær septal fortykkelse

32 Differential Diagnosis of Interlobular Septal Thickening Diagnosis Pulmonary edema Congenital lymphangiectasia Sickle cell disease Idiopathic pulmonary fibrosis Lymphangitic carcinoma Lymphocytic interstitial pneumonia Sarcoidosis Alveolar proteinosis Idiopathic pulmonary hemosiderosis Hypersensitivity pneumonitis CT Appearance of Thickening Smooth Smooth or nodular Smooth Irregular Smooth or nodular Smooth or nodular Nodular or irregular Smooth Smooth Smooth or nodular

33 Subleurale fortykkelser <1 cm fra pleura Ses efter atelektaser, ødem, inflammation og fibrose

34 Honeycombing Fibrose + destruktive forandringer Små subpleurale cyster og små bronkiektasier

35 Nodulære forandringer

36 Differential Diagnosis of Peribronchial Nodules Congenital lymphangiectasia Lymphangitic carcinomatosis Langerhans cell histiocytosis Sarcoidosis Lymphocytic interstitial Pneumonia

37 Peribronkiale fortætninger Sarcoidose A: Centrale og perifere B:Centrale

38 Differential Diagnosis of Centrilobular Nodules Diagnosis CT Appearance of Nodules - Langerhans cell histiocytosis Well defined; mid and upper lung zone predominance, relative sparing of lung bases - Idiopathic pulmonary Well or poorly defined; often central hemosiderosis distribution - Hypersensitivity pneumonitis Poorly defined; bilateral symmetric; patchy or diffuse; mid and lower lung predominance - Cryptogenic organizing pneumonia Ill-defined; subpleural or central - Bronchiolitis obliterans, proliferative type - Endobronchial spread of tuberculosis Well defined Well or ill-defined nodules or tree-in-bud pattern

39 Centrilobulære fortætninger Patient med astma: Dilaterede, væskefyldte bronkioler 5-10 mm fra overfladen Fra 2-3 mm til 1cm i størrelse Med forgreninger Tree-in-bud Tree-in-bud = small airway disease

40 Diffuse fortætninger Langerhans histiocytose Veldefinerede, diffuse og/eller symetriske fortætninger Fordelingen er uden sammenhæng med lungens arkitektur Eksempler: -Miliær tuberkulose -Svampeinfektioner -Metastaser -Langerhans histiocytose

41 Lunge-attenuation Øget Mat-glas konfiguration (Ground-Glass Opacity) Konsolideret lungevæv Nedsat Cystiske lungeforandringer Emfysem Mosaik attenuation

42 Differential Diagnosis of Consolidation Diagnosis - Acute pneumonia (bacterial, fungal, viral, Pneumocystis carinii) CT Appearance of Consolidation Patchy, nodular, lobular, or diffuse - Pulmonary edema, acute Perihilar, diffuse of dependent distribution - Pulmonary hemorrhage, acute Patchy or diffuse - Acute respiratory distress syndrome (ARDS) - Chronic interstitial pneumonia Patchy or diffuse; mainly dependent lung Usually peripheral and lower lobe distribution - Alveolar proteinosis Patchy

43 Ground-Glass Opacity Lungekonsolidering

44 Differential Diagnosis of Cystic Lung Disease Diagnosis - Pulmonary Langerhans cell histiocytosis - Tuberous sclerosis, Marfan syndrome, neurofibromatosis - Idiopathic pulmonary fibrosis (usual interstitial pneumonia) - Hypersensitivity pneumonitis, chronic CT Appearance of Cystic Disease Thin-walled cysts; mid and upper lung zones, relative sparing of lung bases Cysts and bullae Honeycombing; peripheral, basilar, and subpleural predominance Honeycombing in advanced disease; middle lung zones predominance common - Idiopathic pulmonary hemosiderosis Honeycombing in advanced disease - Collagen vascular disease, chronic Honeycombing, basilar distribution - Pneumonias (bacterial pneum., Pneumocystis carinii) Cysts - Lymphocytic interstitial pneumonia Thin-walled cysts

45 Pneumocystis carinii Emfysem: Alfa 1-antitripsin-mangel

46 Eksempler

47 Sygdomme med lineære eller retikulære fortætninger Pulmonal ødem Pulmonal lymfangiektasi Bronkopulmonal dysplasi (BPD) Sickle cell sygdom Idiopatisk interstitiel pneumoni Lymfangitis carcinomtosa

48 Lineære eller retikulære fortætninger Pulmonal lymfangiektasi Bronkopulmonal dysplasi

49 Lineære eller retikulære fortætninger Interstitiel pneumoni

50 Sygdomme med nodulære fortætninger Sarcoidose Wegeners granulomatose

51 Sygdomme med Ground-Glass / Konsolidering Pulmonal ødem ARDS (Acute Respiratory Distress Syndrome) Pulmonal alveolær proteinose Pulmonal Hæmosidrose Hypersensitivitets pneumoni Kollagene-Vaskulære sygdomme COP/BOOP (Cryptogen Organizing Pneumonia) (Brocholitis Obliterans Organizing Pneumonia)

52 Sygdomme med Ground-Glass / Konsolidering Ødem Alveolær proteinose

53 Sygdomme med Ground-Glass / Konsolidering Akut Hypersensitivitets Peumoni

54 Sygdomme med cyster eller emfysem Langerhans celle histiocytose Tuberøs sklerose Marfans Syndrom Neurofibromatosis (Type 1) Langerhans histiocytose

55 Sygdomme med cyster eller emfysem Marfan Tuberøs sklerose

56 Sygdomme med tæt lungestruktur og mosaik perfusion Cystisk fibrose Alfa-1-antitripsin-mangel Bronkiolitis: Proliferativ Obliterativ Swyer-James Syndrom

57 Cystisk fibrose

58 Bronkiolitis obliterans A- Inspiration B- Ekspiration

59 Swyer-James Syndrom Postinfektiøs bronkolitis obliterans Ekspiration Væksthæmmet syge lunge Air trapping

60 Pulmonale infektioner

61 Tuberkulose Primær TB Miliær TB

62 Absces

63 Aspergillus Aspergillom Allergisk bronkopulmonal aspergillose

64 Cryptococcus infektion

65 Cytomegalovirus infektion

66 Spørgsmål? Gratien Andersen Overlæge Billeddiagnostisk Afd. Aarhus Universitetshospital, Skejby 66