山大医学影像学教案10心脏大血管

1、课程： 医 学 影 像 学 专业：临床医学 任课教师： 授课章节第十章 心脏大血管 授课时数4授课时间授课形式课堂理论授课授课基本要求：1. Understand the cardiovascular detections of X-ray and USG2. Master the normal X-ray appearance of the heart and great vessels3. Master the X-ray appearance of enlargment of every chamber4. Master the radiological characters of se

2、veral cardiovascular diseases教学重点、难点和知识点：重点: Radiological appearance (X-ray, USG, CT, MRI) of the normal heart and great vessels and enlargement of every chamber; radiological characters of RHD, ASD, F4, pericarditis and aortic dissection难点: X-ray appearance of enlargement of every chamber; radiolog

3、ical characters of RHD, F4.知识点:X-ray routine films are less useful in cardiovascular diseases.学时分配（共200min，4节课）Unit1 Examination Techniques 20minUnit2 Observation and Analysis of Imaging 80minUnit3 Imaging diagnosis of diseases 100min.教学过程：1. Use the heart model to teach: to give a film first and as

4、k the student: what have you seen on the film.2. Teach the X-ray appearance of normal heart and great vessels and common diseases one by one, and then discuss the correlation between them. 3. Discuss the pathology of each disease, and then guess the radiological findings (X-ray and CT) of each disea

5、se.4. Read several films of each disease.5. Summary the radiological findings of each disease.示教方式与教具：PowerPoint, computer, projector, phantom思考题、作业题及参考书：思考题：1.心脏大血管病变常用哪些影像检查方法？各有什么优势和局限性？ 2.心脏各房室增大的影像特点有何不同？常见于哪些疾病？作业题：课后观察心脏模型及心脏MR片，熟悉心脏左室长轴位（四腔心、两腔心）、短轴位在MR片上各房室结构的特点。参考书：1. 心血管病影像诊断学 安徽科学技术出版社、辽

6、宁科学技术出版社 刘玉清主编 2心血管疾病磁共振成像 人民卫生出版社 张兆琪主编3. 实用放射学 人民卫生出版社 张雪林主编第十章 心脏大血管第一节 检查技术一、X-线检查1. The common X-ray exams (1)Fluoroscopy：优点：方法简便，可以多体位、动态观察；缺点：清晰度差，无永久记录，接受X线剂量大 (2)The plain roentgenogram：四种标准投照体位 PA (posteroanterior view) LA (left lateral view) RAO (45o-60o) (right anterior oblique) LAO (60o

7、) (left anterior oblique)2. Cardioangiography (1)Routine angiography:?Angiography of right heart ?Left ventricular angiography ?Aortic angiography (2)Selective?Coronary angiography * Interventional therapy Coronary/congenital heart diseasesVascular malformationsvalvular disease 3.DSA Digital imaging

8、Temporal subtraction 二、CT检查（1）Common CT:空间分辨力和时间分辨力低，不能克服心脏大血管的搏动伪影,难以用于心血管（2）Ultraspeed CT：如EBCT、Multislice CT、Dual source CT：速度更快，分辨力更高，辐射剂量减低（3） TA ：EBCT、MSCT和DSCT均可实施三、MRI检查(1) Common MRI scanImaging planes：?Transverse plane ?anterior oblique plane ?coronal plane ?long-axis plane parallel to the

9、 interventricular septum ?long-axis plane perpendicular to the interventricular septum ?short-axis plane perpendicular to the interventricular septum (2) Sequence?Spin echo(SE) pulse sequence：T1WI T2WI ?fast imaging sequence: TSE(Turbo SE)；GRE( gradient echo sequence) ；EPI (Echo Planar Imaging) (3)

10、Heart functional imaging：Cine MRI+左室短轴+软件分析计算(4) Perfusion and vibility:首过法：分析对比剂首次通过心肌时动态变化图像，判断心肌有无缺血；延迟法：分析对比剂通过心肌后530分钟MR图像，通过延迟期心肌增强，检测心肌细胞的损伤程度，识别可逆性与不可逆性心肌损伤。(5) Myocardial Tagging：应用空间预饱和技术在心脏电影图像上以交叉的将整体的室壁运动变形分隔成更基本的单元，从而对局部室壁厚度、收缩期室壁增厚情况、室壁运动及室壁变形的判断更为准确。 （图）(6) CEMRA：fast MRI technique +

11、 special sequence+contrast+postprocessing四、USG检查(1) Two-dimensional echocardiography(2) Spectral Doppler echocardiography(3) Color Doppler echocardiography 第二节 影像观察与分析一正常解剖和X-线表现 1. Normal projections of the heart and the great vessels PA?The right cardiac contour ( 2 segments) ?The left cardiac con

12、tour ( 3 segments) RAO (45 o) ?Anterior cardiac border?Posterior cardiac border ?Retrocardiac space ?Retrosternal space LAO (60 o) ?Anterior cardiac border?Posterior cardiac border ?Retrocardiac space ?Retrosternal space LA ?Anterior cardiac border?Posterior cardiac border ?Retrocardiac space ?Retro

13、sternal space2. Pulsation of the heart and the great vessels3. Shape variation of the heart and the great vessels Vertical heart type Oblique heart type Transverse heart type 4. Measurement of the heart and the great vessels Cardio-thoracic ratio: ?M 0.430.04?F 0.450.03?Normal 0.60 5. Factors that i

14、nfluence the shape and the size Age ConfigurationSex Respiration Position二、Normal appearance in cardioangiography1. Right heart: SVC, IVCRARVPA 2. Left heart: PVLALVAO 三、X-ray Signs of Common Pathological Changes1. Position abnormalitiesCardiac displacementCardiac malposition2. Abnormalities of the

15、Cardiac silhouetteMitral configurationAortic configuration Round shape, flask shapeOthers?Resting egg?Ball shape?Triangular shape3. Size abnormalitiesEnlargement of the heart?Hypertrophy of wall ?Dilatation of chambers Measurement: Cardio-thoracic ratio?M 0.430.04?F 0.450.03?Normal 0.60 X-ray signs

16、Enlargement of LVA) x-ray signs PA view displacement of the cardiac apex downward and to the left The length of the left ventricular curvature Segment of LV LAO viewinferior segment of the posterior margin LA view Retrocardiac space B) main causes?Hypertension ?Stenosis / insufficiency of aortic val

17、ve ?Congenital H.D. Such as PDA Enlargement of RVa) X-ray signs PA view Rounded and slightly elevated ardiac apex Bulging pulmonary artery segment LAO(60 o) Retrosternal space LAO view Interventricular grooveb) Main causes ?Mitral valvular stenosis ?Chronic pulmonary heart disease ?Pulmonary hyperte

18、nsion ?Cardiac septal defect ( ASD, VSD ) ?Pulmonary valvular stenosis ?F4 Enlargement of LAa) X-ray signs Esophagus; “Double contour”; The left auricular appendage b) Main causes ?Mitral valvular diseases ?Left heart failure ?Some congenital H.D. (PDA, VSD) Enlargement of RA a) X-ray signs LAO view

19、: the length of the RA curvature PA view: RA segment of the right heart marginb) Main causes ?Right heart failure?ASD?Tricuspid valvular disease, etc. Enlargement of the whole heart a) X-ray signs ?PA view: transverse diameter ?RAO, LA view: Retrocardiac/retrosternal space?LAO viewb) Main causes ?La

20、te stage of valvular diseases ?Pathological changes of myocardium (myocarditis, etc)?Some systemic diseases (severe anemia, etc ) Dilatation of AOa) X-ray signs PA view; LAO viewb) Main causes ?Aortic valvular insufficiency ?Hypertention?Atherosclerosis Dilatation or atrophy of PAa) X-ray signs PA ;

21、 RAOb) Main causes ?Dilatation: pulmonary blood flow pulmonary hypertension pulmonary valvular stenosis?Atrophy: stenosis/ agenesis of the infundibulum of RA Pulsation anomalies / / DisappearCalcificationPericardium Heart valves Coronal artery Aortic wall Cardiac border abnormalitiesStraightening Bu

22、lging Angled Changes of the Hilum and the pulmonary vessels(1) Changes of the Hilum (2) Changes of the pulmonary vessels Pulmonary hyperemiaX-ray signs? Normal lung field transparency? Hilar shadow, pulsation of pul. artery segment and hilar arteries, “hilar dance” ? Dilatation of P. arterial branch

23、es in proportion with clear, sharp borders? Late stage: hyperkinetic pulmonary hypertentionMain causes ?Congenital heart diseases with left-to-right shunt: ASD / VSD, PDA ?Blood volume: Hyperthyroidism; anemia Pulmonary oligemiaX-ray signs?lung field transparency?Hilar shadow, flat/ bulging/ concave

24、 pulmonary artery segment (concavity of the cardiac waist) ?thinness of hilar artery; severe: reticular shadow of collateral vascularity ?thin and sparse pulmonary artery, decreased vascular (arteries) lung markingsMain causes ?Right heart resistance strains: Congenital heart diseases such as pulmon

25、ic stenosis Tricuspid valvalar stenosis, etc. Pulmonary arterial hypertensionIntroduction Normal pressure of pulmonary trunk Systolic : 2-4kpa ( 15-30mmHg ) ;Mean 4kpa ( 30mmHg )?Mean pressure 2.7kpa ( 20mmHg ) X-ray signs? Bulging pulmonary artery segment, extension of hilus shadow with sharp borde

26、r of the large vessels ? Dilatation of hilar arteries and their large branches Right inferior pulmonary artery 1.5cm (a) Thinness of branches in the abrupt reduction middle and outer zones “abrupt reduction” obstructive pulmonary hypertension (b) Dilatation of arterial branches in proportion hyperki

27、netic pulmonary hypertension? Increased pulsation of central pulmonary arteries “hilar dance” ?Enlargement of RV tricuspid valve insufficiencyMain causes ?Pulmonary heart disease ?Pulmonary blood flow:congenital H.D. ?Pulmonary embolismPulmonary venous hypertensionIntroduction pulmonary venous conge

28、stion pulmonary capillary-venous pressure 1.33Kpa (10mmHg ) pulmonary edemapulmonary capillary-venous pressure3.33Kpa(25mmHg) (a) interstitial pulmonary edema (b) parenchymal pulmonary edemaX-ray signsPulmonary venous congestion ? Lung field transparency ? Hilar shadow, Haziness of the Hilum and the

29、 vessel detail? Increased lung vascular markings especially in the upper lung field, and scale disturbance of diameter, sup.pul.Vein inf.pul.VeinInterstitial pul. edema?Basilar septal line: Kerley A/ B/ C lines costophrenic anglesParenchymal pul. edema? “Butterfly pattern”Main causes ?Pulmonary vein

30、left heart resistance Mitral /aortic valve diseases Left ventricular insufficiency 四、心脏大血管常见病变的CT表现CT signs of common pathological changes of the heart and the great vessels五、心脏大血管常见病变MRI征象 MRI signs of common pathological changes of the heart and the great vessels第三节 疾病诊断一、风湿性心脏病Rheumatic Heart Dis

31、easePathology: valvular stenosis / insufficiencyHemodynamics: ?MS: LAPV PA( Pul. Hypertension ) RV ?AS: LVLA,PV, post-stenosis dilatation of aorta ?Valvular insufficiency : dilatation of chambers MI: Early stage Late stage: LA PA(Pul. Hypertension) Clinical features: 20-40Y, female; MS, AS, TS; rare

32、 PS Signs and symptoms Signs of imagingX-ray signs: calcification of valve? MS: ?Mitral configuration (heart shape)Bulging of pul. artery segment, atrophy of knob and LVLA, RV(enlargement),“double contour”, retrosternal space ?Pul. congestion interstitial pul. Edema, “hemosiderosis”（含铁血黄素沉着）?MI: ?LA

33、, LV, RV, normal size or atrophy of aortic knob ?( severe MI ) pul. circulatory hypertension: venous venous and arterial?TS / TI：USG signs?AS / AI: ?“Aortic shape” of the heart silhouette -CT signs?Calcification of valve?Size of chambers?Thrombus in LA -MRI signs?thickening of valve?Size of chambers

34、?Thrombus in LA ?MRI movieDiagnosis and differential diagnosis Clinical signs & symptoms + x-ray USGTherapy: percutaneous balloon mitral valvuloplasty (PBMV, 1984) 二、房间隔缺损Atrial septal defect (ASD)1、Pathology：A hole between LA and RA 2、Hemodynamics: Left-to-right shunt (LARA)bi-directional shuntrigh

35、t-to left shunt (cyanosis)3、Clinical signs and symptoms4、Signs of imaging X-ray Heart shape: mitral configuration Cardio thoracic ratio, RV, RA, obvious bulging of pul. Artery segment Normal size or atrophy of aortic knob pul. Hyperemia pul. Arterial hypertension“hilar dance” “abrupt reduction” Card

36、ioangiography? LV angiography: LARA CT? the hole between LA and RA ? RV,RA MRI? the hole between LA and RA ? RV,RA ? MR movie USG? the hole between LA and RA ? RV,RA ? The color flow from LA to RA5、 Diagnosis and differential diagnosis Clinical signs & symptoms + x-ray, USG6、 Therapya) Interventiona

37、l therapy: i. Transcatheter device closure of ASD ii. Double-hinged (clamshell) umbrella device1. The device is pushed through a large catheter to the site. One umbrella is opened up on each side of the ASD. 三、法乐氏四联症Tetralogy of Fallot pathology Four anomalies Hemodynamics: Decreased flow of blood t

38、o the lung Mixing of the blood from each side of the heart cyanosis, etc Clinical features Signs and symptoms: cyanosis ECG: hypertrophy of LV Signs of Imaging X-ray ? The heart shape: Fallot configuration / “boot shape” Cardio-thoracic ratio is normal or Rounded and slightly elevated cardiac apex f

39、lat/ slightly concave pulmonary artery segment (concavity of the cardiac waist) Width of ascending aorta and aortic arch ? Pulmonary oligemia lung field transparency Hilar shadow thinness of hilar artery; severe: reticular shadow of collateral vascularity thin and sparse pulmonary artery, decreased

40、vascular (arteries) lung markings Cardioangiography（CAG） Selective right heart angiography Ventricular septal defect RV, PA LV, Aorta Pulmonary. stenosis Overriding aorta CT MSCT、EBCT and DSCT with contrast+MIP and/or MPR Show the direct signs: c 、VSD、 Overriding aorta 、hypertrophy of the right vent

41、ricle MRI Tra+Cor: Pulmonary or the outlet of right ventricle stenosis 、VSD、 Overriding aorta 、hypertrophy of the right ventricle Tra+4-ch+short-axi: size of VSD、 hypertrophy of the right ventricle Tra+short-axi: degree of aorta Overriding MR Cine: Pul.valve motionflow direction of VSD CE MRA: Aotor

42、 and Pul. artery USG M,2D: Widening of aortor and Overriding、 VSD、 hypertrophy of the right ventricle、hypertrophy of the right ventricle Doppler：color flow of PS and VSD Diagnosis and differential diagnosis Clinical signs & symptoms +ECG+ x-ray (+angiography, USG) 四、心包炎Pericarditis pathology:? Dry /

43、fibrinous pericarditis ? Effusive pericarditis /Pericardial effusion cardiac tamponade ? Constrictive pericarditis Clinical features? Signs and symptoms? ECG Signs of imaging X-ray A) Pericardial effusion a) Patients with small effusions (less than few hundred milliliters) may present with a normal

44、cardiac silhouette. b)Effusion volume 300ml: ? Cardiomegaly, “flask shape” or “ball shape”? Pulsation of cardiac border Normal pulsation of vessels outside of the pericardium ? Shortening of the aortic shadow? Dilatation of SVC? pul. oligemia or pul. venous hypertensionB）Constrictive pericarditis? S

45、ize of the cardiac silhuette: normal or ? Triangular shape of the cardiac shadow, RA? Pulsation of the heart/ disappear ? Pericardiac calcification ? Dilatation of SVC ? Pul. venous congestion when LA pressure ? Pleural thickness and adhesions ? USG ? The first choice for detecting pericardial effus

46、ion ? CT? Perfect to show the location and amount of pericardial effusion? MRI ? A sensitive technique for detecting pericardial effusion and localized pericardial effusion and thickening? Different the character of the fluid? Diagnosis and differential diagnosis 五、主动脉夹层Aortic dissection Introductio

47、n：The DeBakey classification? Type I involves the ascending aorta, aortic arch, and descending aorta and the middle/distal section of the abdominal aorta. ? Type II is confined to the ascending aorta & aortic arch. ? Type III is confined to the aortic arch, and descending aorta.? Type IIIa is confin

48、ed to the thoracic descending aorta. ? Type IIIb extend to the distal section of the abdominal aorta. pathology:? A tear in the intimal layer formation and propagation of a subintimal hematoma double-barreled aorta (a false lumen and a true lumen ) Clinical features? Old ( 40 y ), male, with hyperte

49、nsion ? Signs and symptoms Signs of imaging X-ray? Widened mediastinum, Abnormal (ie, blunted) aortic knob ? Aortic pulsation / disappear ? Ring sign (displacement of the aorta 5 mm past the calcified aortic intima) a very specific radiographic sign? Other signs: pleural effusion; LV Cardioangiograp

50、hy ? Thoracic aortic angiography ? Visualization of the true and false lumens intimal flap aortic regurgitation stenosis/ obstruction of coronary arteries USG CT? Contrast enhancement CT scan? With the advent of helical CT with multiplanar and 3D reconstruction, CT is quickly replacing the angiogram

51、 as the criterion in many institutions. MRI? Without Contrast enhancement ：MR cine? Contrast enhancement MRA（CE-MRA）Diagnosis and differential diagnosis 第四节 气管、支气管疾病一、支气管扩张【病因病理】是指支气管的持久性、病理性扩张。支气管扩张的因素包括：支气管腔的阻塞；支气管本身的化脓性炎症，引起支气管壁的弹性组织的破坏；外力对支气管的牵引等。少数患者为先天性，多数为继发性。先天性支气管扩张的病理改变是管壁平滑肌、腺体和软骨减少或缺如。感染

52、所致的支气管扩张病理改变为支气管上皮脱落、支气管壁内炎细胞浸润、管壁肿胀及周围有纤维组织增生。根据形态，支气管扩张分为：A柱状支气管扩张，B静脉曲张型支气管扩张，C囊状支气管扩张。【临床表现】患者病史较长，临床表现有咳嗽、咳脓痰。痰量多，约半数患者咯血，常见于成人。儿童咯血少见。病变广泛者有胸闷、气短。可闻及罗音，少数患者可见杵状指。【影像学表现】由于支气管引流的关系，支气管扩张多见于左下叶，其次为中叶及右下叶，病变呈两肺广泛分布者较少见。X线平片可在粗乱的肺纹理中见到杵状、管状透亮影，或囊状、蜂窝状阴影等，为支气管扩张较为特征性之表现。此外，即使见到上述支气管扩张的特征性改变，也不能从平片上

53、确定病变范围。支气管造影支气管造影可确诊支气管扩张的存在，病变的类型和分布范围。CT可以明确支气管扩张的诊断及病变范围，现在已取代支气管造影。支气管扩张一般CT平扫多数可明确诊断，CT表现为支气管局限性扩张，呈柱状或囊状，支气管管经大于伴行的血管，继发性支气管扩张常见瘢痕、纤维化、肺气肿和肺大泡。检出轻度的支气管扩张需行高分辨力CT检查，常规检查易漏诊。二气管、支气管异物bronchial foreign body自学，重点了解通过透视和拍片如何判断异物堵塞哪一侧支气管？第五节 肺部疾病Unit 5 Pulmonary diseases一、肺部炎症Pulmonary inflammatory

54、diseases肺部感染-肺炎系指发生于肺实质与肺间质的炎症性疾患，按病因可分为感染性、理化性、变态反应(过敏)性，其中感染性最常见，包括细菌、病毒、真菌、支原体以及寄生虫等；按解剖分布可分为大叶性、小叶性和间质性。1（一）大叶性肺炎Lobar pneumonia大叶性肺炎指炎症累及一个或多个肺叶、肺段。病因以细菌最常见，其中以肺炎链球菌最常见。典型病理变化分四期：充血期(1224hr)，病变区域毛细血管扩张；红色肝样变期(23d)；灰色肝样变期(46d)；消散期(710d)。全过程中肺结构不受损坏，纤维素吸收不全时可因机化而遗留纤维化。Pathology Lobar pneumonia, t

55、he result of alveolar(腺泡) wall injury with severe haemorrhagic edema induced by inhaled infection organisms that reach the subpleural zone of the lung.This injury is followed by a rapid multiplication of organisms invasion of the infected edematous fluid by polynuclear leukocytes. The process spread

56、s rapidly through the pores of Kohn leading to a consolidation of an entire lobe or segments. The most common causes are streptococcus pneumonia(肺炎双球菌)，klebsiella pneumonial（可雷白杆菌）infection.【临床表现】临床好发于青壮年，冬春多见，多有上感史，起病急，有寒战、高热、咳嗽、胸痛，典型有铁锈色痰，叩诊浊音，语颤增强，听诊有罗音。【影像学表现】充血期，在大叶范围内见肺纹理增强及散在斑片影；肝样变期表现为大片实变阴影

57、，其内可见支气管充气征，CT上显示佳，有时还可见灶性肺充气区；消散期，实变影密度减低，逐渐分散成斑片影，进而演变为条索影，最后完全吸收。The typical radiological pattern The typical radiological pattern is air space consolidation of an entire lobe containing air bronchograms , because of the use of antibiotics , the pneumonia is limited to one or more segments within

58、 a lob.（二）支气管肺炎Bronchopneumonia【病因病理】支气管肺炎又称小叶性肺炎，指炎症累及细支气管、终末细支气管及其远端肺泡，常见致病菌有葡萄球菌、肺炎双球菌及链球菌等。炎症沿支气管自上向下蔓延，也可沿中末细支气管横向蔓延，并引起支气管周围炎及肺泡周围炎。Pathology of bronchopneumonialBronchopneumonia ,a type of pneumonia which results when haematogeneous(血原性的) dissemination of organisms to the lung or colonization

59、 (移植)of airways with subsequent aspiration is responsible for pulmonary infection. As opposed to other acute bacterial or lobar pneumonia which begins in alveoli(肺泡)，bronchopneumonia originate in small bronchioles.Typical bacteria causing this form include staphylococcus (葡萄球菌)【临床表现】支气管肺炎多见于婴幼儿、老年人及

60、极度衰弱的患者或为手术后并发症。临床上表现为高热、咳嗽、呼吸困难等，可闻及干湿罗音。极度衰弱的患者因机体反应力差，体温可不升高，白细胞总数也可不高。【影像学表现】主要表现为斑片状阴影及融合大片阴影，斑片影多在两下肺野中内带，沿支气管分布，各小叶内渗出物的性质可不相同；由于支气管堵塞可见局限性肺气肿于肺不张。CT上还常见小结节影(10mm以下)，呈“树芽”分布。化脓性病变时可有脓腔、肺气囊等多形态影像，肺门淋巴结可增大；治疗不佳可形成脓胸、慢性炎症及支气管扩张等。（三）病毒性肺炎 Viral pneumonia【病因病理】常见致病原有腺病毒、和胞病毒、流感病毒、麻疹病毒及巨细胞病毒等。病毒通过上