医学影像学教学课件：呼吸系统（一）胸部1

ImagingDiagnosisofRespiratorySystem

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呼吸系统（一）ContentPreface(前言）Methodsofchestexamination（检查方法）Normalradiologicalanatomy（正常X线表现）Abnormalchestradiograph（基本病变的X线表现）Preface前言

Goodcontrast,Mostpulmonary,diseasecanbeviewed,Focalofchestcanbelocatedanddefined.病例男，61岁，咳嗽咳痰气促20年，加重伴痰血1月就诊。问题：1.该患者需做什么影像学检查？2.该患者影像学检查是否有病变？3.该患者影像学显示病变的部位在哪里？属于哪种基本病变？4.初步诊断是什么？病变的部位在哪里？1.胸廓？2.肺部？3.胸膜？4.纵膈？----右肺下叶属于哪种基本病变？1.支气管阻塞？2.渗出与实变？3.空洞与空腔？4.结节与肿块？5.线状、网格状级索条状影？6.钙化？初步诊断？1.感染？2.良性肿瘤？3.恶性肿瘤？ExaminationtechniqueX-rayexaminationofchest:1.Chestfluoroscopy2.Chestradiography3.Bronchography

CT

MR

DSA---AngiographyChestfluoroscopy透视

AdvantageSimple,assistedmeans

Multipositionanddynamicview

Diaphragmmovement—

Paralysis膈麻痹

Mediastinummovement—

Obstructiveemphysema阻塞性肺气肿

LocateabnormalityDisadvantage

Hardtodetectsmalllesion

Norecord

HightdoseChestradiography

胸部摄影

Routineexaminationforpatients

Excludeseriouschestdisease;

Provideevidenceofthepreoperativeconditionoflungandheartbeforesurgery;

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

Postero-anteriorview(PA-view)

Standard:ErectpositionAnteriorchestwallagainstthefilmScapulaerotateforwardEnd-inspirationShortexposuretimeCASSETTEChestradiography

胸部摄影Chestradiography

胸部摄影Positionincommonusing:

Lateralview----Leftlateralview----RightlateralviewBronchography

支气管造影

Radiographicexaminationofthebronchialtreebyinstillationofcontrastmediumdirectlyintothetracheaorbronchi.

Evaluationofbronchiectasis(支气管扩张）

ReplacedbyCT,andespecially

highresolutionCT(HRCT)

ComputedTomography

Advantage

Excellentanatomicdetail(chestwall,pleura,lungs,mediastinum)

Contrastenhancement—greatvessels

Indication适应症

Staginglungcancerandothermalignanttumors

Diffuselungdisease—high-resolutionCT

Pleuraldisease

MediastinaldiseaseComputedTomography1.PlainCTscan2.Contrastenhancement：3.HighResolutionCT（HRCT）①鉴别良恶性病变；②了解病变的血供情况；③了解纵隔病变与大血管的关系；④鉴别病变为血管性或非血管性。ComputedTomography4.MSCT(多层面螺旋CT扫描)：X线管一次旋转过程中同时获得多个层面图象数据的成像。扫描时间短、提高空间分辨力等。标准图像

多方位重建图像MagneticResonanceImaging(MRI)

MoresensitivethanCTindetectingHilarandMediastinalLymphadenopathy（淋巴结病变）.Lessvalueinlungdiseases.MultipleImaging;HighResolutionInsofttissue;Flowvoideffect;displayheartandarotaluncontracte

Characteristic:Angiography

血管造影

Pulmonaryarteriography（肺动脉造影）

Pulmonaryembolism肺动脉栓塞

Vascularabnormalities血管畸形

Bronchialarteriography（支气管动脉造影）

Hemoptysis咯血

肿瘤NormalRadiologicalAnatomy

Normalchestimagingisthethree-dimensionalofallofthethoracicviscera.NormalRadiologicalAnatomy

inspirationexpirationNormalRadiologicalAnatomy

1.

Thoraciccage（胸廓）2.Tracheaandbronchu气管与支气管

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

（膈）NormalRadiologicalAnatomy

1.Thoraciccage------SofttissuesBoneNormalRadiologicalAnatomy

Thoraciccage----Softtissues

1.Sternocleidomastoid(胸锁乳突肌)ClavicleSkinrumple(锁骨上皮肤皱折)Thoraciccage----Softtissues

3.Pectoralismajor(胸大肌)Breastandnipple

乳房一般重叠于两肺下野呈半圆形密度高,下缘清楚,上缘模糊.NormalRadiologicalAnatomy

NormalRadiologicalAnatomy

Thoraciccage--boneRibs:markingthechangeofchest.Scapula（肩胛骨）3.Clavicle（锁骨）Thoracicvertebrae（胸椎）2.TracheaandbronchusTracheaisconnectedwithcricoidcartilage(环状软骨）,about11~13cmlength,1.5~2cmwidth.Tracheaisdividedinrightandleftmainbronchion5~6thoracicvertebraplane.Tracheamainbronchus3.LungNormalRadiologicalAnatomy

Lungfields肺野

Lungmarkings肺纹理

Hilumoflung肺门Lobeoflung肺叶Lungfields肺野uppermiddlelowerlateralmiddleinternalzoneHilaofthelungsComposition(组成）:

PulmonaryarteryPulmonaryveinBronchi

LymphThelateralviewofthechest上肺静脉干左肺动脉弓两下肺动脉干Bilateralhilumoflungoverlap；Appearto‘comma’.两侧肺门大部分重叠;右肺门略偏前；肺门表现：似“逗号”。HilaofthelungsPosition:

MiddlezoneInternalstriplungmarkingsComposition：PulmonaryarteryPulmonaryveinLymphaticCharacteristic:

Branchingandtaperingfromthepulmonaryhilaintotheperipherallung.

（从肺门向肺外周呈树枝状分布、逐渐变细)Thelobesofthelung、segmentand

pulmonarylobule

（肺叶、肺段和肺小叶）Thelobesoflung:differentwithlungfield.Lobesareseparatedbyfissures.----Therightlunghas3lobes;----Theleftlunghas2lobes;Interlobarfissure(叶间裂)

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

majorfissureminor(horizontal)fissureFissuresandlobesofthelungsInterlobarfissure(叶间裂)Interlobarfissure(叶间裂)MajorfissureMinor(horizontal)fissure

右肺上叶示图右肺中叶示图右肺下叶示图

左肺上叶示图Thelobesoflung、segmentand

pulmonarylobule

（肺叶、肺段和肺小叶）Segment:Onelobeoflungiscomposedof2~5Segment.Pulmonarylobule:MuchpulmonarylobulearecomposedoftheSegment.

Pulmonaryparenchyma&mesenchyme

肺实质与肺间质LungiscomposedofpulmonaryparenchymaandmesenchymeNormalRadiologicalAnatomy

Fissure:

Horizontalfissure水平裂Obliquefissure斜裂4.PleuraPartialpleura壁层胸膜Visceralpleura脏层胸膜PleuralcavityItsnegativepressuremaintainsthelunginflatedNormalRadiologicalAnatomy

Thenormalpleura

isinvisible,onlyshowedalamellarorstriationinitsdirectionparallelingwithX-Ray

Position

Posteroanterior(PA):BetweenthelungsLateral:BetweenthesternumandthoracicvertebraeMediastinumRegion（分区）RuleofsixornineT4EdgebetweenthemanubriumandbodyofthesternumLinethroughthelowermarginofthe4ththoracicvertebra

SuperiormediastinumInferiormediastinumAnteriormediastinum

MiddlemediastinumPosteriormediastinum

Horizontalline水平线ordinate

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

lesions纵隔病变Bronchialobstruction

（支气管阻塞）InfiltrateandConsolidationoflungCavityandintrapulmonaryaircontainingspaceNoduleandMassReticulate、leptonemaaandtrabsshadowCalcificationPulmonarylesions肺部病变Bronchialobstruction支气管阻塞

Incompletebronchialobstruction(不完全阻塞)

--Obstructiveemphysema(阻塞性肺气肿)Completebronchialobstruction（完全阻塞）

--Obstructiveatelectasis(肺不张)CausesBronchialcarcinomaEndobronchialbenigntumor（支气管内的良性肿瘤）Mucoidimpaction（粘液嵌塞）Postinfectionbronchialnarrow（炎症后的支气管狭窄）Extrabronchialcompression(支气管外的病变压迫)

Bronchialobstruction--Localobstructiveemphysema(局限性阻塞性肺气肿)--Chronicdiffuseobstructiveemphysema(慢性弥漫性阻塞性肺气肿)Obstructiveemphysema

(阻塞性肺气肿)Localobstructiveemphysema(局限性阻塞性肺气肿)

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

Pneumonoresection（肺叶切除）orPulmonaryatelectasis（肺不张）increasethenegativepressure ofthoraciccavity;theadjacentorcontralateral

lungpassivehyperinflationChronicdiffuseobstructiveemphysema

(慢性弥漫性阻塞性肺气肿)Obstructioninbronchiole（细支气管的阻塞）

Secondary

chronicobstructiveairwaysdiseases.Radiologicalappearance

Reductionofperipheralpulmonaryvascularity(外周肺血管纹理的减少):FewerlungmarkingsPulmonaryhyperinflationBarrel-shapedchestFlatteneddiaphragmTranslucentlungfields

Alterationofthecentralpulmonaryarteriesandheart(心脏及中心肺动脉的改变):PulmonaryarteryenlargeHeartelongated(心影狭长）Chronicdiffuseobstructiveemphysema(慢性弥漫性阻塞性肺气肿)Obstructiveatelectasis(阻塞性肺不张)Completebronchialobstruction,gradualresorptionofair.Include:Completecollapseofalung一侧肺不张

Lobarcollapse肺叶不张Roundedatelectasis圆形肺不张

Lobularatelectasis肺小叶不张Characteristic：Opacificationofallorawholelobeorseveralsegmentsofalobe肺叶或肺段的密度增高volumeloss体积缩小Radiologicalsignsofobstructiveatelectasis

(肺不张的影像学表现)CrowdingofvesselsCrowdingofribsShiftofstructuressuchasinterlobarfissuresorthehilumtowardsareasoflungvolumeloss(叶间裂及肺门向不张的肺组织移位，即向心性移位）Elevationofthehomo-diaphragm（患侧膈上抬）Compensatoryhyperinflationofadjoininglung（邻近肺过度充气）Completeatelectasisofalung一侧肺不张ObstructionoccurredinmainbronchiOpacificationofthehemithoraxMediastinumshifttothesideofcollapseofalungDiaphragmraisesThecontralaterallungishyperinflatedandevenherniatedacrossthemidline(对侧肺过度充气，甚至超过中线）.CT---lungwindowCT–MediastinumwindowLobaratelectasis肺叶不张

---ObstructionoccurinlobebronchiOpacificationofawholelobe,associatedwithvolumeloss.Shiftofstructuressuchasinterlobarfissuresorthehilumtowardsareasoflungvolumeloss叶间裂及肺门向心性移位Elevationofthehomo-diaphragm患侧膈肌抬高Compensatoryhyperinflationofadjoininglung邻近肺组织过度充气RightupperlobeatelectasisRightupperlobeatelectasismajorfissuremajorfissureminorfissureminorfissureRightupperlobeatelectasismassRightmiddlelobeatelectasis

minorfissureminorfissuremajorfissuremajorfissureminorfissuremajorfissureminorfissuremassRightmiddlelobeatelectasis

massLeftupperlobeatelectasismajorfissuremajorfissureLeftupperlobeatelectasisRightlowerlobeatelectasisRightlowerlobeatelectasisLeftlowerlobeatelectasisLeftlowerlobeatelectasisLeftlowerlobeatelectasisLeftlowerlobeatelectasis86bronchialobstruction（支气管阻塞）InfiltrateandConsolidationoflungCavityandintrapulmonaryaircontainingspaceNoduleandMassReticulate、leptonemaaandtrabsshadowCalcificationPulmonarylesions肺部病变Exudation

andConsolidation

渗出与实变Exudation

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

obscuredlungmarkings.Airbronchogram(支气管气像)---Airfilledbronchi,normallyinvisible,willbecontrastbyinfiltratecreatingairbronchogram.

NochangeoflobarshapeRadiologicalappearance:Exudation

andConsolidation

渗出与实变AirbronchogramCauses:

Pneumonia肺炎

Pulmonaryedema(肺水肿）

Hemorrhage肺出血

Aspirationpneumonitis吸入性肺炎

AlveolarcellcarcinomaExudation

andConsolidation

渗出与实变Lobularpneumonia

bronchopneumonia

支气管肺炎MultifocalbronchocentricinfectionbasedonthepulmonarylobuleExudation

andConsolidation

渗出与实变Exudation

andConsolidation

渗出与实变Exudation

andConsolidation

渗出与实变Exudation

andConsolidation

渗出与实变Exudation

andConsolidation

渗出与实变MajordifferentiatingfactorsbetweenAtelectasisandPneumoniaAtelectasis肺不张

Pneumonia

肺炎--Lossoflungvolume--Anatomyshiftstowardsatelectasis--Linear,smooth,wedge-shaped--Apexofopacitystartsathilum--Normallungvolume--Noanatomicalshift--Consolidation--Airbronchogramsbronchialobstruction（支气管阻塞）InfiltrateandConsolidationoflungCavityandintrapulmonaryaircontainingspaceNoduleandMassReticulate、leptonemaaandtrabsshadowCalcificationPulmonarylesions肺部病变

Cavityandintrapulmonaryaircontainingspace空洞与空腔Cavity:Necrotictissueventoutthroughbronchi,leavingachambercontainingairorfluid.Groupingdependonpathologicalchange

Mouth-eatencavityThinwalledcavity

ThickwalledcavityCavityandintrapulmonaryaircontainingspace空洞与空腔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（支气管阻塞）InfiltrateandConsolidationoflungCavityandintrapulmonaryaircontainingspaceNoduleandMassReticulate、leptonemaaandtrabsshadowCalcificationPulmonarylesions肺部病变Radiologicappearance:

Diameterlessthan1cm，marginclear；likeaplumblossompetal.Causes:Pulmonarytuberculosis肺结核;Chronicinflammation慢性炎症.Nodule----glandalveolusnodosityshadowPulmonarytuberculosis肺结核GlandalveolusnodosityshadowRadiologicappearance：diameterlessthan4mm，diffuseddistribution

。Causes:acutehematogenous[disseminated]pulmonarytuberculosis急性血行播散型肺结核，noduledisease结节病,lymphangitiscarcinomatosa癌性淋巴管炎等，Nodule----MiliarynoduleshadowNodule---MiliarynoduleshadowMass①Benigntumor：hamartoma(错构瘤)②Malignanttumor：lungcancer③Nontumorousdisease:Tuberculoma(结核瘤）,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（支气管阻塞）InfiltrateandConsolidationoflungCavityandintrapulmonaryaircontainingspaceNoduleandMassReticulate、leptonemaaandtrabsshadowCalcificationPulmonarylesions肺部病变Responseforthepulmonaryinterstitialinpathologicalchanges.肺的网状、细线状及条索状阴影在病理上是肺间质性病变的反应。

Reticulate、leptonemaaandtrabsshadow

肺的网状、细线状及条索状阴影Radiologialappearance:1.Lungmarkingthickening,edgeunsharpness,bronchialwallthickening（大支气管、血管周围）2.Trabs、Reticulate、Honeycombshadowing（小支气管、血管周围）3.Diffusereticulate、Septallines、

Miliaryshadows、Groundglasspattern

（沿肺间质分布）Reticulate、leptonemaaandtrabsshadow

肺的网状、细线状及条索状阴影Reticulate、leptonemaaandtrabsshadow

肺的网状、细线状及条索状阴影peribronchovascularinterstitialthickeningintralobularinterstitialthickeningReticulate、leptonemaaandtrabsshadow

肺的网状、细线状及条索状阴影bronchialobstruction（支气管阻塞）InfiltrateandConsolidationoflungCavityandintrapulmonaryaircontainingspaceNoduleandMassReticulate、leptonemaaandtrabsshadowCalcificationPulmonarylesions肺部病变CalcificationAppeartocataplasiaornecrosistissue,especiallyinhealingphaseofCaseoustubercle(干酪性结节）

inLungorlymphaden.Calcification钙化Radiologicappearance:Highdensityshadow;

Marginclear;kindsofSizeandshape,suchasmottling,lumporglobular.AbnormalchestradiographPulmonarylesions肺部病变Pleuralesions胸膜病变Mediastinallesions纵隔病变Pleuraleffusion胸腔积液PneumatothoraxandHydropneumothorax气胸及液气胸PleuralesionsPleuraleffusion胸腔积液FreepleuraleffusionEncapsulatedeffusion包裹性积液

Interlobareffusion叶间积液

Infrapulmonaryeffusion肺下积液

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

Massivepleuraleffusion:

Completeopacificationofthehemithorax

ContralateraldisplacementofthemediastinumEncapsulatedeffusionNotalteritsappearancewithchangeofpatient’sposition

Fusiformshape

shadowncloseneighbor

chestwall.

Interlobareffusion叶间积液Pneumatothorax（气胸）

Pathwayofairenteringpleuralcavity：①partialpleurabroken壁层胸膜破裂②visceralpleurabroken脏层胸膜破裂Radiologicappearance：Visceralpleurabevisibleasasharpwhitelineseparatefromthechestwall.Thelungretractstowardsthehilum.Pulmonaryvascularmarkingsarenotvisibleperipheraltothevisceralpleura.Pneumatothorax（气胸）Pneumatothorax（气胸）