1. Systemic approach to Chest CT
Hidayatullah Hamidi
4th year radiology resident, FMIC, Kabul
April 2016

2. آنِ دیگران را از خویش می خواهند
بدان ای عزیز که رنج مردم از سه چیز است چون رزق تو از دیگران جداست؛ پس این همه رنج بیهوده چراست؟
از وقت ‍پیش می خواهند
از قسمت بیش می خواهند
آنِ دیگران را از خویش می خواهند
خواجه عبدالله انصاری

3. Review of chest CT requires:
Airway
Lungs
Pleura
Mediastinum
Heart
Vessels
Hila
Bones and soft tissue
Diaphragm & sub diaphragm
knowledge of normal CT anatomy
systematic approach
characterizing the abnormality
Looking for DDx

4. Windowing
Lung
Mediastinum
Bone

5. Post processing MPR: For sagittal and coronal views
MIP: Projects highest attenuation voxels (Nodules)
MiniIP: lowest attenuation pixel values(airway/emphysema)
3D VRT: Displays volume of tissue in 3D

6. HU

7. Chick list

8. Airways: Trachea and Bronchi1
Airways: Trachea and Bronchi
Shape, course, wall thickening, dilatation, narrowing, luminal mass, calcification…
Wall thickness 1-3 mm
Diameter:
M: mm coronal and mm sagittal
F: mm coronal and mm sagittal
Tracheal index: Coronal/ sagittal diameter ≈1
Bronchi: Thin wall, diameter similar to adjacent arteries

9. 2 Lungs Paired, symmetrical, lobar division, architecture
Normal attenuation values: (Inspi –700 to –900 HU)
Complete aeration
Fully apposed to chest wall
Vascular markings (diminish from center to periphery)

10. Abnormalities Pattern High attenuation Low attenuation Reticular
Nodular
Distribution:
Upper/lower
Central/peripheral

11. 3 Pleura Normally very thin, usually not visible on CT
Thickening, enhancement, nodularity, effusion, calcification

12. 4
Mediastinum
Centered
Components: esophagus, Thymus, Heart, great vessels
Compartments: Anterior, middle, posterior
Hilar region: any mass or lymphadenopathy

13. 4a Heart Position, configuration, size, chambers, Normal marks:
Internal diameter of LV is larger than RV
Convexity of IVS is directed toward RV
Atria: smooth, thin walled and similar size
Thin interatrial septum
Myocardium: uniform thickness with homogenous enhancement.

14. Pericardium Thickness: ≤ 3 mm No noticeable enhancement
Effusion, calcification, nodularity

15. 4b Thoracic vessels Origin, course, size, configuration
Veins: BSVs, IVC, SCV, PVs
Arteries: AA, BCA, Left CCA, LSCA, PAs

16. Aorta

17. SVC
Mixing of contrast with unopacified blood often creates artifactual filling defects

18. PAs
MPA: <3.2 cm or smaller than AA

19. 4c
Thoracic Lymph Nodes
Size and location

20. Diaphragm/sub-diaphragmatic area5
Diaphragm/sub-diaphragmatic area
Shape
Contour abnormalities CP angles
Position
Any abnormality in the included sections of abdomen

21. 6a Thoracic skeleton Ribs, clavicle, sternum, scapula, spine Position
Contours
Symmetry
Any bone expansion/destruction
Any lesion

22. 6b
Soft tissues
Configuration
Symmetry
Density

23. Sample of normal Chest CT report
Findings:
Both lungs are normally aerated and are applied to the chest wall on all sides. There is no sign of circumscribed pleural thickening and no fluid collection.
Pulmonary structure is normal showing normal vascular markings. There are no intrapulmonary nodules or consolidation
The mediastinum is centered and of normal width. No evidence of any mass lesion.
The hilar region on each side is unremarkable, and the main bronchi appear normal.
The heart is normal in size and configuration. The cardiac chambers are of normal size.
Major intrathoracic vessels and imaged portions of the supra-aortic vessels are unremarkable.
The thoracic skeleton and thoracic soft tissues show no abnormalities.
Conclusion:
No abnormal CT findings

24. References CT of the Airways, Boiselle, Phillip M., Lynch, David, 2008
Normal Findings in CT and MRI, Torsten B, Moeller, 2000
Brent P. Little, MD, Approach to Chest Computed Tomography; Clin Chest Med 36 (2015) 127–145

25. Post presentation evaluation

26. Find the abnormality
Saber-sheath trachea :TI <0,5
COPD

29. Lunate trachea: TI >1

30. Pattern of abnormality?

31. pattern and distribution in lung?
Central
Ground glass
Peripheral
Consolidation
Lower lung
Honeycombing
Upper lung
Traction broncheictasis

32. Distribution of small nodules

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