胸部常见CT征象认读..ppt

胸部常见CT征象认读 麻涌医院放射科 卢劲松 The Secondary Pulmonary Lobule肺小叶（直径肺小叶（直径1-2.5CM）小叶支气管、终末细支气管 肺动脉pulmonary artery 小叶间隔interlobular septa 肺静脉pulmonary vein 腺泡pulmonary acini 正常HRCT.中央肺动脉。支气管与相邻肺动脉直径大致相等。肺动脉常分为两个直径相当的分支。肺静脉常分成许多细小的分支,这些分支与主支构成直角。叶间裂（厚度小于1mm，边缘光滑，均一厚度）常见伪影 双侧下肺近心脏处，肺血管脉动伪影。低密度区，可以错当作扩大的支气管。常见伪影 主叶裂伪影。常见伪影 血管双重伪影。正常小叶间隔normal septa 正常小叶中心动脉 正常小叶中心动脉centrilobular artery 2 肺静脉Pulmonary veins 肺间质病变 发生于：慢性间质性肺炎、弥漫性间质纤维化、结节病、癌性淋巴管炎、结缔组织病（红斑狼疮、类风湿性关节炎、硬皮病、皮肌炎）、尘肺（矽肺、煤矽肺、石棉肺）、组织细胞病、淋巴管平滑肌瘤病。：界面征、小叶间隔增厚、小叶中心结构增厚、胸膜下线、长疤痕线（扭曲肺结构）、蜂窝样改变、结节影、牵拉性支扩、磨玻璃样改变。Case 1 F/60y 乳腺癌术后，现呼吸困难。分析：（1）小叶间隔增厚 分析：（2）支气管血管周围间质增厚 支气管袖口症：分析：(3)斜裂增厚 分析：（4）大结节影 网状阴影：病理上主要为小叶间隔增厚、小叶内间隔增厚、小叶核心增厚、胸膜下线影、蜂窝肺和支气管血管周围间质增厚等改变。可见于特发性间质性肺炎、结节病、癌性淋巴管炎、特发性含铁血黄素沉积、感染性疾病等。双肺网状阴影多见与特发性间质性肺炎、结缔组织病肺浸润、结节病等。单侧以癌性淋巴管炎和放射性肺炎为主。上病例为癌性淋巴管炎。Case 2 79岁、淋巴瘤病史 小叶间隔增厚？(a)Yes(b)No 双侧光滑增厚的小叶间隔 支气管血管间质是否增厚？(a)Yes(b)No 增厚的支气管血管间质 胸膜下间质增厚？(a)Yes(b)No 斜裂增厚 What is the most likely diagnosis?最可能的诊断？(a)Pulmonary edema(肺水肿）(b)Interstitial fibrosis（间质纤维化）(c)Lymphangitic spread of lymphoma（癌性淋巴管炎）Diagnosis:Lymphangitic spread of lymphoma,with interlobular septal thickening。癌性淋巴管炎（小叶间隔增厚）lymphocytic interstitial pneumonitis(LIP)淋巴间质局限性肺炎 Case 3 58-year-old man with heart disease 小叶间隔增厚？(a)Yes(b)No 双侧小叶间隔增厚 支气管血管间质增厚？(a)Yes(b)No 支气管血管间质增厚 Is there thickening of the subpleural interstitium?(胸膜下间质增厚？)(a)Yes(b)No NO!What is the most likely diagnosis?(最可能的诊断？)(a)Pulmonary edema肺水肿(b)Interstitial fibrosis间质纤维化(c)Lymphangitic spread of carcinoma癌性淋巴管炎(a)Pulmonary edema肺水肿 Correct.Because of the history of heart disease心脏病史,characteristic abnormalities典型的异常,ymmetry对称,and the predominance of septal thickening in dependent lung,this diagnosis must be considered 考虑most likely.文献：间质性肺水肿（1）肺血重新分布）肺血重新分布：左心衰-肺淤血。（2）支气管周围袖口症）支气管周围袖口症：正常厚度约1mm结缔组织内液体存积增厚。X-肺纹理及肺门血管增粗、模糊.（3）肺透过度下降）肺透过度下降：液体分布到支气管血管周围、小叶间隔、小叶内支气管血管周围、肺泡间隔透过度下降。（4）间隔线）间隔线：Kerley B线x上与肋膈角处与胸膜垂直。（5）胸膜增厚）胸膜增厚：液体入脏层胸膜下薄层结缔组织胸膜下结缔组织水肿-水肿位于脏层胸膜与结体组织间，不随体位移动。（）胸腔积液（）胸腔积液：胸膜腔内液体来自壁层胸膜。不同原因的肺水肿 心源性肺水肿：左心衰（见于心梗、二尖瓣病变。肾性肺水肿：急慢性肾功能衰竭，可合并尿毒症水钠潴留、左心衰肺水肿上腔静脉、奇静脉增宽。肺微血管损伤性肺水肿：除肺水肿外，还可见出血及细胞渗出 肺血分布正常、无袖口症、间隔线。肺泡实变斑片状，肺野外为分布。毒性气体吸入、胃液吸入、药物、溺水、颅内压升高、高原性肺水肿、复张性肺水肿。Case 4 a 53-year-old woman with and abnormal chest radiograph and mild shortness（短缺）of breath（异常胸片，气短）Is septal thickening present?(a)Yes(b)No 小叶间隔增厚吗？增厚的小叶间隔 Are the septa smooth or nodular in appearance?(a)Smooth(b)Nodular 小叶间隔增厚是结节状还是光滑增厚？小叶间隔结节状增厚 胸膜下间质结节影 支气管袖口症 Possible diagnoses include:(a)pulmonary edema肺水肿(b)interstitial fibrosis间质纤维化(c)sarcoidosis结节病 最可能的诊断？sarcoidosis结节病 Correct.Nodular thickening of interlobular septa and fissures can be seen in this disease and lymphangitic spread of carcinoma.（小叶间隔结节状改变可见于结节病、癌性淋巴管炎、尘肺）。支气管血管间质、胸膜下间质结节状改变对结节病有特征性的诊断。Case 5 a 42-year-old man with mild shortness of breath for a number of years（气促多年）Is septal thickening visible?(a)Yes(b)No Next Page 小叶间隔增厚吗？增厚的小叶间隔 扭曲的肺结构 叶间裂的扭曲 Diagnosis:End-stage sarcoidosis with fibrosis and interlobular septal thickening.结节病伴随征象：肺结构扭曲、小叶间隔结节状增厚、牵拉性支扩、蜂窝肺等。文献：肺间质病变 界面征：支气管血管间质增厚支气管血管束增粗、支气管袖口症；液体边缘光滑、肿瘤或肉芽组织结节状界面。胸膜下线：近胸膜面1cm内弧线状影为肺纤维化征象。长疤痕线：蜂窝肺：结节影：小结节2-5mm，肉芽、肿瘤、纤维组织。肺结构扭曲变形及牵拉支扩：磨玻璃样改变：Case 6 a 68-year-old woman with rheumatoid arthritis（风湿性关节炎）and progressive 累计shortness 短缺of breath over a 2-year period The predominant abnormal finding on these scans is?(a)interlobular septal thickening小叶间隔增厚。(b)honeycombing蜂窝肺 主要的异常表现？蜂窝肺 部分层面小叶间隔增厚 What does honeycombing reflect histologically?(a)Interstitial edema肺间质水肿(b)Interstitial infiltration 渗透by cells(c)Interstitial fibrosis 蜂窝肺的组织学肺间质纤维化的后期表现。Diagnosis:Rheumatoid lung disease,with fibrosis and honeycombing.风湿性肺疾病，肺纤维化、蜂窝肺。壁厚0.8-1MM，胸膜下3-4cm范围内或近叶裂处；早期囊腔小而少；囊壁为折叠破坏的肺泡壁及气道壁。Case 7 a 74-year-old woman with progressive shortness of breath over 6 months The most significant abnormal finding in this study is:(a)interlobular septal thickening小叶间隔增厚(b)honeycombing蜂窝肺(c)subpleural emphysema胸膜下肺气肿 主要的异常表现？蜂窝肺 What is the most likely diagnosis?(a)Idiopathic pulmonary fibrosis(IPF)特发性肺间质纤维化(b)Autoimmune disease(e.g.,rheumatoid lung disease)自身免疫性疾病(c)End-stage hypersensitivity pneumonitis过敏性肺炎(d)Asbestosis石棉肺(e)Drug-related lung injury麻醉药物肺损害(f)Sarcoidosis结节病 最可能的诊断？IPF:特发性肺间质纤维化 磨玻璃密度：肺野周围活动性肺泡炎症。网状改变：小叶间隔、小叶中心结构增厚蜂窝状改变的前期。蜂窝状改变：胸膜下间质纤维化：胸膜下弧线状影、脏层胸膜及叶间胸膜增厚。肺气肿：小叶中心型肺气肿。肺实变：支扩：蜂窝肺 牵拉性支扩 小叶间隔增厚 Case 8 86-year-old man with chronic myelogenous leukemia骨髓性的白血病,treated using methotrexate化疗,now complains of shortness of breath 气短.Does this man show evidence of fibrosis and UIP?(a)Yes(b)No 显示明显的纤维化和普通间质性肺炎？屑性间质性肺炎（DIP）、普通性间质性肺炎（UIP）。(a)Yes Correct.Findings indicative of usual interstitial pneumonitis(UIP)visible in this patient include:honeycombing;蜂窝肺 irregular fissures;叶裂扭曲 irregular interlobular septal thickening;小叶间隔不规则增厚。traction bronchiectasis.牵拉性支扩 蜂窝肺 叶裂扭曲 不规则小叶间隔增厚 牵拉性支扩 The most likely diagnosis is:可能的诊断？(a)idiopathic pulmonary fibrosis(IPF)(b)lung involvement by leukemia白血病肺浸润。(c)drug-related lung injury化疗药物肺损害。(c)drug-related lung injury Correct.The pattern of fibro