Practice viva Flashcards
Pulmonary hypertension, plain film
Elevated apex - RVH
Enlarged right atrium
Prominent pulmonary outflow tract, enlarged pulmonary arteries
Pruning of peripheral pulmonary vessels
Mural calcification of pulmonary vessels highly specific - seen in Eisenmengers
Pulmonary HTN 2008 world sympsosium
PA pressure >25, wedge pressure >15
1 - idiopathic, drug toxin induced, connective tissue disease
2 - left sided heart disease
3 - lung disease or hypoxia - COPD, interstitial lung disease
4 - thromboembolism
5 - multifactorial
Mediastinal mass localisation
Mediastinal masses create obtuse angles with lung, and disrupt mediastinal lines
Anterior mediastinal mass
Obliterated retrosternal clear space
Loss of sharp ascending aorta or anterior junctional line (lower of the two lines, doesn’t go above 1st rib / clavicle)
Hilum overlay (most will be anterior)
Loss of cardiophrenic angle
Lymphoma most common child (actually thymic hyperplasia 1), thymic adult
Middle mediastinal mass
To 1cm posterior to anterior vertebral line
AP window, paratracheal stripes
Azygooesophageal recess displacement (Right - new intervace, looks like a paravertebral line) (Can be displaced by posterior mass)
Left pseudoparavertebral line
Mass on posterior trachea on lateral
Doughnut sign - mass surrounds bronchus on lateral
Lateral chest x-ray (add stuff from the MCQ file)
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Cervicothoracic sign
Superior border of mass descernible, above the clavicels
Must be in Apical upper lobe, pleural, or posterior medastinum
Foregut duplication cyst
Generic term
Encompasses neurenteric cysts and bronchogenic cysts., oephageal
Bronchogenic tend to be middle mediastinum, neurenteric posterior.
Paeds mediastinal masses
Lymphoma most common anterior
Duplication cyst most common middle
Neurogenic tumour most common posterior
ECMO
Venoarterial or venovenous
Venoarterial - out via right atrium (via femoral or IJV), in via femoral, subclavian artery line, aorta.
Venovenous - In and out via central venous lines. Can have double lumen catheter.
Anticoagulated (consider if need to put chest drain)
Mitral stenosis
Often secondary to rheumatic fever
Left atrial enlargement - splayed carina, elevation left main bronchus, convex left atrial appendage, double right heart border,
Upper lobe venous engorgement from venous hypertension
Other valvular diseases?
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Chest wall soft tissues
Alway evaluate for mastectomy
Secondary findings
E.g. right sided arch, but also lymphoma
Or additional aberrant subclavian
Primary TB
Patchy or lobar consolidation, any lobe, preference for middle and lower lobes
Lymphadenopathy (especially in children - 90%, only 10-30% adults. Low density with rim enhancement)
May be miliary (immunocompromised more)
Pleural effusions (30-40% adults, 10% children)
May resolve without any radiological abnormality, or Ghon focus scar may remain (calcified granuloma)
Symptoms only in 5%
Cavitation uncommon
May have massive haemoptysis from erosion into a bronchial artery
Secondary TB
Upper zone predominant Far more likely to cavitate Lymphadenopathy less common Effusion less common Usually patchy Can have lobar consolidation, miliary, tuberculoma
Massive haemoptysis
Cancer Bronchiectasis, bronchitis TB Aspergilloma Pneumococcal Contusion PE Other
Bronchiectasis is most common cause of bronchial artery hypertrophy leading to massive haemoptysis
Left atrium, congenital
Enlarged in VSD, PDA. Normal size in ASD
Left atrial enlargement
Congenital (VSD, PDA)
Or acquired - mitral valve disease, most commonly Rheumatic
Tetralogy of fallot
VSD
Overarching aorta
Pulmonary stenosis
RVH
Dilated ascending aorta
Aneurysm HTN Dissection Coarctation Valvular disease including bicuspid valve Congenital heart disease Connective tissue disorders.
Bicuspid aortic valve
Major cause of aortic valve disease in young adults 2% incidence, more common in males Dilated ascending aorta 70% of coarctations have bicuspid valve 10% of Turners have it Associated with ADPKD Associated with berry aneurysms
Pacemaker
Single chamber
Dual chamber
Biventricular (additional lead through coronary sinus to left ventricular vein)
Coronary sinus drains to RA, drains cardiac veins, courses along posterior LA.
Unroofed coronary sinus has opening to LA also, a rare ASD
Hiccups?
Ribbon ribs
Thinned ribs
Commonly due to neurofibromas in NF1
Also seen in OI, Edwards (18), Gorham disease (progressive massive osteolysis)
Left to right shunt
ASD, VSD, PDA, AVSD
Sarcoid, biochemical markersm, imaging stage
ACE - 40% false negative, 10% false positive
30-50% hypercalcuric, 10-20% hypercalcaemic
May be stage 1-3 at presentation, unlikely 4 (fibrosis)
Common cavitating lesions
Malignancy most common
Then infection
Cancer, autoimmune, vascular, infection, trauma, young
Sarcoid can cavitatae
Transposition
L - congenitally corrected
D - egg-on-a-string - narrowed superior mediastinum due to stress thymic atrophy and pulmonary hyperexpansion, parallel great vessels, globular heart from LA enlargement and convex RA
L - AV discordance and VA discordance
Plain film appearance?
Scleroderma
Dilated oesopagus
Soft tissue calcification - subcutaneous and periarticular
Acroosteolysis
Finger contractures
Atrophic finger tips
Resorption
UIP, NSIP, PAH
Egg-shell calcification of mediastinal nodes (seen in other conditions e.g. silicosis (more pathognomonic of this), treated lymphoma rarely sarcoid)
TIP
Be wary of recommending CT on chest viva. Get most out of the plain film
Cystic lung disease
LIP (Sjogrens, women), LAM, LCH (smokers)
LIP lower zone (and ground glass), LCH upper (nodules which cavitate), LAM uniform (prone to chylothoraces and pneumothoraces)
UIP, Cystic bronchiectasis, pneumocystis, pulmonary lac
Burt-Hogg-Dube - Lower zone lung cysts, chromophobe RCC and oncocytomas, cutaneous manifestations, chromosome 17, AD, rare
Pneumomediastinum
Asthma Barotrauma Interstitial lung disease Infection Booerhaves Oesophageal cancer
Supine pneumothorax
Deep sulcus
Cannonball mets
RCC, choriocarcinoma
Less commonly, prostate, synovial, endometrial. bladder TCC
Chest wall mass
Soft tissue, benign, malignant
Ribs, benign, malignant
ST B - haemangioma, lymphangioma, lipoma, nerve sheath
ST M - rhabomyosarc, Askin Ewings sarc, malignant fibrous histiocytoma (/PUS), neuroblastoma, malignant peripheral nerve sheath tumour
Ribs B - Fibrous dysplasia, ABC, GCT
Ribs M - myeloma, mets, osteosarcoma, chondrosarcoma
TNM staging of lung cancer
.8th edition staging 2016
T1 <3, 2 2-5 or main bronchial involvement or atelectatic, 3 5-7 or tumour nodule same lobe, 4 >7 or tumour nodule different lobe or invasive
N1 ipsilateral hilar, N2 ispilateral mediastinal or subcarinal, N3, contraleteral mediastinal or hilar, or supraclavicular
M1a - pleural or pericardial, b single extrathoracic, c multiple extrathoracic
Once N3 or T3/4 N2, can’t operate, stage 3b
Posterior medastinal mass
Neurogenic tumour - benign and malignant (most common. Includes neurofibroma, schwannoma, MPNST, neuroblastoma, ganglioneuroblastoma, ganglioneuroma - ganglioneuroma most common, with both the ganglios in older patients than neuroblastoma)
Neurenteric duplication cyst
Paravertebral mass - include abscess, haematoma, mets
Descending thoracic aneurysm
Lymphadenopathy / extramedullary haematopoiesis
Oesophageal neoplasm
Also pancreatic pseudocyst, dermoid, sarcoid
Double aortic arch
Narrowed trachea
Most common symptomatic aortic arch variant
50-60% of vascular rings
Thoracic nodal stations
1 - supraclavicular 2-4 - superior medastinal 5-6 - aortic 7-9 - Inferior mediastinal 10-14 - N1 nodes, hilar, then through lungs
2 upper paratracheal
3 prevascular and retrotracheal
4 lower paratracheal
5 AP window
6 para-aortic
7 subcarinal
8 paraoesophageal (below carina)
9 pulmonary ligament
10 hilar 11 interlobar 12 lobar 13 segmental 14 subsegmental
Dense bones and no splenic flexure visible
Myelofibrosis with splenomegaly
Hampton hump
Dome-shapled pleural based opacification from embolism and infarction
The apex of the wedge may be spared due to collateral supply causing the rounding.
If infarcts, linear scar. Otherwise melting sign.
Diffuse alveolar haemorrhage
Vasculitis (Wegeners, Churg-strauss, Goodpastures), SLE, coagulation disorder, PE, mitral stenosis and regurg, diffuse alveolar damage
PCP
CD4 <200 Lavage to confirm diagnosis Perihilar distribution Pneumatoceles and subpleural blebs Effusions rare Adenopathy uncommon (10%)
PCP
CD4 <200 Lavage to confirm diagnosis Perihilar distribution Pneumatoceles and subpleural blebs Effusions rare Adenopathy uncommon (10%)
Atypical findings more common in those receiving aerosolised prophylaxis - upper lobe predominant, adenopathy, effusions
Malplaced PICC line
Going into neck
Malplaced intercostal drain
Straight course, in a fissure
Miliary metastases
Breast, ovarian, thyroid, renal, melanoma, pancreatic, trophoblasic
Metastatic calcification
Centrilobular ground glass nodules, may appear calcified
Upper zone predominant
Renal failure most common
But also primary HPT, sarcoid, osteolysis e.g. mets, vit D intoxication
Right sided aortic arch
Mirror image branching associated with cyanotic heart disease - TOF, truncus, tricuspid, transposition
Aberrant left no association
Pericardial effusion, mm
Must be at least 3mm on CT
Bronchial carcinoid
Bronchial obstruction, wheeze Carcinoid syndrome rare (diarrhoea, flushing, RHF, bronchospasm, pain, from excess serotonin) May produce Cushings Association with MEN1 Marked homogeneous contrast enhancement Endobronchial Can have peripheral calc but not common
Cystic adventitial disease
Young to middle age without evidence of vasculitis or atherosclerosis
Male predominant
Peripheral arteries
Striking prediliction for popliteal region
See cysts in the wall, which may displace the artery
Main differential in popliteal region is popliteal artery entrapment syndrome (medial head of gastroc, or popliteus or fibrous band)
(not same as cystic medial necrosis or degeneration, seen in aorta in Marfans)
Upper lobe predominant
Beryllosis, radiation, EAA (HSP), ank spond, sarcoid, TB (secondary), histiocytosis X (metastatic calc and PCP in patients receiving prophylaxis)
Hypersensitivity pneumonitis
Upper lobe predominant
Bird fanciers, hot-tub
Ground glass, centrilobular nodules, air trapping,
Small airways inflammation, interstitial lymphocytic infiltrates, granuloma formation
Fibrosis in latter stages
CAVITY
Cancer (SCC), autoimmune (Wegeners, RA), vascular (PE), infection (abscess, TB), trauma, young (CPAM, sequestration, cyst)
VOTE SSSX
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Pulmonary hamartoma
6% of solitary pulmonary nodules
Fat pathognomonic
Popcorn calc
Other benign option is chondroma, but has ossified segments, form part of Carneys triad
Carneys triad
Pulmonary chondroma, GIST, spinal paraganglioma
Grid cutoff
Can stimulate assymetric lucency / opacity
NF1 MSK manifestations
Rib notching Ribbon ribs Vertebral body scalloping Limb bowing Limb pseudoarthroses - tibial, ulnar Scoliosis Multiple non-ossifying fibromas
Chronic airspace opacity
Organising pneumonia (peripheral), chronic eosinophilic pneumonia (upper lobe predominant usually)
Atypical infection - TB, fungal
Neoplasia esp adenocarcinoma, also consider lymphoma
Other lung patterns e.g. crazy paving
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Don’t forget to look at neck
Don’t forget
Perilymphatic nodules
Sarcoid, lymphangitis, silicosis
Coal pneumoconiosis, amyloidosis, LIP
Centrilobular nodules
Infection Neoplasia with airway spread HSP RB-ILD (becomes DIP) (lower zone predominant) Vasculitides e.g. Churg-Strauss
Random nodules
Haematogenous mets, septic emboli
Lateral radiograph
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Plombage
Extrapleural pneumonolysis
Historical treatment of upper lobe cavitatory TB
Surgical cavity created under upper ribs, filled with inert material e.g. ping pong balls, parrafin wax, gauze, acrylic / lucite balls
Oleothorax
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Thoracoplasty
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Thoracic lymph node levels
10 hilar 11-14 Interlobar through subsegmental 7 subcarinal 1-6 higher than carina 8-9 lower than carina
