Curs 2 - Radioimagistica Toracelui
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Transcript of Curs 2 - Radioimagistica Toracelui
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RADIOIMAGISTICA TORACELUI
CATEDRA DE RADIOLOGIE SI IMAGISTICA MEDICALA SUUBUMF CAROL DAVILA
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TEHNICI DE INVESTIGARE.INDICATII RADIOGRAFIA PULMONARA
de fata: incidenta P-A / A-P d.d., poz. sezanda inspir / expir – dgn. pneumotorax, tulburari de ventilatie manevre Valsalva / Mueller – modificarile vascularizatiei pulmonare, studiul maselor vasculare hiperlordoza – studiul varfurilor pulmonare cu raze dure-moi decubit lateral – revarsate pleurale copii:fara grila, in stativ de contentie
profil oblice tintite, tangentiale ! compararea cu rgr. anterioare! rgr digitala: rezolutie spatiala mai mica
RADIOSCOPIA TELEVIZATA examen dinamic al diafragmelor, leziunilor pleuro-pulmonare- timpul inspirator, manevre Valsalva,
tuse, pozitie si incidenta MRF
depistare in masa, doza de iradiere ~ rgr. toracice, cost redus TOMOGRAFIA CONVENTIONALA
utila cand nu se dispune de CT confirma:
o leziune vizibila pe rgr. sediul intrapulmonar al leziunii leziuni situate in varfurile/ hilurile pulmonare
TRANZITUL BARITAT – in leziuni ale mediastinului posterior, pneumopatii de inhalatie BRONHOGRAFIA – locul e luat de bronhoscopie si CT (bronsiectazii, malformatii bronho-pulmonare) LIMFANGIOGRAFIA
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RGR.PULMONARA DE FATA RGR. PULMONARA DE PROFIL
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TOMOGRAFIE CONVENTIONALA
BRONHOGRAFIEFLEISCHNER
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TOMOGRAFIA COMPUTERIZATA utila in stadializarea tumorilor detectarea metastazelor pulmonare si pleurale diagnosticul leziunilor parietale/ pleurale/ pulmonare/ hilare high resolution – utila in bolile pulmonare difuze/ bronsiectazii angioCT: poate vizualiza embolii in vase de pana la 2-3 mm ghidare punctii-biopsii sau drenaje
SCINTIGRAFIA studii de perfuzie – cu Tc - in suspiciunile de embolie pulmonara studii de ventilatie – cu Xe, Kr – evaluarea emfizemului
ANGIOGRAFIA “gold standard-ul” ptr. emboliile pulmonare malformatii vasculare, pediatrie – explorare pulmonara functionala
ECOGRAFIA poate explora peretele toracic/ diafgragmul / pleura + ghidare a punctiei
BIOPSIA ptr. diagnosticul in tumorile pulmonare / pleurale / parietale maligne
IRM diagnosticul maselor hilare / limfadenopatiilor / leziunilor mediastinale
TEHNICI DE INVESTIGARE.INDICATII
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ANATOMIA RADIOLOGICA
Pasii de urmat in interpretarea radiografiilor + CT: Criterii de executie corecta a cliseelor
Analiza continatorului schelet : coloana, stern, coaste, clavicule, cap humeral parti moi: perete toracic,glanda mamara, axile, gat, diafragm
Analiza continutului pleura plaman mediastin
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CONTINATORRgr. fata Rgr. profil
Coloana vertebrala
+ CT
- primele 3-4 v. toracale
- corp, ap. spinoasa, pediculi
~ap. transverse
-spatiile intervertebrale
-g. de conjugare
Stern
+ CT
margine superioara ±dreapta manubriu, ev. oblice
-toate cele trei segmente
Coaste
+ CT
-nr., structura, contururi
-orientarea (pozitie si incidenta)
-spatiile intercostale
-dificil-arcuri posterioare decalate stg -dr
Cartilaje costale
Calcificari - centrale
- periferice
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Clavicule -suprapuse pe varfurile pulmonare
-contururi nete
Omoplati -spina, varful, marginea interna - 2 linii opace oblice
Parti moi parietale
+ CT
-mm. SCM-p. moi supraclaviculare-mm. pectorali-gl. mamara + mameloane
Diafragm
+ CT
-cupole convexe cranial
-dr. mai sus ca stg., poz: cVI ant.-insertii costale
-paralele – dr-intersectate - stg
CONTINATOR
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CONTINUTRgr. fata Rgr. profil
Pleura -vizibila doar in incidenta tangentiala-domul pleural
-scizura orizontala dr. – in dr. coastei IV
-scizuri supranumerare: azygos, apicala LI, paracardiaca, lingulara
-scizura orizontala + oblice
-scizurile supranumerare: lingulara, apicale ale LI
formarea scizurii bulbului venei azigos
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CONTINUTArbore traheo-bronsic
-trahee median-bifurcatie T4-T5-unghi bifurcatie 40-70%-bronhia I stg mai orizontala
-trahee in med.mijl.
-carina + br. I stg : ortograde
Plaman Hipertransparente (aer) +
+interstitiu,pereti bronsici, artere, vene, limfatice radiologic:
opacitati arteriale (hil manta)
= Spatii clare -retrosternal
-retrocardiac
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LOB SUPERIOR LOB MIJLOCIU LOB INFERIOR
SEGMENTATIA PULMONARA
Ap
DV
Ax
apical
bazal
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CONTINUTCT
Pleura Scizurile : -spatii avasculare-benzi dense-plaje discrete de atenuare crescuta
Arbore traheo-bronsic
=benzi sau imagini rotunde de densitate aerica, inconjurate de perete dens
Plaman =atenuare scazuta
+ artere, vene : benzi sau noduli
- hilurile pulmonare: bine vizibile
IRM
CT
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FALSE IMAGINI PATOLOGICE. VARIANTE DE NORMAL
cartilaje costale calcificate suprapunere de par, bijuterii,
imbracaminte nedegajarea marginii interne
a bratului sau scapulei mameloane marginea externa a sanului nuclei epifizari izolati ancose costale foseta ligamentului romboid coaste supranumerare,
hipoplazii, sinstoze, bifiditati
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SEMIOLOGIE GENERALA
1.Asimetrie de forma, dimensiuni si transparenta a celor doua hemitorace
2.OPACITATIa. Numarb. Localizarec. Forma d. Dimensiuni
a. punctiformeb. micronodulare ( pana la 3mm)c. nodulare ( : 3mm - 1cm) d. macronodulare ( peste 1cm)e. intinsef. masive
e. Intensitate f. Structura
a. omogenab. neomogena : calcificari, transparente
g. Contururia. netitateb. forma
h. Relatii cu vecinii
3.HIPERTRANSPARENTEa. difuze ± desen pulmonar vizibilb. Circumscrise
a. cu inel opac finb. cu inel opac gros
4.IMAGINI MIXTE = hidro-aerice
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SEMIOLOGIE GENERALA
SEMNUL SILUETEI (FELSON) 2 opacitati situate in acelasi plan
isi sterg conturul la interfata BRONHOGRAMA AERIANA
ramurile bronsice aerate apar radiotransparente datorita disparitiei aerului din alveole
pneumonii boala membranelor hialine,
limfom, sarcoidoza, carcinom alveolar, sdr. de detresa respiratorie a adultului
UNGHIURILE BERNOU Stabilesc apartenenta la perete
sau la plaman a unei opacitati
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SINDROAME RADIOLOGICE1. SINDROMUL PARIETAL = ansamblul de semne
radiologice ce traduc o atingere a peretelui toracic (parti moi, schelet)
2. SINDROMUL PLEURAL
3. SINDROAMELE PULMONAREa. SINDROMUL ALVEOLAR
b. SINDROMUL INTERSTITIAL
c. SINDROMUL BRONSIC
d. SINDROMUL VASCULAR
e. SINDROMUL PARENCHIMATOS
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1. SINDROMUL PARIETAL LEZIUNILE PARTILOR MOI
Cresteri localizate ale grosimii peretelui
= opacitati omogene, intensitate variabile, racordate in panta lina, eventual cu lizereu transparent de demarcatie fata de plaman (dezvoltate endocavitar)
Cresteri/ reduceri difuze ale grosimii (comparativ)
hipertrofie m. pectoral asimetrii congenitale agenezie de m. pectoral mastectomie atrofie musculara de cauza
neurologica Calcificari :
adenopatii parazitoze hematoame vechi
Hipertransparente: emfizem subcutanat
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1. SINDROMUL PARIETAL LEZIUNILE SCHELETULUI OSOS
Modificari costale Numar:
coaste supranumerare, hipo/aplazii, absenta congenitala/ dobandita
Dimensiuni:
modificari generalizate/ localizate Pozitie, orientare
tipul constitutional hiperinflatie,pleurezie, atelectazie,
fibrotorax modificari de ax ale CV
Contur coarctatie Ao, neurofibromatoza,
fracturi Structura
osteolitice, osteocondensante, mixte
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1. SINDROMUL PARIETAL LEZIUNILE SCHELETULUI
OSOS Modificarile coloanei
vertebrale de ax:
scolioze, cifoze, sdr. spatelui drept
modificari de forma - eroziuni fata anterioara
corpuri vertebrale: anevrism Ao - largirea g. de conjugare :
neurinom modificari de structura modificari ale spatiilor i.v.:
pensari, calcificari, vid discal
Modificarile sternului, etc.
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1. SINDROMUL PARIETAL LEZIUNILE DIAFRAGMULUI
pozitie Sus situatbilateral unilateral
- expir- sarcina- ascita- tumori abd. volumin.-obezitate-hepatosplenomegalie- reducerea compliantei pulmonare
- hepatomegalie- splenomegalie- pareza de nv frenic- atelectazie- fibroza pulmonara- pneumonectomie- pahipleurita- scolioze
Jos situat : hiperinflatie, inspir profund
contur: alterare tonus/ fibreimpingere/ tractionare
mobilitate: redusa, absenta, paradoxala rupturi, hernii diafragmatice
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2. SINDROMUL PLEURAL
PLEUREZII
1. libere in marea cavitate pleurala mici, medii, masive
2. inchistate parietal diafragmatic mediastinal interlobar (scizural)
PNEUMOTORAX HIDROPNEUMOTORAX
PLEUREZIIPNEUMOTORAXHIDROPNEUMOTORAXPAHIPLEURITETUMORI PLEURALE
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PNEUMOTORAX liber in marea cavitate
mediu: hipertransparenta periferica fara desen pulmonar colabarea plamanului la hil: bont pulmonar
mai opac centrat pe hil, bordat de un fin lizereu opac = pleura viscerala
mediastin nemodificat ca pozitie hiperinflatie a plamanului controlateral uneori: benzi opace in perimetrul
transparentei = aderente pleurale mic
dificil de evidentiat banda fina hipertransparenta, fara desen
pulmonar, apico-laterala rgr. in expir fortat, radioscopia CT
important, sufocant (cu supapa) urgenta clinico-radiologica pp o solutie de continuitate de mari
dimensiuni, cu supapa important efect de masa
partial, cloazonat ! diagnosticul diferential
PLEUREZIIPNEUMOTORAXHIDROPNEUMOTORAXPAHIPLEURITETUMORI PLEURALE
2. SINDROMUL PLEURAL
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FORMATIUNI SOLIDE
•PAHIPLEURITE
•TUMORI PLEURALE BENIGNE
•Fibrom, angiom, condrom, tumora amiloida, lipom•Mezoteliom local benign
•TUMORI PLEURALE MALIGNE
• primare•fibrosarcom•mezoteliom difuz
•secundare
PLEUREZIIPNEUMOTORAXHIDROPNEUMOTORAXPAHIPLEURITETUMORI PLEURALE
2. SINDROMUL PLEURAL
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3. SINDROAMELE PULMONAREA. SINDROMUL ALVEOLAR
= disparitia aerului din alveole si inlocuirea lui printr-un fluid (exudat, transudat,sange)
OPACITATE ALVEOLARA (“EXUDATIVA”)
-intensitate submediastinala, mai slaba spre periferie
-structura omogena
-prezenta bronhogramei si alveologramei aeriene
-contururi sterse / nete la scizuri
-evolutie rapida
-nu modifica “vecinii”
-sistematizate / nesistematizate
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Infectii – pneumonii, bronhopneumonii Edem pulmonar cardiogen / necardiogen Neonatal: boala membranelor hialine, aspiratie Hemoragia pulmonara, sdr. Good – Pasture, infarct pulmonar Tumori :
carcinom alveolar limfom leucemie
Altele: proteinoza alveolara pneumonita de iradiere Sarcoidoza plaman eozinofilic
INDICATII CT
cautarea leziunilor excavate cautarea etiologiei / leziuni ascunse de sdr. alveolar ghidarea punctiei
IRM: interes teoretic in pneumopatiile de inhalare (cu uleiuri) proteinoze hemoragii intra-alveolare
3. SINDROAMELE PULMONAREA. SINDROM ALVEOLAR - cauze
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CONTUZII PULMONARE
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PNEUMONITA DE IRADIERE
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PNEUMONIILE BACTERIENEFAZA ANAPAT RADIOLOGIE
CLASICADURATA
CONGESTIE dilatarea capilarelorexudat ce ocupa partial alveoleleingrosarea peretilor alveolari
opacitate de intensitate foarte mica = voal
24 ore
Ziua 1
HEPATIZATIE ROSIE
alveolele ocupate in totalite de hematii=bloc
Opacitate intinsasistematizataintensitate submediastinalacontururi nete doar la scizuriomogenabronhograma si alveolograma aeriana
4-5 zile
Z 2-6
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PNEUMONIILE BACTERIENE
HEPATIZATIE CENUSIE
continutul alveolar se elimina partial, intrand si aer in alveole
Opacitate in “rezolutie”de la periferie spre centrudin centru spre periferiein tabla de sah
2-5 zile
Z7-14 aspect normal dupa 3 sapt.
CRONICIZARE predomina fibroblastii
Opacitate retractila
bronsiectazii
HEPATIZATIE GALBENA
Alveole pline de piocitePerete alveolar distrus
Abces In perioada febrila sau dupa
FAZA ANAPAT RADIOLOGIE CLASICA
DURATA
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Pneumonie axilara LSD
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Pneumonie axilara LSD in rezolutie
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Pneumonie LM in rezolutie
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Pneumonie apicala LID
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Pneumonie bazala LID
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Pneumonie lingulara
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Pneumonie LIS
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Faza de abcedare
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Faza de rezolutie
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Pneumonie pseudotumorala
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Pneumonie Infarct pulmonar
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BRONHOPNEUMONII
ANAPAT: procese de bronhoalveolita, edem, atelectazii
RX: mai multe opacitati nodulare uni/bilateral centru mai opac, periferia mai intensa contururi difuze dimensiuni variate si rapid variabile tendinta la confluare Forme radiologice: miliara, micronodulara, macronodulara,
pseudolobara Forme etiologice: STF, STR, GRAM-
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BRONHOPNEUMONIA Anatomopat:
Forme acute, galopante – tablou clinic de edem pulmonar grav
Forme insidioase – abcese peribronsice care ulterior comunica cu bronhia si apar pneumatocele
Rx: Noduli Imagini buloase Imagini hidro-aerice Aspect polimorf Remaniere in timp scurt
Particularitati: Copii:
60% pneumatocele 90% revarsat pleural sau pneumotorax/ piopneumotorax
Adulti: mai frecvent forma pneumonica 20-50% forma buloasa 50% revarsat pleural cu tendinta la inchistari multiple foarte rar piopneumotorax
STAFILOCOCICA
Rx: Lobi inferiori Nu exista tendinta pentru
dezvolatera pneumatocelelor sau a piopneumotoraxului
Empiem obisnuit + aderente
STREPTOCOCICA
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BRONHOPNEUMONIA KLEBSIELLA
segmente posterioare ale lobilor superiori si segmentele superioare ale lobilor inferiori, mai frecvent pe dreapta
opacitate lobara / segmentara tendinta la exudate inflamatorii
voluminoase, pputand afecta intreg plamanul
tendinta la abcedare cu formare de cavitati
PROTEUS segmente posterioare lobi superiori segmente superioare lobi inferiori abcedare frecventa aspect bronhopneumonic
E.COLI necaracteristic
GRAM (-) PIOCIANIC
segment posterior lob inferior opacitati nodulare multiple cu
tendinta la conglomerare / formare de opacitati pneumonice cu bronhograma aeriana
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Bronhopneumonia cu B.Gram (-)
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Bronhopneumonie nosocomiala
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B. SINDROMUL INTERSTITIAL= ansamblul de semne radiologice ce atesta ingrosarea tramei de tesut conjunctiv al plamanului (compartiment peribronhovascular, interlobular, parietoalveolar)
CAUZE infiltratie lichidiana
(edem hemodinamic, inflamator, toxic)
staza venoasa cronica sau limfatica
proliferare de celule anormale
Caracteristici radiologice:
•nesistematizate•contur net•absenta confluarii•evolutie lenta
LEZIUNI ELEMENTARE
Opacitati nodulare Opacitati lineare Opacitati reticulare
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B. SINDROMUL INTERSTITIAL Imagini liniare : liniile septale (Kerley)
edem interstitial prin staza limfatica acute: edem pulmonar, pneumopatii
virale cronice: cancer bronsic cu obstructie
limfatica, limfangita carcinomatoasa, pneumoconioze, stenoza mitrala, sarcoidoza, limfom, limfangiomiomatoza, proteinoza alveolara
Imagini reticulare:
= Ingrosare septuri interlobulare si interlobare, centrate pe artera centrolobulara
alveolita alergica extrinseca maladii sistemice fibroza interstitiala difuza pneumocistoza limfangita carcinomatoasa…
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Imaginea in “fagure de miere”
= spatii aeriene chistice inconjurate de retea opaca grosiera, dispusa paralel cu peretele
=distructie pulmonara in faze tardive de fibroze interstitiale:
Histiocitoza X
Fibroza interstitiala primitiva
Pneumoconioze
Sarcoidoza
Alveolita alergica
B. SINDROMUL INTERSTITIAL
Fibroza pulmonara difuza idiopatica
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B. SINDROMUL INTERSTITIALImaginea de “geam mat”, “sticla pisata”
= afectare interstitiala la debut = micronoduli foarte fini in ansamblu imagine opaca flu
-HRCT: vasele vizibile in aria de crestere difuza a densitatii
infectioase (virale, pneumocistoza in cursul SIDA)
imunoalergice (alveolita extrinseca)
sarcoidoza : debut (+micronoduli)
Sida, pneumocistis carinii
Histiocitoza
Alveolita extrinseca
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B. SINDROMUL INTERSTITIAL Opacitati punctiforme, micronodulare
miliara tuberculoasa miliara carcinomatoasa pneumoconioze sarcoidoza fibroza interstitiala idiopatica af. infectioase (pneumopatii virale, oportunisti,
micoze, parazitoze) neoplazii (cancer bronhiolo-alveolar, limfom,
leucemie) boli de colagen microlitiaza alveolara hemosideroza
Opacitati macronodulare Tuberculoza Metastaze Pneumoconioze Abcese pulmonare multiple Hidatidoza ….
Elemente de diagnostic: Distributia (bilaterala / unilaterala, nesistematizata, difuza,
bazala) Asocierea altor anomalii parenchimatoase si pleurale Leziuni ggl Calcificari Anomalii cardiace Anomalii osoase Anamneza, evolutie, corelatii biologice, functionale si
anatomopatologice Sarcoidoza
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Pneumoconioze SilicozaAzbestoza
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ETIOLOGIA: Mycoplasma pneumoniae virusuri (influenza, parainfluenza, VSR, virusul rujeolei,
Coxsakie, adenovirusuri, herpes virus, virusul varicelei, CMV)
ANAPAT: edem, infiltrat histiocitar, monocitar si plasmocitar al
interstitiului peribronhovascular alveole Rx:
predomina in lobii inferiori, segmente posterioare accentuarea desenului pulmonar peribronhovascular si
periacinar / perilobular imaginea radiologica se constituie de timpuriu in raport cu
debutul clinic in 15 zile: resorbtie (initial atelectaziile lobulare, apoi
componenta alveolara si in final cea interstitiala) in 25 zile: normalizare radiologica pn. cu mycoplasme: mai grava, mai prelungita
PNEUMONIA INTERSTITIALA
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PNEUMONIA INTERSTITIALA
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PNEUMONIE VIRALA
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C. SINDROMUL BRONSIC IMAGINI DIRECTE
INGROSAREA PERETILOR BRONSICI
cu calibru normal inflamatie cronica
bronsica cu calibru crescut bronsiectazii
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IMAGINI INDIRECTEconsecinte ventilatorii
obstructie completa atelectazii pulmonare, lobare, segmentareobstructie incompleta
atelectazie incompletahiperinflatie (air-trapping)
consecinte circulatorii
evanescenta pulmonara
C. SINDROMUL BRONSIC
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C. SINDROMUL BRONSIC
IMAGINI INDIRECTEconsecinte ventilatorii
obstructie completa atelectazii pulmonare, lobare, segmentareobstructie incompleta
atelectazie incompletahiperinflatie (air-trapping)
consecinte circulatorii
evanescenta pulmonara
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D. SINDROMUL PARENCHIMATOS= totalitatea informatiilor radiologice privitoare la afectiuni parenchimatoase pulmonare, care nu respecta teritoriile histologice definite anterior si, deci, nici semnele sindroamelor respective: afectiuni neoplazice / inflamatorii necrozante
1. macronoduli solitari intraparenchimatosi unic
benigne sancru de inoculare tuberculom infiltrat tuberculos caverna neevacuata chist hidatic tumori pulmonare benigne:
adenom hamartom
abces pulmonar neevacuat aspergiloza silicoza hematom posttraumatic infarct pulmonar angiom pulmonar nodul reumatoid infiltrat fugace
maligne cancer bronsic metastaza pulmonara unica
multiplii benigne
tuberculoame infiltrate tuberculoase caverne neevacuate chiste hidatic tumori pulmonare
benigne: adenomatoza abcese pulmonare
neevacuate aspergiloza silicoza infarcte pulmonare noduli reumatoizi infiltrate fugace
maligne cancer bronhiolo-alveolar metastaze pulmonare
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tuberculom
Infiltrat eozinofilic
hamartom
aspergiloza
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Caractere de benignitate
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Caractere de malignitate
•contur•dimensiuni•leziuni asociate
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metastaze pulmonare multiple
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Chiste hidatice multiple
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D. SINDROMUL PARENCHIMATOS2. cavitati intrapulmonare
cu pereti grosi abces pulmonar partial/total
evacuat caverna tuberculoasa recenta cancer pulmonar I excavat metastaze excavate aspergilom pulmonar excavat chsit hidatic partial / total
evacuat
cu pereti subtiri chist aeric plaman polichistic bule de emfizem pneumatocele bronsiectazii abcese , caverne vechi
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Abces pulmonar. Hidropneumotorax
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Cancer pulmonar excavat
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E. SINDROMUL VASCULAR Circulatia pulmonului:
nutritiva apartinand marii circulatii Ao toracica – aa. i.c – aa bronsice
functionala – apartinand micii circulatii aa vizibile Rx pana la manta vv: traiect orizontal, ramificatie
laterala capilare: normal nevizibile, in
manta
debit mare, presiune mica, rezistenta periferica mica, complianta mare
variatii presionale fctie de gravitatie, timpul respirator (redistributia vasculara normala)
Sdr. vascular precapilar capilar postcapilar
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E. SINDROMUL VASCULAR precapilar cu hipervascularizatie = hiperemie pulm.
boli cu sunt sistemico-pulmonar (DSA) hipervolemie (IR cu sdr. nefrotic) hiperchinezie (hipertiroidism) Rx:
reducerea transparentei pulmonare cresterea grosimii desenului pulmonar absenta sindromului alveolar sau interstitial artera pulmonara in hil de dimensiuni crescute
cu hipovascularizatie = olighemie bilateral (tetralogia Fallot) unilateral (stenoze de artera pulmonara congenitala
sau dobandita ;ex:sdr. Mc Leod) Rx:
hipertransparenta pulmonara difuza desen pulmonar gracil hil , dar uneori
hipertensiune pulmonara precapilara spasm arteriolar de protectie a segmentului din aval Rx:
hil, vase perihilare dilatate, amputate cu reducerea desenului vascular in periferie (unde plamanul apare hipertransparent)
dilatarea cavitatilor cardiace drepte
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E. SINDROMUL VASCULAR capilar Cauze:
compromiterea patului capilar prin procese de fibroza interstitiala hiperinflatie alveolara
Rx: sdr. interstitial / bronsic hipertensiune pulmonara
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E. SINDROMUL VASCULAR postcapilar= staza venoasa pulmonara
afectiuni ce blocheaza intoarcerea sangelui spre AS
1. acuta prin insuficienta ventriculara
stg ac. Rx:
sdr. alveolar = EPA
2. cronica prin acumulare pasiva de
sange in teritoriul venos Rx.:
redistributia vasculara edem interstitial: linii Kerley,
desen reticular, micronoduli edem alveolar in ariile
pulmonare neprotejate; nu se mai produce odata cu aparitia HTP
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TUMORILE PULMONARECea mai frecventa si mai importanta tumora primara a plaminului este CARCINOMUL BRONSIC
Frecventa : mai mare la barbati, dar incidenta la femei este in crestere.
Incidenta : 40-70 ani ; neobisnuit sub 30 ani. Etiologie :
cel mai important: fumatul – riscul este pp cu nr. de tigari poluare atmosferica anumite ocupatii – lucratori cu azbest, substante radioactive,
anumite chimicale, incluzind minele de uraniu, hematita, cromati, nichel, arsenic,
fumatorii cu expunere la azbest au un risc crescut fata de fumatorii fara expunere la azbest.
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CARCINOMUL BRONSIC - Anatomopatologic
carcinomul cu celule scuamoase (epidermoid) : 30-50 %
adenocarcinom (incluzind si carcinomul alveolar) : 15-35 %
carcinomul anaplastic cu celule mari:10-15 %
carcinomul cu celule mici: 20-30 %
unele cancere pulmonare nu se pot incadra perfect in aceste categorii, avind componente ce corespund mai multor tipuri, de ex. carcinom adenoscuamos
alte tumori rare sunt clasificate separat, de ex. carcinom cu celule clare, carcinom cu celule bazale si carcino-sarcomul.
1.Cancerul cu celule scuamoase central creste relativ incet excaveaza mai frecvent ca
alte tipuri2.Adenocarcinomul :
periferic de ob. uneori pe plamin fibros excaveaza mai rar
3.Tumora cu celule mici : are rata de crestere cea mai
mare de obicei la prezentare are si
determinari secundare centrala de ob. asociaza tipic adenopatii
mediastinale sau hilare rar excaveaza
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Aprox. 50% din cancere apar central (in sau proximal de bronhiile segmentare) tumora apare la nivelul mucoasei bronsice si invadeaza peretele bronsic poate creste in jurul bronhiei si de asemenea in lumenul bronhiei obstructia duce la atelectazie / deseori la infectii in plaminul distal de tumora
Tumorile periferice apar ca noduli de “parti moi” sau mase neregulate invadeaza tesuturile adiacente semne de colaps sau consolidare pot apare, dar sunt mai putin evidente fata de
tumorile centrale Ambele tipuri (central sau periferic) pot asocia :
adenopatii mediastinale sau hilare (ceea ce poate constitui cauza de obstructie a cailor aeriene centrale)
necroza centrala excavatii
tumorile periferice pot apare in zone cu cicatrici (cunoscut fiind ca fibroza predispune la modificari neoplastice)
metastaze de la cancerul pulmonar pot apare oriunde in corp, dar cele mai comune locuri sunt : ggl. hilari, mediastinali, supraclavicular , ficat, oase, creier, glande suprarenale si piele
cancerul pulmonar este o cauza comuna de limfangita carcinomatoasa
CARCINOMUL BRONSIC
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Largirea hilului in tumora centrala =
manifestarea insasi a tumorii +/- adenopatii
in tumora periferica = adenopatii
afectarea reala a hilului este apreciata prin CT sau IRM
CT: rezolutie mai buna IRM: contrast natural mai bun
– fara contrast i.v.
CARCINOMUL BRONSIC - semne Rx
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Obstructia cailor aeriene atelectazie distal de tumora: segmentara / lobara / a
intregului plamin pneumonie distal de obstructia
bronsica, secundara acesteia, fara bronhograma aeriana prezenta, putind acoperi tumora
(suspectata daca pneumonia nu se vindeca cu tratament corect)
atelectazie incompleta / hiperinflatie
CARCINOMUL BRONSIC - semne Rx
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Mase periferice masa periferica + largire a hilului +
metastaze osoase = cancer daca masa periferica este singurul
element anormal diagnosticul diferential dificil, mai ales ca nu exista semne radiologice sigure de diferentiere intre benign si malign. Totusi :
nodulul malign este mai mare la prezentare decit unul benign
prezinta contur extern difuz, lobulat sau ombilicat, spiculat
pot exista noduli sateliti formatiunii principale : mai frecvent in t. benigne, dar pot fi asociate si cu cancerul
calcificarile difuze sau centrale intr-o masa periferica sunt sugestive ptr. leziuni benigne, dar ocazional o tumora maligna poate « inghiti » un granulom calcificat
rata de crestere : o tumora maligna se dubleaza in 1-18 luni, a.i. un nodul care nu isi schimba dimensiunile in 2 ani poate fi considerat benign
CARCINOMUL BRONSIC - semne Rx
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Mase periferice excavare :
10-15% in cancerul periferic pe rgr. mai bine demonstrata pe CT datorata necrozei centrale sau
formarii de abces secundar obstructiei bronsice
+/- nivel de lichid peretele cavitatii este de obicei
gros si cu contur intern neregulat, nodular, dar uneori apare subtire
bronhograma aeriana uneori in adenocarcinoame,
obisnuit in carcinomul alveolar
CARCINOMUL BRONSIC - semne Rx
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CARCINOMUL BRONSIC - Cancerul virfului pulmonar (Pancoast)
Rx masa sau doar ingrosare
pleurala + distructie osoasa (coaste, vertebre, etc.)
- invadeaza plexul brahial si ggl. simpatic cervical inferior - cel mai bine demonstrat prin CT si IRM
CT bun in special ptr. interesarea
osoasa IRM
sectiunile in plan coronal si sagital care demonstreaza raporturile tumorii cu plexul brahial si vasele subclaviculare
ptr. invadarea grasimii extrapleurale
Echografia prin fosa supraclaviculara ptr.
biopsie percutanata
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Interesare mediastinala adenopatiile mediastinale apar tipic in
cancerul cu celule mici, dar poate apare si in celelalte cancere bronsice
= mediastinul apare largit, policiclic
adenopatiile sau tumora centrala pot afecta esofagul – tranzit esofagian baritat : compresie sau invazie
afectarea nervului frenic : hemidiafragm sus situat (poate fi determinat si de atelectazie / afectiune subfrenica), cu miscare paradoxala(fluoroscopie sau echografie)
obstructia venei cave superioare : CT, IRM
invazie a pericardului prin adenopatii sau de catre tumora primara: pericardita sau revarsat pericardic
invazie a atriului sting : CT, IRM
CARCINOMUL BRONSIC
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Interesare pleurala revarsatul pleural poate
apare prin invazie directa obstructie limfatica secundar unei pneumonii
obstructive ca raspuns la prezenta
tumorii uneori pneumotorax
datorita unei tumori excavate subpleurale
Metastaze pulmonare limfogene (carcinoza miliara,
limfocarcinomatoza) hematogene (micronodulare,
nodulare, macronodulare)
CARCINOMUL BRONSIC
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Interesare osoasa carcinomul periferic poate
invada coastele sau coloana direct
metastazele hematogene osoase sunt de ob. osteolitice + durere
( depistate precoce prin scintigrafie osoasa)
dureri osoase, in special la nivelul pumnului, gleznei, miini, picioare sunt datorate osteoartropatiei hipertrofice
pe rgr. se ct. periostoza bine delimitata
scintigrafia poate fi pozitiva inaintea modificarilor rgr.
CARCINOMUL BRONSIC
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- Frecventa crescuta- Polimorfism lezional
- Anatomo-clinic:1.Tbc primara = primoinfectia2.Tbc secundara = reinfectia / reactivarea
Varsta copilariei= Complexul primar
1. Afect primar = sancru de inoculare = focar de alveolita
2. Limfangita specifica3. Adenopatie hilara sau mediastinala
Evolutia afectului primar: Resorbtie Fibroza Calcificare Cazeificare : caverna primar / tuberculom
TUBERCULOZA
1.TUBERCULOZA PRIMARA
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ComplicatiiA. locale
epituberculoza = congestie perifocala opacitate segmentara, omogena, intensitate micaprimoinfectia extensiva, cazeoasa = pneumonie cazeoasa opacitate lobara / segmentara, intensitate mediecaverna primaracomplicatii bronsice sau pleurale
B. diseminare bronhogena = bronhopneumonia tuberculoasa
C. diseminare hematogenamiliara tuberculoasadiseminari paucibacilare
la nivelul septurilor / interstitiului fibrozala apexuri nodulii Simon
1.TUBERCULOZA PRIMARA
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din nodulii Simon, in conditiile scaderii rezistentei organismului INFILTRATE TBC
rotund = opacitate macronodulara, apicosubclaviculara (exudativa) nebulos = leziune exudativa + proliferativa evolutie – caverne
TUBERCULOAME TBC CAVITARA CU DISEMINARI
BRONHOGENE fibrozare leziuni HEMATOGENE cazeificare proteiforme
TBC FIBROCAVITARA= fibroza – leziune inactiva+ caverne – leziuni in stadii diferite de activitate
2.TUBERCULOZA SECUNDARA
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