9. 5-Spine :
a) Fracture :
-Multiple in 10%
-Thoracic spine injuries have a much higher
incidence of neurological deficit than cervical or
lumbar spine injuries
b) Cord trauma
c) Nerve root trauma :
-Especially to the brachial plexus
12. 1-Definition :
-Refers to the presence of air in the pleural space
2-Etiology :
a) Primary Spontaneous
b) Secondary Spontaneous
c) Iatrogenic
d) Traumatic
13. a) Primary Spontaneous :
-A primary spontaneous pneumothorax is
one which occurs in a patient with no
known underlying lung disease
-Tall and thin people are more likely to
develop a primary spontaneous
pneumothorax
14. b) Secondary Spontaneous :
-When the underlying lung is abnormal , a
pneumothorax is referred to as secondary
spontaneous
-There are many pulmonary diseases which
predispose to pneumothorax including :
a) Cystic Lung Disease
b) Parenchymal Necrosis
c) Others
19. a) Upright Position :
-Visible visceral pleural edge see as a very thin sharp white
line
-No lung markings are seen peripheral to this line
-The peripheral space is radiolucent compared to adjacent
lung
-The lung may completely collapse
-The mediastinum should not shift away form the
pneumothorax unless a tension pneumothorax is present
-Subcutaneous emphysema and pneumomediastinum may
also be present
20.
21.
22. Arrows point to thin white visceral pleural line which
is the single best sign for a pneumothorax
29. b) Supine Position :
-Deep sulcus sign :
Anterior costophrenic angle sharply delineated
When the patient is in the supine position , air in
the pleural space (pneumothorax) collects
anteriorly and basally within the nondependent
portions of the pleural space , if air collects
laterally rather than medially , it abnormally
deepens the lateral costophrenic angle and
produces the deep sulcus sign
-Double diaphragm sign :
Air may outline the anterior portions of the
hemidiaphragm and cause visualization of
the anterior costophrenic sulcus
34. c) Other Positions :
1-Lateral decubitus radiograph :
-Should be done with the suspected side up
-The lung will then fall away from the chest
wall
2-Expiratory chest radiograph :
-Lung becomes smaller and denser
3-CT most sensitive
36. Inspiratory film
Expiratory film (The image shows
increase in apparent size of the
pneumothorax on the expiratory
view compared to the inspiratory
view , arrows show the pleura)
37. d) Size of Pneumothorax :
Average distance (AD in cm) = (A + B + C)/3
% Pneumothorax = AD (in cm) ,
e.g. AD of 1 cm corresponds to a 10%
pneumothorax
AD of 4 cm corresponds to a 40%
pneumothorax
40. a) Definition :
-occurs when intrapleural air accumulates
progressively in such a way as to exert
positive pressure on mediastinal and
intrathoracic structures
41. b) Radiographic Features :
-Over expanded hemithorax
-Shift of the mediastinum to the contralateral
side
-Depression of the hemidiaphragm
42. Tension pneumothorax on left (blue arrow) is displacing the heart and
mediastinal structures to the right (red arrow) ; this case also shows
a deep sulcus sign on the left (yellow arrow)
43. The left lung is completely compressed (arrowheads) , the trachea is
pushed to the right (arrow) , the heart is shifted to the contralateral
side , note right heart border is pushed to the right (red line) , the left
hemidiaphragm is depressed (orange line)
50. 1-Definition :
-Means blood within the chest , is a term usually
used to described a pleural effusion due to
accumulation of blood
-If a hemothorax occurs concurrently with
a pneumothorax it is then termed
a hemopneumothorax
-A tension hemothorax refers to hemothorax that
result from massive intrathoracic bleeding
causing ipsilateral lung compression and
mediastinal displacement
52. a) Traumatic :
-In 25-50% of patients with blunt chest
trauma and 60-80% of patients with
penetrating wounds
53. b) Spontaneous :
1-Primary Spontaneous :
-Spontaneous pneumothorax , spontaneous
hemopneumothorax
2-Secondary Spontaneous :
a) Neoplastic
b) Anticoagulant Medication
c) Vascular Rupture
54. a) Neoplastic :
1-Intra thoracic malignancy :
-Usually occurs with thoracic wall tumors
Thoracic wall schwanommas
Thoracic wall neurofibromas
2-Soft tissue tumors :
-Sarcomas , thoracic angiosarcomas
3-HCC with thoracic invasion or thoracic metastases
4-Lung cancer is a distinctly uncommon cause of
hemothorax even in the setting of pleural extension
55. b) Anticoagulant Medication
c) Vascular Rupture :
1-Aortic Dissection
2-Pulmonary AVM
3-Pulmonary Infarction
4-Thoracic Endometriosis
57. a) Plain Radiography :
-A large hemothorax may be seen as a
pleural effusion
-It can be almost impossible to differentiate
a hemothorax from other causes of pleural
effusion
58. There is complete opacification of the right hemithorax with slight shift
of the trachea towards the left , fluid is seen tracking up the lateral
margin of the thorax (red arrow) , the clue to the diagnosis is the
bullet (blue circle)
59.
60. Pneumohemothorax , after a stab injury . blood accumulates in the
pleural space (hemothorax) , no pulmonary vasculature can be
noted beyond the visceral pleural line in the upper lung due to the
accumulation of air in the same space (pneumothorax)
61. b) CT :
CT is useful in determining the nature of pleural
fluid in the setting of trauma by assessing the
attenuation value , blood in the pleural space
typically has an attenuation of 35-70 HU
-Pleural fluid attenuation measurement should be
routine in the interpretation of chest trauma CT
to distinguish simple fluid from acute blood
-In the setting of trauma , there may be other
ancillary features such as pulmonary
contusions & lacerations
65. a) Definition :
-Refers to an interstitial and/or alveolar lung
injury without any frank laceration
-It usually occurs secondary to non-
penetrating trauma
67. 1-Plain Radiography :
-Not sensitive
-Faint patchy consolidative regions following
history of blunt trauma
-Usually shows rapid improvement with time
usually days
68.
69.
70. 2-CT :
Typically seen as focal non segmental
(typically crescentic) areas of parenchymal
opacification
-Can have sub-pleural sparing with smaller
contusions which can be a distinguishing
feature
-Commoner posteriorly and in lower lobe
71.
72.
73. 2-Hematoma :
-Usually appears following resolution of
contusion
-Round well-defined nodule
-Resolution in several weeks
75. a) Definition :
-Results from frank laceration of lung
parenchyma secondary to trauma , there
is almost always concurrent contusion
-There is a linear tear (may be
radiographically visible) that becomes
round or ovoid (pneumatocele) with time
76. b) Classification :
Type I : compression rupture
Type II : compression shear
Type III : direct puncture / rib penetration
Type IV : adhesion tears
80. Flail Chest , CXR shows multiple rib fractures (black arrows) with some
ribs fractured in two or more places , there is also a pulmonary
contusion (red arrow) and subcutaneous emphysema (white arrow)
81. 2-CT :
-Regions of pulmonary contusion with added blebs
(pneumatocoeles) with air fluid levels
-Due to normal pulmonary elastic recoil , lung
tissues surrounding a laceration often pull back
from the laceration itself , this results in the
laceration manifesting at CT as a round or oval
cavity instead of having the linear appearance
typically seen in other solid organs
82. Pulmonary Laceration , there is a soft tissue density in the right lower
lobe (black circle) with several small air-containg cavities within it in
a patient with recent trauma
83. Axial CT shows a hole in the lung with air-fluid level (arrow) surrounded
by ground glass opacity (arrowheads) in a trauma patient , findings
represent pulmonary laceration surrounded by contusion
87. a) Etiology :
-Lipid emboli from bone marrow enter
pulmonary and systemic circulation
-1 to 2 days post-trauma
-Resolves in 1-4 weeks
-Frequently CNS is also affected
90. The chest x ray showed bilateral homogenous opacities
91.
92. 2-CT :
-Three predominate patterns are observed :
1-Ground-glass change with geographic
distribution
2-Ground glass opacities with interlobular
septal thickening
3-Nodular opacities
93. A 17 year old man with a
comminuted femur fracture
Top , A: HRCT scan obtained the
second day after injury shows
ground-glass opacities
Bottom , B: HRCT at a lower level
shows ground-glass opacities
confined to some lobules with
a sharp margination between
areas of involved and
noninvolved lung resulting in a
geographic appearance , also
noted is smooth and nodular
interlobular septal thickening
94. A 19 year old man at 2 days after
femur shaft fractures
Top , A: HRCT scan obtained at
the lower lung zones reveals a
predominantly peripheral
distribution of ground-glass
opacities associated with
smooth and nodular septal
thickening
Bottom , B: HRCT obtained at a
lower level shows relative
sparing of some secondary
lobule
95. Top , A: HRCT obtained just
below the tracheal
bifurcation reveals a
predominantly nodular
pattern , note that
bronchovascular bundles
are thin and smooth
Bottom , B: HRCT obtained
at the level of pulmonary
veins shows similar
pattern and severity of
findings
96. 5-Aspiration Pneumonia
6-Foreign Body
7-Pulmonary Edema :
-Following blast injuries or head injury
(neurogenic edema)
8-Adult Respiratory Distress Syndrome :
-Widespread air-space shadowing
appearing 24-72 hours after injury
97. 8-Trachea & Bronchi :
-Laceration or fracture :
Initially surgical emphysema and
pneumomediastinum followed by collapse
of the affected lung or lobe
99. a) Incidence :
-In 3-7% of patients with blunt and 6-46% of
patients with penetrating thoraco-
abdominal trauma
-Ninety percent of tears occur on the left
side
101. 1-Plain Radiography :
-Herniated stomach or bowel above the
diaphragm
-Pleural effusion
-A supradiaphragmatic mass or a poorly
visualized or abnormally contoured
diaphragm
102.
103.
104.
105. 2-CT :
a) Direct CT Signs :
1-Segmental Diaphragmatic Defect (focal and
abrupt loss of continuity in the diaphragm)
2-Dangling Diaphragm (the free edge of the torn
diaphragm which curls inward from its normal
course toward the center of the body forming a
comma shaped or curvilinear structure)
3-Absent Diaphragm (absence of part or all of the
hemidiaphragm without demonstration of a tear)
106. b) Indirect CT Signs Related to
Herniation:
1-Herniation through a Defect
2-Collar Sign
3- & 4-Hump and Band Signs
5-Dependent Viscera Sign
6-Sinus Cutoff Sign
7-Abdominal Content Peripheral to the
Diaphragm or Lung Sign
8-Elevated Abdominal Organs Sign
107.
108. 10-Mediastinum :
a) Aortic Injury
b) Mediastinal Hematoma
c) Pneumomediastinum
d) Hemopericardium
e) Esophageal Rupture
112. a) Plain Radiography :
1-Widening of the mediastinum
2-Abnormal aortic contour
3-Tracheal displacement to the right
4-Nasogastric tube displacement to the right of the
T4 spinous process
5-Thickening of the right paraspinal stripe
6-Depression of the left mainstem bronchus > 40°
below the horizontal
7-Loss of definition of the aortopulmonary window
114. b) CT :
1-Non-Contrast :
-May show indirect signs of aortic injury :
a) Mediastinal hematoma
b) Periaortic fat stranding
c) Other chest injuries
115. 2-CTA :
a) Signs of mediastinal hematoma :
-Abnormal soft tissue density around the
mediastinal structures
-Location is important , periaortic hematoma
much more suggestive of aortic injury than
isolated mediastinal hematoma remote
from the aorta
116. b) Signs of aortic injury :
-Intraluminal filling defect (intimal flap or
clot)
-Abnormal aortic contour (mural hematoma)
-Pseudoaneurysm
-Extravasation of contrast
120. 1-Etiology :
1-Blunt or penetrating chest trauma
2-Secondary to thoracic , neck or
retroperitoneal surgery
3-Esophageal perforation
4-Tracheobronchial perforation
5-Vigorous exercise , child birth , valsalva
maneuver
6-Asthma
7-TB
8-Perforation of a hollow abdominal viscous (with
extension of gas via the retroperitoneal space)
121. 2-Radiographic Features :
-Small amounts of air appear as linear or
curvilinear lucencies outlining mediastinal
contours :
1-Thymic sail sign
2-Air anterior to the pericardium
3-Air around the pulmonary artery or its major
branches
4-Air around the aorta or its major branches
5-Double bronchial wall sign
6-Subcutaneous emphysema
128. 1-Definition :
-Accumulation of blood in the pericardium
2-Radiographic Features :
->250 mL is necessary to be detectable
-Subpericardial fat stripe measures >10 mm (a
stripe 1 to 5 mm can be normal)
-Symmetrical enlargement of cardiac silhouette
(water-bottle sign)
129. Pericardial effusion on both chest radiograph and axial CT , Red arrow points to
fat outside of pericardium , Green arrow points to pericardial space which is
8 mm in this patient (<4 mm is normal) , Yellow arrow points to fat outside
of heart and the blue arrow to the myocardium
135. a) Plain Radiography :
-Chest radiographs are nonspecific and
usually show wide mediastinum , left
pleural effusion or hydropneumothorax
-Pneumomediastinum is common but is a
nonspecific finding
136. 77 year old man with esophageal rupture , portable chest radiograph
shows subtle retrocardiac opacity (arrow) and blunted left
costophrenic angle (arrowhead) consistent with mild pleural fluid
and overlying consolidation
137. b) Contrast Enhanced Esophography :
-Extravasation of contrast material into the
mediastinum
138.
139. c) CT :
-Focal esophageal wall thickening
-Periesophageal fluid collections
-Free mediastinal air
-Contrast extravasation into the
mediastinum and pleural space
140. 77 year old man with esophageal rupture , CT of the abdomen and pelvis with oral and intravenous
contrast , Axial (A) CT at the level of the aortic arch shows a dilated, air-and-fluid-filled thoracic
esophagus (arrow) , Axial (B) and coronal (C) show extraluminal contrast and air (large arrows)
extending to the left of the distal esophagus (e) , also note associated bilateral pleural fluid (B, pf)
and overlying left-lung base atelectasis (B, arrowheads)
141. Acute mediastinitis in a patient
with esophageal perforation
(a) CT+C shows esophageal wall
thickening (arrow) and a
posterior mediastinal air-fluid
collection (arrowhead) abutting
the esophagus
(b) CT+C shows the probable site
of esophageal perforation
(arrowhead) and esophageal
wall thickening (arrow)