呼吸影像总论.pptx

单击鼠标编辑大纲正文格式,第二个大纲级,第三个大纲级,第四个大纲级,第五个大纲级,第六个大纲级,第七个大纲级,第八个大纲级,第九个大纲级,#,医学影像教研室,单击鼠标编辑大纲正文格式,第二个大纲级,第三个大纲级,第四个大纲级,第五个大纲级,第六个大纲级,第七个大纲级,第八个大纲级,第九个大纲级,06/11/2019,#,医学影像教研室,本系统学习要点：,Outline of,the respiratory system,：,一,.,呼吸系统总论,Pandect,of the respiratory system,1.,常用的影像学检查方法,Imaging check-up method in common use,2.,正常影像学表现和常见变异,normal imaging and familiar variance,3.,胸部基本病变影像学表现,Basic pathological changes imaging represent,二,.,呼吸系统疾病,the respiratory system disease,第一章 呼吸系统总论,Pandect,of the respiratory system,本节课要点：,emphases of this class:,1.,了解胸部检查技术,Know chest check-up technic,2,掌握正常胸部的,X,线、,CT,解剖,Master normal chest X-ray,CT anatomy,3.,掌握纵隔正常,X,线、,CT,、,MR,解剖和纵隔分区,Master mediastinal normal X-ray,CT,MR anatomy and mediastinal district,4.,熟悉横膈、胸膜的,X,线、,CT,解剖,Familiar with the diaphragmatic,pleural X-ray,CT anatomy,第一节 常用的影像学检查方法：,Common Examinations,1.X,线检查,X-ray examination,2.CT,检查,CT,examination,3.MRI,检查,MRI,examination,4.,血管造影及介入放射学检查,angiography and interventional radiology,5.,超声检查,ultrasonograph,6.,核素检查,nuclein,examination,7.PET,检查等,PET,examination,一、,X,线检查,X-ray examination,：,1.X,线胸部透视,Chest fluoroscopy,2.,摄片,CR,、,DR,3.,体层摄影,tomography,4.,支气管造影,bronchophy,X,线检查方法,X-ray examination,：,（一）普通检查,Common Examinations,：,1.,透视,fluoroscopy,：,简便、经济、应用广泛,simple and convenient,、,economy and widely used,多用隔室和电视透视,compartment and fluoroscopic television image,2.,摄影,radiography,：,常规摄影体位,routine posture,：,正位,normotopia,：,通常为后前位,posteroanterior position,站立前胸壁靠片,Anterior chest wall close to the film,双臂尽可能内旋,both arms adtorsion,X,线自背部射入,X-ray come from backside,不能站立的患者，采用仰卧前后位,the patient couldnt stand employ supine body anteroposterior position(A-P position),侧位,lateral position,：,患侧侧胸壁靠片,affected side chest wall close to the film,两手抱头,two tactics on head,X,线自健侧射入,X-ray come from uninjured side,斜位,oblique position,：常用于显示肋骨腋段的骨折,show fructure in parasternal costa,前弓位,lordotic position,：,为立位，主要用于显示肺尖部及与锁骨、肋骨重叠的病变,show pathological changes in apical lung and overlap section of clavicle and costa,（二）特殊检查,Special examinations,：,体层摄影,Tomography,：,基本淘汰,fall into disuse,高仟伏摄影,High KV radiography,：,电压不低于,120kV,，,5mAs,7mAs,的摄影,120kV,57mAs,1.X,线穿透力强,strong penetrating power,2.,可减少胸壁软组织、肋骨对肺内病变的干扰,reduce the interference of the soft tissue of chest wall and rib,3.,使肺纹理显示清楚,show pulmonary markings clear,4.,有利于中央型肺癌、纵隔病变及尘肺等的观察,profit observing central lung cancer,disease of mediastinum and pneumonoconiosis,5.,由于,DR,、,CT,及,MR,的应用，高千伏摄影应用已不多,high kV radiography,has been condemned.,（三）造影检查,contrast examination,：,1.,支气管造影（,bronchography,）：,目前很少使用,Now rarely used,曾适用于支气管扩张,for bronchiectasis,肺癌,lung cancer,慢性肺化脓症,chronic pulmonary,suppuration,肺不张,pulmonary atelectasis,支气管胸膜瘘等,bronchopleural fistula,2.,血管造影,angiography,：,肺动脉造影,Pulmonary arteriography,：,支气管动脉造影,（,bronchoarteriogrphy,）：,用于,:,肺动脉瘤,pulmonary artery aneurysm,肺动静脉瘘,pulmonary arteriovenous fistula,肺动脉发育不良,hypoplasia of pulmonary artery,不明原因的咯血,unexplained hemoptysis,等,目前多层,CT,增强扫描的广泛应用，肺部血管造影也已很少应用,Pulmonary angiography has been mainly displaced by enhancement scanning of CT,气管、支气管造影,bronchography,二,.CT,检 查,CT examination,：,1.,普通扫描（平扫）,plain CT,：,系不使用对比剂的常规扫描,no contrast medium conventional scanning,扫描范围通常从肺尖至肺底,from apex pulmonis to base of lung,也可根据定位片所见，进行局部选层扫描,partial slice selective scanning,一般有肺窗和纵隔窗,lung window and mediastinum window,2.,增强扫描,enhancement scanning,：,通常是在平扫的基础上进行,base on the plain scan,经静脉快速注射对比剂后再进行的扫描,after contrast medium intravenous injection,使用纵隔窗观察,medistinal window,主要用于鉴别病变为血管性或非血管性,differentiate vascular or nonvascular,明确纵隔病变与心脏大血管的关系,make the relationship of disease of mediastinum and cardiac and large vessel clear,了解病变的血供情况,blood supply,帮助鉴别良、恶性病变等,differentiate benign or malignant,3.,高分辨力扫描,high-resolution scanning,：,高分辨力,CT,扫描技术为薄层（,1mm,2mm,）扫描及高分辨力算法重建图像的检查技术,thin layer chromatogram scanning and high-resolution algorithmic reconstructed image,主要用于：,（,1,）观察病灶的微细结构,fine structure of focus of infection,（,2,）对弥漫性肺间质病变及支气管扩张的诊断等具有突出效果,outstanding,used for,diagnosis of diffuse interstitial pulmonary disease and bronchiectasis,（,3,）多用肺窗观察,lung window,（,4,）是常规扫描的一种补充,supply scan,4.,动态扫描,dynamic scanning,：,注射对比剂后对某感兴趣区行多次快速扫描,multiple fast scan after contrast medium,以了解对比剂的浓度变化,concentration of contrast medium,主要用于明确血供丰富的病灶或血管性病变，,例如肺癌鉴别,affluent blood supply or vascular disease,，,for,example lung cancer differentiate,5.,多层面,CT,扫描,multi-section CT scan,：,X,线管一次旋转过程中同时获得,4,、,8,或,16,、,64,等层面图像数据的成像系统,multi-section,明显缩短胸部扫描的时间，提高纵轴方向的空间分辨力,reduce sweep time,enhance spatial resolution in Y direction,再现技术,:rendering technic,1.,表面再现,surface rendering,2.,最大强度投影,maximum intensity projection(MIP),3.,容积再现,Volume rendering,仿真内窥镜技术：,SimulateddEndoscopic technique,可对肺部病灶进行多方位观察,omnibearing observation,具有：,肺结节分析功能,pulmonary node functional-analytical,肺支气管成像,bronchopulmonary imaging,肺含气量测定,pulmonary gas mensuration,支气管仿真内镜功能等,bronchial virtual endoscopy,6.CT,灌注成像,Perfusion Imaging of CT,：,在静脉快速团注对比剂时，对感兴趣区层面进行动态,CT,扫描,dynamic CT scanning after contrast medium,获得感兴趣区时间,-,密度曲线，曲线中,CT,值的变化,time-density curve,changes of CT value,可反映组织中碘聚集量随时间的变化而变化,iodine accumulation change time-variation,可有效地反映局部肺组织血流灌注量的改变,pulmonary perfusion change,男，,73,岁,male,73 years old,咳嗽、胸闷气急半年,cough,、,chest tightness and dyspnea Six months,近半个月加重,Recently a half months Increased illness,该病人行纤维支气管镜电切术,bronchofibroscope electrotomy,病理,pathology,：,炎性肉芽肿,inflammatory granuloma,三、,MRI,检 查：,MRI,examination,1.,检查方式,examination techniques,：,自旋回波（,SE,）,反转恢复,inversion recovery;IR,饱和恢复序列等,saturation recovery,以自旋回波最常用,2.,扫描断面,scanning section,：,常规先行横断面成像,必要时行冠状面或矢状面成像,Axial section firstly,coronal section or sagittal section if necessary,3.,肺血管成像,Pulmonary Angiography,：,成像技术有：,时间飞越法和相位对比法两种,time of flight TOF and phase contrast PC,时间飞越法是利用流动相关增强效应,TOF:enhanced effect correlate with flow,相位对比法是利用血流中的相位效应,PC:phase effect in blood stream,正常胸部轴位,MRI,表现,主肺动脉与右肺动脉层面,main pulmonary trunk and right pulmonary artery section,AVM,第二节 胸部正常,X,线表现和常见变异,normal X-ray and common variance,学习总原则,:,认准正常,了解变异,（一）胸廓（,Thorax,）,1.,软组织胸廓,soft tissue of chest wall,：,胸锁乳突肌,sternocleidomastoid muscle,锁骨上皮肤皱褶,skin reflection over the clavicle,胸大肌,major pectoral muscle,女性乳房及乳头,female breast and papilla,伴随阴影,companion shadow,2.,骨性胸廓,Bony Thorax,：,胸骨,sternum,肋骨,rib,（肋软骨,costicartilage,）,锁骨,clavicle,肩胛骨及胸椎,scapula and thoracic vertebra,肋骨先天变异,costal inborn variation,：,1.,叉状肋（,bifid,）,:,易发生于第,2,、,4,肋,2nd,4th rib,2.,颈肋,cervical rib,：,发生于第,7,颈肋,7th rib,3.,肋骨联合,fused rib,：,常发生于第,1,、,2,肋骨,1st,2nd rib,锁骨菱形窝（,rhomboid fossa,）,（二）纵隔,（,Mediastinum,）,1.,解剖组成,anatomy,：,含心脏,heart,大血管,great vessels,气管,trachea,主支气管,primary bronchi,淋巴组织,lymph tissue,胸腺,thymus,神经,nerve,脂肪,fat,等,位于胸廓中央,central thorax,上为胸廓入口下为横膈,Superior,part is thoracic entrance,inferior part is diaphragm,前壁,paries anterior,由胸骨,sternum,和相关肋软骨,costicartilage,后壁,paries posterior,由脊柱,spine,及相关肋骨,ribs,两侧,side wall,由纵隔胸膜,medistinal pleura,所围绕而形成的区域,纵隔内包含心脏大血管,heart and large vessel,、气管,trachea,及食管,oesophagus,等结构,又有神经组织,nerve,、淋巴组织,lymph tissue,及脂肪组织,fat,等,上端,upper end,直接与颈部相连,jioned cervix,下至膈,midriff,与腹腔相隔,apart abdominal cavity,2.X,线表现及分区,subarea,：,胸骨后,retrosternal,，胸椎前,thoracic vertebra,，两肺间,between lung,为纵隔,气管,trachea,、支气管,bronchia,呈管状透明区,transparent zone,其余组织均呈灰色软组织影,gray soft tissue density,侧位胸片：,从胸骨柄体交界处至,T4,下缘画一水平线，其上为上纵隔，下为下纵隔,以气管、升主动脉及心脏前缘的连线作为前、中纵隔的分界,以食管前壁及心脏后缘连线作为中、后纵隔的分界,从而将上、下纵隔各分为前、中、后三区，共,6,区,由,2,纵线,ordinate,和,2,横线,transverse line,分为九区,分区对纵隔肿瘤定性有关,determine the nature,（三）膈肌（,Diaphragm,）：,由薄层肌腱组织构成肌腱,分左右两叶，介于胸、腹腔之间,between thorax and abdominal cavity,呈光滑弧形,arc,一般右膈平,9-10,后肋，左膈低,1-2cm,平静呼吸,1-3cm,，深呼吸,3-6cm,肋膈角,costophrenic angle,，,心膈角,cardiophrenic angle,横膈上有多个连结胸腹腔结构的裂孔,hiatus,.,主动脉裂孔,hiatus aorticus:,有主动脉,arteriae aorta,、奇静脉,venae azygos,、胸导管,left lymphatic duct,和内脏神经,splanchnic nerves,通过,.,食管裂孔,esophageal hiatus:,有食管,esophagus,及迷走神经,pneumogastric nerve,通过,.,腔静脉裂孔,:,有腔静脉,vena cava,通过,此外还有：,胸腹膜裂孔,pleuroperitoneum hiatus,胸骨旁裂孔,parasternal hiatus,为横膈的薄弱区,disphragmatic muscle,weakness,是膈疝的好发部位,common site of diaphragmatic hernia,横膈,dome of the disphragmatic muscle,的圆顶偏内侧及前方所以呈内高外低，前高后低,正位胸片上,:,膈内侧,wall of the midriff,与心脏形成心膈角,cardiophrenic angle,，外侧逐渐向下倾斜，与胸壁间形成尖锐的肋膈角,costophrenic angle,侧位片上,:,膈前端与前胸壁形成前肋膈角,pre-,costophrenic angle,圆顶,posterior dome,后部明显向后、下倾斜,declination,，与后胸壁形成后肋膈角,posterior costophrenic angle,，位置低而深,平静呼吸,eupnea,状态下，横膈运动幅度约,为,amplitude of motion 1cm,2.5cm,深呼吸,deep breathing,时可达,3cm,6cm,横膈运动两侧大致对称,movement symmetry,横膈的局部发育较薄弱,dysplasia,或张力不均,anisotonic,时，向上呈一半圆形凸起，称为局限性膈膨出,localized diaphragmatic eventration,多发生于前内侧,anteriomedialis,，右侧较常见，深吸气,deep,inspiration,时明显，为正常变异,normal variant,有时在深吸气状态下,deep inspiration,，横膈可呈波浪状,wavilness,，称为“波浪膈”,wavy midriff,系因膈肌,disphragmatic muscle,附着于不同的肋骨前端,different,anterior extremity of ribs,，在深吸气时受肋骨的牵引,draught,所致,膈 肌,disphragmatic muscle,（四）胸膜,Pleura,胸膜正常时不显影,dont develop,当胸膜反褶,pleura pleat,与,X,线平行,parallel,时可显示为线状或薄层状致密影,line,or,lamella,high density,（五）气管和支气管,（,Trachea and bronchus,）,1.,气管,trachea,：,呈管状透明区,tubular transparent zone,上缘,superior border,自,C6,、,7,水平,气管分叉,tracheal bifurcation,平,T,5-6,分叉角,pronghorn,60-85,（右,20-30,，左,30-45,）,2.,支气管,bronchia,：,呈树枝状,arborization,左、右主支气管,primary bronchi,亦呈管状透明区,tubular transparent zone,叶支气管,lobar bronchia,左,2,支，右,3,支,段支气管,rami bronchiales segmentorum:,左,8,支，右,10,支,两侧主支气管,primary bronchi,逐级分出：,叶,lobe,肺段,segment,亚肺段,subsegment,小支气管,bronchium,细支气管,bronchiole,呼吸细支气管,respiratory bronchiole,肺泡管,ductuli alveolares,和肺泡囊,air saccules,（六）肺,lungs,：,1.,肺野,lung field,：,由,含气肺泡,alveolus,构成,呈均匀透过度高的阴影,homogeneous low density,上、中、下三野,upper,middle and lower zones,内、中、外三带,inner,middle and outer zones,2.,肺纹理,lung markings,：,由肺动脉,pulmonary artery,静脉,pulmonary vein,支气管,bronchia,淋巴组织,lymph tissue,等解剖结构,anatomic structure,组成,X,线上,要由肺动、静脉分支构成,branching of pulmonary artery and pulmonary vein,X,线表现：,自肺门向肺野呈放射分布的干树枝状致密影,radial dendritic high density,均匀光滑,正位胸片,normotopia sternum,：,肺纹理自肺门向肺野中、外带延伸,lung marking,outward extention,逐渐变细,taper off,至肺野外围几乎不能辨认,couldnt identify in periphery of lung,下肺野肺纹理比上肺野多而粗,lung marking of lower field more and wide than upper field,右下肺野肺纹理比左下肺野多而粗,right side wider than left side,正常气管、支气管造影 正常肺野与肺纹理,3.,肺门,pulmonary hila,：,由肺动脉,pulmonary artery,静脉,pulmonary vein,支气管,bronchia,淋巴组织,lymph tissue,神经,nerve,等解剖结构,anatomic structure,组成,X,线：,主要是肺动、静脉的大分支显影,branching,of pulmonary artery and pulmonary vein,呈均匀中,等密度阴影,homogeneous mid-density shadow,左侧较右侧高,left higher than right12cm,位于,24,肋前端,anterior ribs,的肺内带,（,1,）右肺门分上、下两部,right hilus pulmonis,：,上部,upside,：,由上肺静脉、动脉及下肺动脉干后回归支组成,pulmonary artery,pulmonary vein and inferior trunk pulmonary,下部,inferior part,：由右下肺动脉干,right inferior trunk pulmonary,组成,正常人宽度,breadth15mm,上、下肺门夹角为肺门角,pulmonary hilar angle,（,2,）左肺门,left,hilus pulmonis,：,由左肺动脉,left pulmonary artery,及上肺静脉,branching of superior pulmonary vein,分支构成,上部为左肺动脉弓,left pulmonary arches,下部为左下肺动脉,left inferior pulmonary artery and branching,及其分支,（,3,）侧位肺门,lateral hilus pulmonis,：,侧位胸片上两侧肺门大部分重叠,bilateral hilus pulmonis overlaped mostly,右肺门多位于前方,侧位肺门表现,lateral hilus pulmonis,：,似一尾巴拖长的“逗号”,comma,其前缘,anterior border,为上肺静脉干,left,superior pulmonary vein,后上缘,superior border,为左肺动脉弓,left pulmonary arches,拖长的逗号尾巴由两下肺动脉干构成,inferior trunk pulmonary,（,3,）侧位肺门,lateral hilus pulmonis,：,呈“逗号”样,comma,前缘为上肺静脉干,上、后缘为左肺动脉弓,尾巴为两下肺动脉干重叠影,4.,肺叶,lobe,、肺段,segment,和肺小叶,lobule,（,1,）肺叶,lobe,：,解剖分左上下叶及右上中下叶,斜裂及水平裂,major fissure and minor fissure,将右肺,分为上叶、中叶和下叶,upper lobe,、,middle lobe and lower lobe,斜裂,major fissure,将左肺分为上叶和下叶,upper lobe,and lower lobe,左肺上叶又分为上部与下（舌）部,upside part and lingua part,（,2,）肺段,segment,：,其分布及名称与肺段支气管一致,comport with segmental bronchi,正常平片不能显示,couldnt show in plain film,副叶,accessory lobe,：,额外,excess,的,胸膜裂,pleura,深入肺段之间，形成额外的肺叶,奇叶,azygos lobe,（位于右侧肺门上方纵隔旁）,（,3,）肺小叶,lobule,：,肺小叶既是解剖单位又是功能单位,anatomic unit,and functional unit,许多肺小叶组成一个肺段,A lot of lubule make up a segment,小叶的大小不完全一致,dissimilar,直径约为,10mm,25mm,肺小叶,lobule,由小叶核心,core,、小叶实质,parenchyma,和小叶间隔,septa interlobulare,组成,小叶核心主要是小叶肺动脉,arteriae interlobulares,和细支气管,bronchiole,，其管径约,1mm,左右,小叶实质,parenchyma,为小叶核心的外围结构,periphery of the core,小叶间隔,septa interlobulare,由疏松结缔组织,loose connective tissue,组成，内有小叶静脉,interlobular vein,及淋巴管,lymphatic,走行,每个小叶又由,3,5,个呼吸小叶,respiratory,lobule,（又称腺泡）构成,gland alveolus,终末细支气管直径约,0.6,0.8mm mmterminal bronchiole,在腺泡,gland alveolus,内继续分出,l,、,2,、,3,级呼吸细支气管,respiratory bronchiole,然后再分为,:,肺泡管,ductuli alveolares,、肺泡囊,air saccules,、最后为肺泡,alveolus,肺泡壁,air saccules,上有小孔,pore,，称为肺泡孔,alveolar pore,空气可经肺泡孔,alveolar pore,相互沟通,communicate,呼吸细支气管,respiratory bronchiole,、肺泡管,ductuli alveolares,、肺泡囊,air saccules,、肺泡,alveolus,为肺的气体交换部分,gas exchange,（,4,）肺实质和肺间质：,肺实质,lung parenchyma,：,具有气体交换功能,gas-exchange function,的含气间隙,pneamatic space,及结构,structure,（肺泡及其壁）,肺间质,lung interstitium,：,支气管和血管周围、肺泡间隔和小叶间隔、脏层胸膜下结缔组织,conjunctive tissue,正 常 肺 门,normal hilus pulmonis,CT,、,MRI,CT,MRI,正常胸部轴位,MRI,表现,主肺动脉与右肺动脉层面,main pulmonary trunk and right pulmonary artery section,正常胸部轴位,MRI,表现,左心房层面,left atrium,section,：,脊柱左前方为降主动脉,aorta descendens,，降主,动脉前方为左心房,left atrium,左心房前部为主动脉根部,root of the,aorta ascendens,，其右侧为右心房,right,atrium,，其左前方为右心室及流出道,right ventricle and right ventricular outflow,正常胸部轴位,MRI,表现,左心房层面,left atrium,section,正常胸部冠状位,MRI,表现,右心室层面,right ventricle section,：右心室,right ventricle,向上与右室流出道及主肺动脉,main pulmonary trunk,相连，部分左心室,正常胸部冠状位,MRI,表现,右心室层面,right ventricle section,正常胸部冠状位,MRI,表现,升主动脉层面,aorta ascendens,section,：,右心房,right atrium,居心脏右下方，左室,left ventricle,居中，左室流出道,left,ventricular outflow,斜右上方与升主动脉,aorta ascendens,相连，左侧主肺动脉，并见由主动脉分出的无名动脉,anonyma,和左颈总动脉,left arteriae carotis communis,升主动脉,aorta ascendens,右上可见左、右头臂静脉汇合处,confluence of venae brachiocephalica,正常胸部,MRI,表现,升主动脉层面,aorta ascendens,section,正常胸部,MRI,表现,上腔静脉层面：右侧与右心房相连，主动脉弓位于其左侧，左上方可见左锁骨下动脉，主肺动脉在主动脉弓下方，右心房左上方可见左室流出道,正常胸部冠状位,MRI,表现,肺动脉层面：气管,trachea,、主动脉结，下方可见左右并列的左右肺动脉，下方为左心房,left atrium,和与之相连的两侧上肺静脉,正常胸部冠状位,MRI,表现,气管分叉层面：两侧主支气管、隆突,carina,，主动脉结,aortic knob,、左心房,正常胸部冠状位,MRI,表现,降主动脉层面：降主动脉偏脊柱左侧下行，奇静脉在其右缘走行,正常胸部矢状位,MRI,表现,自右向左选择四个层面,上腔静脉层面,superior vena,section,：,前方为升主动脉,aorta ascendens,，后方为上腔静脉,superior vena,，向下与右心房,right atrium,相连,上腔静脉后方可见右侧肺动脉,right pulmonary artery,，其下为左心房,left atrium,右肺动脉后方可见上下走行的右侧主支气管,right,及中间支气管,central bronchia,正常胸部矢状位,MRI,表现,上腔静脉层面,superior vena section,正常胸部矢状位,MRI,表现,升主动脉层面：纵隔前上方为升主动脉，有无名动脉与其相连，后方为右侧肺动脉，再后方为气管,trachea,，升主动脉根部后方为左心房，其下为右心房,正常胸部矢状位,MRI,表现,升主动脉层面,aorta ascendens,section,正常胸部矢状位,MRI,表现,右心室层面,right ventricle section,：,气管居中,trachea placed in the middle,，后方为食管,esophagus,，其前方为左心房,left atrium,，上方为右肺动脉,right pulmonary artery,，最上方为主动脉弓,aortic arch,左房前方为升主动脉根部,root of the,aorta ascendens,，前下方为右心房,right atrium,，最前方为右心室,right ventricle,正常胸部矢状位,MRI,表现,右心室层面,right ventricle section,