Radiographic Findings

Radiograph from 2/97			Preoperative radiograph 5/99

2/97-- Hazy pulmonary density is present in the right upper lobe, best seen in the 4 cm area above the minor fissure. The chest film also showed mild cardiomegaly, mild basilar strandy densities with associated thickening of the bronchial markings, and an enlarged main pulmonary artery and central hilar vessels consistent with pulmonary hypertension.

5/99--There is interval increase in heart size, with increase in prominence of the main pulmonary artery and central hilar vessels consistent with increasing pulmonary hypertension and vascular congestion. Minimal perihilar pulmonary hazy density suggests early edema. Pleural effusions are absent.

Causes of pulmonary hypertension have different mechanisms. Match the disorders associated with pulmonary hypertension in the first column with one of the mechanisms in the second column [1].

Atrial septal defect Schistosomiasis Obesity Pulmonary veno-occlusive disease Sarcoidosis Mitral stenosis Chronic pulmonary embolism Mediastinal fibrosis Plexogenic pulmonary angiopathy

Increases the resistance to pulmonary venous drainage Increases resistance because of arterial-arteriolar wall or lumen abnormalities Increases pulmonary vascular resistance due to pleuropulmonary disease Increases pulmonary blood flow Results in hypoventilation

Answer

The following are views of a CT scan taken in October, 1997.

CT #1. Small (1-1.5 cm) focal areas of ground-glass opacity are present in the upper lobes. Small subpleural consolidations are seen in the lateral left upper lobe. Mild bronchial wall thickening is present.

Throughout the lungs on all images, there are subtle, 1-2 mm, nodular densities in a centrilobular-bronchocentric distribution. These are best seen on CT #2 throughout the left lower lobe. Note that these evenly-spaced tiny densities are seen to extend up to, but not beyond, an imaginary line drawn approximately 3 to 5 mm from the pleura--a line that defines the peripheral limits of the centrilobular structures of the lung.

CT #2. In the mid and central lung, there is enlargement of the pulmonary arteries. The arteries and bronchi are normally approximately the same size, while here the arteries are almost twice the size of their accompanying bronchi.

The right lower lobe (circled area) shows evidence of mosaic perfusion: focal 1-2 cm regions of subtly hyperlucent lung are associated with vessels of diminished size compared to the adjacent lung (see diagram below).

Diagram

CT #3. A dense, ground-glass, ovoid nodule is present in the anterior left upper lobe. In the perihilar regions, again note the bronchial wall thickening and the enlarged accompanying pulmonary arteries.

CT #4. Note how the thin parenchymal line (1 mm thick x 1 cm in length) touching the anterolateral pleura of the RUL is perpendicular to the pleural surface. What does this line correspond to anatomically? If this line is seen on a chest radiograph, what is it called? Answers

Reference

1.Hansell D, Peters M. Pulmonary vascular diseases and pulmonary edema. In P Armstrong, A Wilson, P Dee, D Hansell (eds): Imaging of Diseases of the Chest, 2nd ed. St. Louis, 1996, Mosby-Year Book, Inc., p. 394.

Clinical summary Image 1

Table of Contents

Answer

Atrial septal defect--4. Schistosomiasis--2. Obesity--5. Pulmonary veno-occlusive disease--1. Sarcoidosis--3 and sometimes 2. Mitral stenosis--1. Chronic pulmonary embolism--2. Mediastinal fibrosis--1. Plexogenic pulmonary angiopathy--2.

Increases the resistance to pulmonary venous drainage Increases resistance because of arterial-arteriolar wall or lumen abnormalities Increases pulmonary vascular resistance due to pleuropulmonary disease Increases pulmonary blood flow Results in hypoventilation [1]

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Answers

What does this line correspond to anatomically? A slightly thickened interlobular septum (see diagram below). If this line is seen on a chest radiograph, what is it called? Kerley B line.

Diagram

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Clinical summary Image 1

Table of Contents