The anterior wall stripe of the left lower lobe bronchus on the lateral chest radiograph: CT correlative study

We designed a study to determine whether thickening or effacement of the anterior wall stripe of the left lower lobe bronchus on the lateral chest radiograph implies adjacent disease, as it does for the posterior wall stripe of the right bronchus intermedius. The anterior wall stripe of the left lower lobe bronchus originates from the inferior anterior aspect of the end-on left bronchus and descends in a gentle posteriorly convex curve. The left lower lobe bronchus was identified on routine lateral chest films in 86 of 90 consecutive patients who also had chest CT. In those cases the anterior wall stripe was measured and categorized on chest films. On the CT scans, the length of the left lower lobe bronchus and its relationship to the left lower lobe artery and left upper lobe, lingular, and lower lobe veins were assessed. The presence of adjacent disease was noted. A complete anterior wall stripe was seen in 59 of 86 cases. It was effaced by anterior soft tissue in 15 of 86 cases; in 12 of 86 cases only the superior 0.5-1.5 cm was effaced. A normal anterior wall stripe was as thick as 12 mm in one case, but was 6 mm or less in 90%. Shapes other than linear were common. Anatomic variation accounted for nearly all of these findings. There was no focal abnormality in the 12 cases with partial effacement or in nine of the 15 cases with complete effacement; disease was significant in only two of these six. We concluded that thickening or effacement of the anterior wall stripe is an unreliable sign of disease.     

Right upper lobe versus right middle lobe: differentiation with thin- section, high-resolution CT

A new method was developed to differentiate the upper lobe from the middle lobe of the right lung with thin-section, high-resolution computed tomography. In the upper lobe, a medial subsegmental bronchus of an anterior segmental bronchus is always located lateral to the corresponding artery. In the middle lobe, a medial subsegmental bronchus of a lateral segmental bronchus and a superior and inferior subsegmental bronchus of a medial segmental bronchus are always located medial to the corresponding artery. In other words, the anatomic relationship between the subsegmental bronchi and the corresponding pulmonary arteries in the upper lobe is opposite to that in the middle lobe. One hundred seventeen cases, including 54 cases of lobar volume loss, were reviewed with this method, and in each case it was possible to differentiate the upper lobe from the middle lobe without the contiguous section analysis.     

CT anatomy of the lingular segmental bronchi

Thin-section CT scans were performed in 40 patients to demonstrate the normal appearance of the lingular division (LD) bronchus and its segmental and subsegmental bronchi and to search out the possible anatomical landmark dividing the anterior segment and LD of the left upper lobe. The LD bronchus was identified in all patients. The complete branching pattern of the lingular segmental and subsegmental bronchi could be traced in 19 (47.5%) patients. Since the lower branch of the draining vein of the anterior segment of the left upper lobe (V3b) runs horizontally between the anterior segment and the LD of the left upper lobe, it is a good landmark dividing the anterior segment and LD of the left upper lobe. Familiarity with thin-section CT anatomy of the lingular segmental and subsegmental bronchi and surrounding vascular structures is helpful in identifying the lingular bronchial tree precisely and localizing a lesion in the left upper lobe correctly.     

The normal angiographic sylvian point on the lateral cerebral angiogram

Summary The angiographic sylvian point (ASP) is one of the most useful landmarks on cerebral angiograms for detecting retrosylvian masses. Although it is suggested to be the halfway point on the clinoparietal line (CPL), its exact normal position has not been defined. The lateral carotid angiograms of 100 consecutive patients from 22 to 65 years of age were used to study the normal ASP in relation to the CPL. Patients with severe neurological deficits or angiographic evidence of hydrocephalus, severe vascular disease or mass lesions were eliminated from this study. In our 100 normals, the normal ASP was within 8 mm above and below the CPL, and in the majority (82%) it was located behind the midpoint of the CPL. It was not situated more than 14.4 mm posterior and never more than 3.1 mm anterior to the midpoint. Application of these normal relationships facilitates detection of small, deep retrosylvian masses occupying the medial portions of the parietal, occipital and temporal lobes.     

Congenital bronchial abnormalities revisited.

Bronchial anatomy is adequately demonstrated with the appropriate spiral computed tomographic technique on cross-sectional images, multiplanar reconstruction images, and three-dimensional reconstruction images. Contrary to the numerous variations of lobar or segmental bronchial subdivisions, abnormal bronchi originating from the trachea or main bronchi are rare. Major bronchial abnormalities include accessory cardiac bronchus (ACB) and "tracheal" bronchus. An ACB is a supernumerary bronchus from the inner wall of the right main bronchus or intermediate bronchus that progresses toward the pericardium. Fourteen ACBs were found in 17,500 consecutive patients (frequency, 0.08%). The term tracheal bronchus encompasses a variety of bronchial anomalies originating from the trachea or main bronchus and directed to the upper lobe. In a series of 35 tracheal bronchi, only eight originated from the trachea, three originated from the carina, and 24 originated from the bronchi. Displaced tracheal bronchi (27 of 35) are more frequent than supernumerary tracheal bronchi (eight of 35). Minor bronchial abnormalities include variants of tracheal bronchus, displaced segmental bronchi, and bronchial agenesis. The main embryogenic hypotheses for congenital bronchial abnormalities are the reduction, migration, and selection theories. Knowledge and understanding of congenital bronchial abnormalities may have important implications for diagnosis, bronchoscopy, surgery, brachytherapy, and intubation.     

Analysis of interlobar (between upper and middle lobes) lymph node enlargement on hilar tomography

We examined interlobar (between upper and middle lobes) lymph node enlargement by compensating filter hilar tomography in cases of central vein type right upper lobe vein. The control group consisted of 100 randomly selected specimens, in which hilar lymphadenopathy such as malignant lymphoma or sarcoidosis, and displacement of interlobar fissure due to atelectasis or tuberculosis were excluded. Eighty-four of the control cases were central vein type. As a lung cancer group, 18 cases were analyzed. These cases consisted of central vein type, and interlobar lymph node enlargement was noted on operation, in the course of therapy or on enhanced CT study. The right hilum bordered by the upper lobe bronchus (medial to the orifice of B1) and segmental bronchus (B2 or B3) above, central vein lateral and intermedial arterial trunk on the mediastinal side were evaluated. The shadows that obscured the inner margin of the central vein and lower margin of the upper-lobe and segmental bronchi were analyzed. The inner margin of the central vein was visible in 75 cases (89.3%) in the control group, compared to 1 (5.6%) of 18 cases in the lung cancer group. Decreased radiolucency beneath the upper lobe bronchus and segmental bronchus was found in 10 cases (11.9%) in the control, compared to 16 cases (88.9%) in the lung cancer group. In conclusion, obliteration of the inner margin of the central vein and the opacity that decreased the radiolucency extending to the peripheral side of the upper lobe bronchus are strongly suggestive of interlobar lymph node enlargement. Recognition of interlobar lymph node enlargement is useful for the staging of lung cancer and diagnosis of the disease that accompanies systemic hilar lymphadenopathy.     

Computed tomography of the tracheal bronchus

Tracheal bronchus is an uncommon anomaly in which an ectopic bronchus arises from the trachea above the carina. It occurs on the right side and two types are described: "supernumerary," which is associated with a normal trifurcating right upper lobe bronchus, and "displaced," in which instance the ectopic bronchus supplies the apical segment of the upper lobe. The CT appearance of this anomaly is described in two cases. Findings include identification of a bronchus arising from the trachea in a section more cephalad than the carina and the presence of only two segmental bronchi arising from the anatomic right upper lobe bronchus when the anomaly is of the "displaced" type. Thin axial sections and coronal imaging display the tracheal bronchus to best advantage.     

原发性气管、支气管黏液表皮样癌的CT表现

目的 探讨原发性气管、支气管黏液表皮样癌的特征性CT表现.方法 回顾性分析经病理证实的10例气管、支气管黏液表皮样癌的CT特征、临床表现及对应病理资料.结果 (1)部位:位于气管1例、主支气管1例、叶支气管3例、段支气管5例,均呈中央型.(2)形态及大小:分叶状2例、椭圆形或圆形7例、不规则形1例.肿瘤最长径10~39 mm(平均25 mm).(3)边缘:8例边缘光滑,2例边缘毛糙,邻近肺实质存在浸润.(4)密度:其中6例密度不均匀,3例密度均匀.4例密度高于胸壁肌肉,4例与胸壁肌肉相仿,1例低于胸壁肌肉.4例肿瘤内见钙化.(5)强化特点:9例行CT增强扫描中8例呈相对轻度强化,1例轻微强化.(6)周围情况:所有病例均显示气管或支气管狭窄、阻塞,5例伴阻塞性肺炎,2例伴阻塞性肺不张,3例伴远端支气管阻塞性黏液栓塞,1例伴阻塞性肺气肿,纵隔或肺门淋巴结均未见明显肿大,1例合并左肺多发肺大疱及左侧气胸.结论 原发性气管、支气管黏液表皮样癌多为中央型、低度恶性肿瘤.CT表现为气管、支气管腔内或远端边缘光滑的椭圆形或分叶状肿物,常伴钙化,少数可呈浸润性生长,增强后呈轻度强化.     

Two radiological observations on chest radiographs of children.

A. The frequency with which a ring shadow of the anterior bronchus could be clearly seen was investigated. The annual radiographs of the same normal children studied in another paper (Simon and Rona, 1976) were examined to see how often a small 3-5 mm ring shadow lying laterally near the upper part of the hilum could be clearly seen. This was the ring shadow most frequently seen and appears to be due to the anterior bronchus seen end on. B. In some children vessel size in the upper lobes is the same as that in the lower lobes. This tends to change to the adult pattern as the child grows older.     

Pathogenetic left tracheal bronchus. A review of the literature in connection with four cases (author's transl)

The so-called left "tracheal" bronchus is usually found to be a transposition of the segmental apicoposterior bronchus of the upper left lobe onto the terminal portion of the main trunk. This systematisation abnormality is less common on the left than on the right. In our experience, based on 1,500 bronchographs carried out on adults and children, we have discovered seven left "tracheal" bronchi four of them associated with an obstructive emphysema in the same area. Although this malformation is rarely encountered in the etiologies of interlobular or poly-segmental emphysemas in children, it does however appear that an upper left emphysema has two etiologies which are peculiar to it: segmental bronchial atresia and left "tracheal" bronchi. Why the left "tracheal" bronchi is more often pathogenetic in comparison with the right is open to speculation. As in many other examples of tracheo-bronchial compression for vascular reasons, the close contact between the hyperarterial ectopic bronchi and the left pulmonary artery seems, logically, to be the culprit.     

SPECT/CT肺灌注显像中肺段精确定位方法的研究

目的 研究SPECT/CT肺灌注显像中肺段横断面、矢状面及冠状面的精确定位方法.方法 分析12名健康成人的肺灌注断层图像、CT图像及二者的融合图像,按CT解剖命名标准对肺灌注横断面、矢状面及冠状面图像上肺段进行划分.即右肺10段:上叶尖段、后段、前段,中叶外侧段、内侧段,下叶背段、内基底段、前基底段、外基底段、后基底段;左肺8段:上叶尖后段、前段、上舌段、下舌段,下叶背段、前内基底段、外基底段、后基底段,并总结3个层面肺段分布的特点.结果 确定了左右肺在横断面、矢状面及冠状面上的典型层面及各个肺段的主要分布特点:(1)横断面双肺由肺尖至肺底选取11个层面:胸锁关节层面及以上,主动脉弓上缘层面,主动脉弓层面,奇静脉弓层面或气管杈层面,右肺上叶支气管层面或左肺动脉层面,左肺上叶支气管层面或右肺动脉层面,中叶或舌叶支气管层面,底干支气管层面,下肺静脉层面,上下底段静脉层面,底段静脉层面;(2)双肺由内向外分别选取6个层面,左肺:左肺门层面,左主支气管杈层面,左肺动脉叶间部层面,心尖层面,心尖左侧第一层面,心尖左侧第二层面;右肺:右肺门层面,中间支气管杈层面,叶间动脉层面,叶间动脉分杈层面或右心房右侧第一层面,右心房右侧第二层面,右心房右侧第三层面向外;(3)冠状面双肺由前向后选取7个层面:胸锁关节层面,升主动脉层面,肺动脉杈层面,气管杈层面,中间支气管层面,底段总静脉层面,胸主动脉层面.结论 按该研究方法划分肺段,可为肺灌注断层图像中肺段的精确定位提供参考依据.     

SPECT/CT肺灌注显像中肺段精确定位方法的研究

目的 研究SPECT/CT肺灌注显像中肺段横断面、矢状面及冠状面的精确定位方法.方法 分析12名健康成人的肺灌注断层图像、CT图像及二者的融合图像,按CT解剖命名标准对肺灌注横断面、矢状面及冠状面图像上肺段进行划分.即右肺10段:上叶尖段、后段、前段,中叶外侧段、内侧段,下叶背段、内基底段、前基底段、外基底段、后基底段;左肺8段:上叶尖后段、前段、上舌段、下舌段,下叶背段、前内基底段、外基底段、后基底段,并总结3个层面肺段分布的特点.结果 确定了左右肺在横断面、矢状面及冠状面上的典型层面及各个肺段的主要分布特点:(1)横断面双肺由肺尖至肺底选取11个层面:胸锁关节层面及以上,主动脉弓上缘层面,主动脉弓层面,奇静脉弓层面或气管杈层面,右肺上叶支气管层面或左肺动脉层面,左肺上叶支气管层面或右肺动脉层面,中叶或舌叶支气管层面,底干支气管层面,下肺静脉层面,上下底段静脉层面,底段静脉层面;(2)双肺由内向外分别选取6个层面,左肺:左肺门层面,左主支气管杈层面,左肺动脉叶间部层面,心尖层面,心尖左侧第一层面,心尖左侧第二层面;右肺:右肺门层面,中间支气管杈层面,叶间动脉层面,叶间动脉分杈层面或右心房右侧第一层面,右心房右侧第二层面,右心房右侧第三层面向外;(3)冠状面双肺由前向后选取7个层面:胸锁关节层面,升主动脉层面,肺动脉杈层面,气管杈层面,中间支气管层面,底段总静脉层面,胸主动脉层面.结论 按该研究方法划分肺段,可为肺灌注断层图像中肺段的精确定位提供参考依据.     

Evaluation of tracheobronchial lesions with spiral CT: comparison between virtual endoscopy and bronchoscopy]

INTRODUCTION: The aim of this study is to describe the scanning parameters for virtual bronchoscopy in the evaluation of the tracheobronchial tree and to compare the results of this examination with the endoscopic findings. MATERIAL AND METHODS: 27 patients with tracheobronchial neoplasms suspected at preliminary clinical and chest film findings or postoperative follow-up for malignant disease were evaluated with spiral CT of the chest and bronchoscopy. Virtual endoscopy was performed on the pulmonary volume involved by the lesion, using narrow axial images (thickness 2 mm, table index 3 mm, reconstruction index 1 mm.) so as to obtain MPR, MIP and 3D reconstructions with 3D Endo Vew program (Philips Medical System, Eindhoven, Holland). We compared these reconstructions and the findings the normal spiral CT scanning with the corresponding endoscopic examinations. RESULTS: In all patients we were able to study the lobar and segmental bronchi in all patients and in 2 we also evaluated the subsegmental bronchi. 25 lesions in 23 patients were shown by virtual endoscopy (8 occlusions, 8 stenosis, 5 compressions, 3 flogosis with endobronchial mucus, 1 bronchocele) and in 4 patients the examinations were negative. The bronchoscopy was negative in 4 patients and positive in 23 patients with 25 lesions, but we had agreement in 23/27 patients (85,1%). In 2 patients virtual endoscopy showed the lesions in a different bronchus compared to bronchoscopy. In one patient we interpreted the obstruction as neoplastic instead of mucus inside the bronchi and in the last patient bronchoscopy was not performed due to his old age and the virtual endoscopy showed total obstruction of a segmental bronchus. DISCUSSION AND CONCLUSIONS: The results show that virtual endoscopy can study the tracheobronchial tree as far as the segmental bronchi, and sometimes also the subsegmental bronchi and the bronchi below a closed obstruction. In addition, it can evaluate the extraluminal location of the lesions. For these reasons virtual endoscopy provides a road map for bronchoscopy as a guide for transbronchial biopsy and for endobronchial treatment planning. The limitation of this technique is its inability to evaluate the mucosal surface and distinguish flogosis from neoplastic lesions by biopsy. It can be used however in the postoperative follow-up both for cancer and transplant, when immediate biopsy is not necessary.     

SPECT/CT肺灌注显像中肺段精确定位方法的研究

目的 研究SPECT/CT肺灌注显像中肺段横断面、矢状面及冠状面的精确定位方法.方法 分析12名健康成人的肺灌注断层图像、CT图像及二者的融合图像,按CT解剖命名标准对肺灌注横断面、矢状面及冠状面图像上肺段进行划分.即右肺10段：上叶尖段、后段、前段,中叶外侧段、内侧段,下叶背段、内基底段、前基底段、外基底段、后基底段 左肺8段：上叶尖后段、前段、上舌段、下舌段,下叶背段、前内基底段、外基底段、后基底段,并总结3个层面肺段分布的特点.结果 确定了左右肺在横断面、矢状面及冠状面上的典型层面及各个肺段的主要分布特点：（1）横断面双肺由肺尖至肺底选取11个层面：胸锁关节层面及以上,主动脉弓上缘层面,主动脉弓层面,奇静脉弓层面或气管杈层面,右肺上叶支气管层面或左肺动脉层面,左肺上叶支气管层面或右肺动脉层面,中叶或舌叶支气管层面,底干支气管层面,下肺静脉层面,上下底段静脉层面,底段静脉层面 （2）双肺由内向外分别选取6个层面,左肺：左肺门层面,左主支气管杈层面,左肺动脉叶间部层面,心尖层面,心尖左侧第一层面,心尖左侧第二层面 右肺：右肺门层面,中间支气管杈层面,叶间动脉层面,叶间动脉分杈层面或右心房右侧第一层面,右心房右侧第二层面,右心房右侧第三层面向外 （3）冠状面双肺由前向后选取7个层面：胸锁关节层面,升主动脉层面,肺动脉杈层面,气管杈层面,中间支气管层面,底段总静脉层面,胸主动脉层面.结论 按该研究方法划分肺段,可为肺灌注断层图像中肺段的精确定位提供参考依据.     

Quantification of bronchial dimensions at MDCT using dedicated software

This study aimed to assess the feasibility of quantification of bronchial dimensions at MDCT using dedicated software (BronCare). We evaluated the reliability of the software to segment the airways and defined criteria ensuring accurate measurements. BronCare was applied on two successive examinations in 10 mild asthmatic patients. Acquisitions were performed at pneumotachographically controlled lung volume (65% TLC), with reconstructions focused on the right lung base. Five validation criteria were imposed: (1) bronchus type: segmental and subsegmental; (2) lumen area (LA)>4 mm²; (3) bronchus length (Lg) > 7 mm; (4) confidence index - giving the percentage of the bronchus not abutted by a vessel - (CI) >55% for validation of wall area (WA) and (5) a minimum of 10 contiguous cross-sectional images fulfilling the criteria. A complete segmentation procedure on both acquisitions made possible an evaluation of LA and WA in 174/223 (78%) and 171/174 (98%) of bronchi, respectively. The validation criteria were met for 56/69 (81%) and for 16/69 (23%) of segmental bronchi and for 73/102 (72%) and 58/102 (57%) of subsegmental bronchi, for LA and WA, respectively. In conclusion, BronCare is reliable to segment the airways in clinical practice. The proposed criteria seem appropriate to select bronchi candidates for measurement. This work has been supported by William G Coolidge ECR2004 R & E Fund grant.     

Using edge enhancement to identify subtle findings on soft-copy neonatal chest radiographs.

OBJECTIVE: The purpose of this study was to evaluate whether edge enhancement could improve the visibility of subtle findings on soft copies of neonatal chest radiographs. MATERIALS AND METHODS: Two radiologists reviewed 82 soft-copy neonatal chest radiographs before and after the application of edge enhancement on our picture archiving and communication system (PACS). The visibility of a pneumothorax (n = 22), central venous catheter (n = 32), umbilical arterial catheter (n = 36), endotracheal tube (n = 40), and normal anatomic structures (the minor fissure, anterior segmental bronchus of the right upper lobe, and aortic arch, n = 57) was evaluated. Six of 22 soft-copy images depicting a pneumothorax were excluded from the evaluation of image quality either because of the large size of the pneumothorax itself (n = 7) or because of the lack of confirmatory evidence that would have been provided by an additional lateral decubitus (n = 6) or cross-table lateral radiograph (n = 3). Image quality was evaluated by visual grading analysis. RESULTS: The visibility of a pneumothorax (p < 0.01), vascular catheters (p < 0.001), the minor fissure (p < 0.001), and the anterior segmental bronchus of the right upper lobe (p < 0.001) improved significantly after applying edge enhancement to soft copies of neonatal chest radiographs, whereas the visibility of the aortic arch did not improve. Evaluations of the improvements in the visibility of the endotracheal tube were inconsistent. CONCLUSION: Application of edge enhancement to soft copies of neonatal chest radiographs helps radiologists to identify small pneumothoraces, vascular catheters, and delicate normal structures, thereby improving the detection of subtle chest findings in the neonatal intensive care unit.     

先天性支气管闭锁的多层螺旋CT和X线表现

目的分析先天性支气管闭锁的CT和X线表现，以提高对该病的认识和诊断。方法对11例支气管闭锁患者进行了多层螺旋CT（MSCT）扫描。其中3例经手术证实，6例有支气管镜结果，2例随诊1年以上。肺部常规10mm层厚扫描，在16层螺旋CT机进行1．25mm后处理重组，获得多平面重建（MPR）、最大密度投影（MIP）和最小密度投影（MinIP）图像，记录病变的部位和周围肺组织改变。结果11例病变CT均能显示黏液栓和周围气肿改变，其中3例黏液栓内含气体；x线平片亦能显示全部黏液栓，但仅显示8例气肿改变和2例黏液栓内的气液平。3例支气管闭锁位于左侧，8例位于右侧；发生于段支气管者10例，亚段1例；6例位于肺门旁，5例远离肺门。结论黏液栓和周围肺气肿改变是先天性支气管闭锁的典型表现，在先天性支气管闭锁诊断和鉴别诊断上，多层面螺旋CT能提供比x线平片更多的信息。     

Ankle instability: evaluation of the lateral ligaments

Bilateral ankle stress testing was performed on 25 subjects in a device which controlled position of the foot and the amount of force applied during the examination. Both inversion testing in the anteroposterior plane and anterior drawer testing in the lateral plane were performed in the same group of symptom-free patients. The reproducibility of the test was demonstrated. Previous history of injury, left vs. right handedness, side and anthropometric measurements did not affect the test. There was no difference in the inversion test between ankles tested in neutral and plantar flexion. In functionally normal ankles, the range of inversion "talar tilt" was 0 to 18 degrees while the maximum of anterior displacement on drawer testing was 3 mm. The effective stiffness of the anterior talofibular ligament was thus computed as 65 +/- 34 N/m. Anterior drawer testing appears to evaluate lateral ligamentous integrity of the ankle more critically than the talar tilt test.     

The effect of cortical button location on its post-operative migration in anatomical double-bundle anterior cruciate ligament reconstruction

Purpose

To investigate the effect of EndoButton^® (Smith & Nephew Endoscopy, Andover, MA, USA) location on post-operative migration in anterior cruciate ligament (ACL) reconstruction.

Methods

Seventy-seven patients underwent anatomical double-bundle ACL reconstruction using EndoButtons. Comparing patient radiographs immediately post-operatively with those at 1 year, migration was defined when EndoButtons moved more than 1 mm or rotated over 5°. Initial location of EndoButtons was evaluated on radiographs immediately post-operatively. We measured distances from the EndoButton to the posterior and distal edge of the femur (D1, D2) on lateral radiographs and distances from the EndoButton to the lateral and distal edge of the femur (D3, D4) on anteroposterior radiographs. The relationship between supracondylar line and the ratio of migration was also investigated.

Results

D1 in the migrated group were significantly lower than those in the non-migrated group (11.8 ± 12.7 vs. 16.0 ± 10.2 mm). D2, D3 and D4 were not of significant difference in the two groups. The ratio of migration in the area posterior to the supracondylar line was significantly higher than that in the anterior area (54.3 vs. 15.1 %).

Conclusion

EndoButtons, which was located distally and posteriorly, especially in the area posterior to the lateral supracondylar line, migrated more frequently, although migration of the button had no effect on the clinical parameters evaluated in this study.

Clinical relevance

It is preferable to settle EndoButton anteriorly to the lateral supracondylar line in order to avoid its migration for the graft tension due to our findings about the relationship between initial location of EndoButton and the rate of migration.

Level of evidence

Prognostic case series, Level IV.