LEARNING ART OF

HRCT CHEST
HRCT LUNG

• High Resolution CT or HRCT of

the lung is a medical diagnostic
test used for diagnosis and
assessment of diffuse lung
disease. It involves the use of
special computed tomography
scanning techniques in order to
assess the lung parenchyma
 IMAGING QUALITY AND
RADIATION DOSE
Image is affected by
- Contrast
- Noise
- Spatial resolution
- Radiation dose
Artifacts – which degrade
image quality.
Tissue Density

The densities are measured in

“ Hounsfield Units
”
Density in Hounsfield Units

Metal + 5000
Bone + 1000
Calcification + 300
Soft Tissues + 60
Water 0
Fat - 100
Air - 1000
contrast
- Difference in HU values
between tissues
- Contrast increases with
decrease in KVp
- Not affected by mA & scan time
Contrast medium (Iodine)
increases tissue contrast
Isodense / low contrast lesion
is masked by noise
Window level and/or window
width sets contrast of
displayed image
 NOISE / QUANTUM
MOTTLE
Variation in the number of photons in
each pixel
It is assessed by standard deviation
(SD) which is
square root of total number of photons
in an image
100 Photons SD 10%
1000 Photons SD 3.2%
10,000 Photons SD 1%
QM decreases as no of photons increases
CT noise will

in KVp

in mA

in Scan time

(If all other parameters constant)

 CT NOISE DECREASES
BY Voxel size
Matrix size

FOV

Section thickness
Typical noise in modern CT is 5 HU i.e. 0.5% /
difference in attenuation coefficient
 SPATIAL RESOLUTION
It is discrimination between adjacent
objects which depends on pixel size

Best spatial resolution for CT 1 lp/mm

A line pair (lp) requires two pixels.
Typical Resolution range in CT is 0.7 – 1.5
lp/mm
 HIGH RESOLUTION
MODE

 Smaller FOV
 Larger matrix size
 Smaller pixel size
Doses at surface of patients higher than its centre.
CT section dose extends beyond section edges.
Tissues beyond section are thus exposed to
radiation
On contiguous sections
Cumulative dose to a section is higher than a
single section dose
Pitch
• Ratio of table movement
during 360 deg scan to slice
thickness
• SL thickness 7 mm and table
movement of 7 mm equal to
pitch 1
SL thickness of 7 mm and table
movement of 10.5 mm = pitch
of 1.5 (10.5 / 7 )
A greater pitch allows scanning of greater volumes for a
given time but at the cost of image noise and poor
resolution
PROTOCOL OF HRCT
• Thin collimation (1-2 mm)
• 15 mm interslice gap
• Bone algorithm (or sharp filter for
reconstruction)
• Targeted images (enlarged images of
only one lung)
• Supine images and prone imaging in
selected cases with basilar
parenchymal disease
• No iv contrast
• From lung apices to lung bases
• Expiratory images may be
obtained in deep expiration to
differentiate between focal
areas of ground glass
attenuation due to focal air
trapping from mosaic pattern
• kVp 120-140 mAs 200-250
• Pitch 1.0-2.0
MDCT HRCT
• SUPINE POSITION
• VOLUMATRIC HELICAL CT
• .625-1.25 MM DETECTORS
• PITCH 1
• RECONSTRUC WITH HIGH
SPATIAL FREQUENCY OR EDGE
ENHANCING ALGORITHM
• EVERY ROUTINE CHEST CT
CAN BECOME HRCT USING
SAME DATA
Conventional vs Spiral
CT
2D Slice 3D Volume

I.S.D No I.S.D
INDICATIONS
• Confirmation of abnormality in
patienats with symptoms
suggestive of DLD with normal
or near normal chest x-ray
• Specific diagnosis or further
assessmant in patients with an
abnormal but non-diagnostic
chest radiograph
• As a guide to site and method of
biopsy
INDICATIONS
• As a guide to the assessment of
disease activity especially in
fibrosing alveolitis
• To diagnose superimposed
complications such as tumor or
infection when they are clinically
suspected but not visible on chesr x-
ray
• To determine relative importance of
each condition in patients with more
than one chronic DLD
SECONDARY
PULMONARY LOBULE
• The secondary pulmonary lobule
is a fundamental unit of lung
structure, and an understanding
of lobular anatomy is essential
to the interpretation of thin-
section CT of the lung.
SECONDARY
PULMONARY LOBULE
• 3-5 PRIMARY LOBULES FORM A
SECONDARY LOBULE
• BASIC PULMONARY UNIT VISIBLE ON
HRCT
• POLYHEDRAL
• 1.5 CM
• SURROUNDED BY CONNECTIVE
TISSUE(INTERLOBULAR SEPTA)
• CENTRAL ARTERY AND BRONCHIOLE,
PERIPHERAL VEIN AND LYMPHATICS
SECONDARY LOBULE
1-mm lung slice taken from peripheral lower lobe showing 2

secondary lobules S, interlobular septa. V, vein. B, bronchioles.

A, artery
CHOOSING THE RIGHT
WINDOW
Window level / window
width
It is for the balance between
Contrast
Brightness
 Window level

It is chosen close to the average

HU value of the tissue of interest
e.g. 10 - 50 HU for soft tissue
WINDOW WIDTH
- Range of CT number displayed
around the selected centre
- It determines contrast
- Narrow window width, higher
contrast and vice versa
Subtle density difference on CT, is
recorded on film
e.g. An Image selected

Window width 100 HU

Window level 50 HU
so
CT No 0 or < black
HU, 100 or > white
And HU, 50 mid grey
Windowing is for displayed image
only
Mediastinal Window
Lung Window
Bone Window
Abdominal ( soft tissue ) Window
 -700/1000 Hounsfield
Units (HU) lung windows
This window
provides excellent
contrast between
lung parenchyma
and lung structures
or abnormalities.
Lung parenchyma
should appear
slightly grayer than
air in the trachea.
An extended window
(mean -700 HU; width
1500 HU)
An extended
window reduces
contrast between
the air containing
lung and lung
structures such as
vessels and bronchi
useful in evaluating
the relationship of
peripheral
parenchymal
abnormalities to the
pleural surfaces
 A wider window (mean -
600; width 2000 HU)
useful when pleuro-
parenchymal
abnormalities are
being evaluated. The
pleural surface and
chest wall structures
are seen with this
window, but contrast
between lung and
parenchymal
structures is reduced.
Low window settings
with narrow window
widths (-800 to -900 HU;
width 500 HU)
contrasting
emphysema
or air-filled
cystic
lesions with
normal lung
parenchyma.
Window level/width
settings of50/450

best for
evaluating of
the
mediastinum,
hila, and pleura,
information
sometimes of
value in
interpreting
HRCT of the
lung.
NORMAL LUNG
BRONCHOVASCULAR
BUNDLE
The diameter of an
artery and its
neighboring
bronchus should
be approximately
equal, although a
vessel may appear
slightly larger than
its adjacent
bronchus,
particularly in
dependent lung
regions.
INTERLOBULAR SEPTA
Pulmonary artery divide
into two equal branches
Pulmonary veins often give
rise to small branches and
are independent of bronchi
Normal fissure

• Less than 1 mm thick

• Smooth in contour
• Uniform in thickness
• Sharply defined
ARTIFACTS

• Pulsation artifacts are

commonly visible, particularly
at the left lung base, adjacent
to the heart
STREAK ARTIFACTS
thin streaks
radiate from the
edges of vessels
or other visible
structures,
resembling stars;
small areas of
lucency may be
seen between
these streaks.
These lucent
areas, if not
recognized as
artifactual, may
be mistaken for
dilated bronchi.
doubling artifact"
he major fissure,
usually on the
left, or other
parenchymal
structures such
as vessels and
bronchi, may be
seen as double
because of
cardiac pulsation
(i.e., a "doubling
artifact"). This
appearance can
mimic
bronchiectasis
Normal dependent
opacity
ABNORMAL DEPENDENT
OPACITY
APPROACH FOR D/D
[Link] OF DISEASE
[Link]
upper lobes or lower lobes
[Link]
acute or chronic
[Link] VOLUMES
increased or decreased
[Link] DISEASE
plaques or effusion
[Link] NODES
enlarged calcified
PREDOMINANAT
FINDINGS
A. Reticular opacities
B. Nodules
C. Increased lung opacity
D. Decreased lung opacity
Interlobular septal
thickening
PERIBRONCHIAL
CUFFING thickening of
the peribronchovascular
interstitium
an increase in
bronchial wall
thickness; and
2) an increase
in diameter of
pulmonary
artery
branches
PERIBRONCHIAL
CUFFING
thickening of the
subpleural interstitium
INTRALOBULAR SEPTAL
THICKENING
• A fine irregular reticular pattern
is present in the lung periphery
• Represented by a fine reticular
network within the pulmonary
lobule
• Additional findings of interstitial
lung disease are also commonly
seen
• Can also result in traction
broncheactasis
Intralobular interstitial
thickening

The
differential
diagnosis
of this
appearance
is identical
as that for
honeycomb
HONEY COMBING

• indicates the presence of "end-

stage" lung and can be seen in
almost any process leading to
severe pulmonary fibrosis
• Honeycomb cysts usually range
from 2 to 20 mm in diameter,
but can be larger
• They typically appear to share
walls on HRCT and usually occur
in several layers in the subpleural
lung this finding can allow
honeycombing to be distinguished
from subpleural emphysema
(paraseptal emphysema) in which
subpleural cysts usually occur in a
single layer.
• predominate in the peripheral
and subpleural lung regions
regardless of their cause
• clearly definable walls 1-3 mm
in thickness.
• appearance of honeycombing is
so characteristic that lung
biopsy is not usually performed
when this finding is visible
CAUSES
• idiopathic pulmonary fibrosis
(IPF) accounting for about 60%
of such cases
• autoimmune diseases such as
scleroderma and rheumatoid
arthritis
• Asbestosis
• end-stage hypersensitivity
pneumonitis
• drug-reactions
• End stage sarcoidosis
[Link]
OPACITIES
• Interlobular septal thickening
• Smooth
• Nodular
• Irregular
• Peribronchovascular interstitial
thickening
• Subpleural interstitial thickening
• Honeycombing
• Intralobular septal thickening
INTERLOBULAR SEPTAL
THICKENING
• SMOOTH
• Lymphangitic spread of tumor
• Unilateral or asymmetric
• Interstitial nodules
• Pleural effusions
• Thickening of fissures
• Thickening of the peribronchovascular
interstitium
• lung biopsy is uncommonly performed
• lung, breast, stomach, prostate, lymphoma
LYMPHANGITIS
CARCINOMATOSA
Pulmonary edema

Patients with • Symmetric

pulmonary edema
are not generally • Lung bases
imaged using • Pleural
HRCT AS their effusions
diagnosis is
usually based on a
combination of
clinical and chest
radiographic
findings
PULMONARY OEDEMA
H/O LYMPHOMA
INTERLOBULAR SEPTAL
THICKENING
• NODULAR
• Sarcoidosis
• Upper and mid
zones
• Nodular
peribronchovascul
ar interstitum
• Lymphangitic
spread
• Silicosis
INTERLOBULAR SEPTAL
THICKENING
• IRREGULAR
• Idiopathic pulmonary fibrosis (UIP)
• Connective tissue disorders
• RA ,SLE ,MCTD
• Drugs
• Methotrexate,Busulfan
• Pneumoconiosis
• Asbestosis
• Silicosis
• CWP
• Hypersensitivity pneumonitis
 IDIOPATHIC PULMONARY
FIBROSIS
• progressive shortness of breath and a dry
cough.
• Ground glass suggests active disease
• 60% of lung fibrosis
• 90% will have honeycombing
• Majority demonstrate usual intersitial
pneumonitis
• Peripheral, subpleural, and lower lobes
• patchy distribution
• 40 and 60 years of age
Areas of mild and severe
fibrosis, mild and marked
inflammatory activity, and
normal lung are often
present in the same
patient, in the same lung,
and in the same lobe.
Concentric subpleural
honeycombing is
characteristic of IPF.
ASBESTOSIS
[Link]
• Size
• Appearance (well-defined or ill-
defined)
• Attenuation (soft-tissue or
ground-glass opacity;
calcification)
• Distribution most important
single factor in making an
accurate diagnosis
[Link]
Perilymphatic
Distribution
• nodules occur in relation to
lymphatics
• Nodules are almost always
visible in a subpleural location,
particularly in relation to the
fissures, although the presence
of nodules in the other
perilymphatic regions varies
with the disease
1) pleural surfaces
2)interlobular septa
3) the
peribronchovascular
interstitium
peribronchovascular
interstitium in a
centrilobular location
CAUSES

• Sarcoidosis
• Silicosis
• coal-worker's pneumoconiosis
• lymphangitic spread of
carcinoma
SARCOIDOSIS
systemic disorder of unknown
cause
Upper and mid zones
noncaseating granulomas
symmetric bilateral hilar and
paratracheal lymphadenopathy

perilymphatic distribution of
granulomas
A predominance of nodules
in the peribronchovascular
regions and adjacent to the
fissures is very suggestive
of sarcoidosis, and a
confident HRCT diagnosis
can often be made.
PERILYMPHATIC NODULES
SILICOSIS
2 to 5 mm in diameter
bilateral, symmetrical,
and have an upper lobe
and posterior
predominance.
45-year-old South African
diamond miner with
progressive dyspnea
 lymphangitic spread of
carcinoma
Nodular LC results in a perilymphatic
distribution of abnormalities, also
commonly seen in patients with
sarcoidosis and coal worker's
pneumoconiosis or silicosis. However, in
sarcoidosis and coal worker's
pneumoconiosis, septal thickening is
usually less extensive than that seen in
patients with lymphatic spread of tumor. In
addition, the presence of pleural effusion
would be more in keeping with LC than
sarcoidosis or silicosis.
63-year-old woman with breast cancer
and progressive shortness of breath
33-year-old man with shortness of
breath and an abnormal chest
radiograph
43-year-old man with AIDS, cutaneous
Kaposi sarcoma (KS), and progressive
shortness of breath
44-year-old woman with
AIDS, fever, and an abnormal
chest radiograph
 RANDOM DISTRIBUTION
Randomly distributed relative
to structures of the lung and
secondary lobule. In general,
they appear evenly distributed
throughout the lung, and tend
to involve both lungs
symmetrically Nodules can
usually be seen to involve the
pleural surfaces and fissures,
but lack the subpleural
predominance often seen in
patients with a perilymphatic
distribution.
CAUSES
Hematogenous metastases

Miliary tuberculosis
Miliary fungal infections
 43-year-old man with
fever and cough
Uniformly-sized discrete 1 to 4 mm nodules involving the
intralobular interstitium, interlobular septa, and the subpleural,
and perivascular regionsFindings of miliary TB may be seen in
isolation or in association with other HRCT findings of active
disease, such as air-space consolidation, cavitation, ill-defined
air-space nodules (endobronchial spread), pleural effusion, and
lymph node enlargement with central necrosis.
57-year-old woman with a
history of breast cancer
 51-year-old asymptomatic woman with
breast cancer who is post liver
transplantation
CENTRILOBULAR
NODULES
• Indicate endobronchial
inflammation or spread
• Nodules are usually 5-10mm
away from pleural surface
• nodules are limited to the
centrilobular regions
• centrilobular nodules spare the
pleural surfaces
 CENTRILOBULAR
DISTRIBUTION
In many cases,
centrilobular nodules can
be correctly identified by
noting their association
with small pulmonary
artery branches. It is
typical for centrilobular
nodules to surround or
obscure the smallest
pulmonary arteries
visible on HRCT
CAUSES

• Bronchiolitis
• Bronchopneumia
• TB
• HP
• BOOP
• Pulmonary Edema
• Vasculitis
• Aveolar CA
Centrilobular nodules can be seen
in patients with a variety of
diseases affecting centrilobular
bronchioles or arteries. Of value in
narrowing the differential
diagnosis is recognition of the
presence of a finding termed tree-
in-bud which describes the
appearance of an irregular and
often nodular branching structure,
most easily identified in the lung
periphery
 Tree-in-bud appearance
Tree-in-bud represents a
dilated and impacted (mucus
or pus filled) centrilobular
bronchiole. The tree and its
branches represent the
dilated bronchiole. Nodular
opacities often seen at the
tips of the branches, allows
tree-in-bud to be
distinguished from normal Tree-in-bud
appearance almost
branching arteries, which are
always indicates
thinner, and taper toward the infection (TB, MAC,
pleural surface. bronchopneumonia)
73-year-old woman with cough and an
abnormal chest radiograph
57-year-old woman with progressive
shortness of breath over several weeks, a
nonproductive cough, and low-grade fever
28-year-old woman with
cough and night sweats
35-year-old man with
cough and night sweats
[Link] DENSITY
 GROUND GLASS
OPACITY
• minimal air-space disease, interstitial
thickening, or both
• patchy in distribution, affecting some
lung regions while others appear
spared
• Ground glass opacity does not
obscure underlying vessels
• 60-80% of patients showing this
finding on HRCT have an active, and
potentially treatable, lung disease
• Reliance on history for
diagnosis or further diagnostic
evaluation is often needed.
• D/D pulm. edema, blood, HP,
atypical pneumonias, aveolar
proteinosis, ARDS, DIP, UIP
GOODPASTEUR
SYNDROME
HYPERSENSITIVITY
PNEUMONITIS

• Ground glass opacity

• Centri-lobular nodules
• Patchy lucencies
• Can progress to
fibrosis
• Peripheral
• Lower lobes are
spared
HYPERSENSITIVITY
PNEUMONITIS
57-year-old woman with exposure to birds as
pets, progressive shortness of breath, low-
grade fever, and nonproductive cough
56-year-old woman with chronic cough,
whose symptoms began at a time she was
burning moldy wood in the fireplace
42-year-old HIV positive man fever and
shortness of breath
54-year-old woman with lymphoma
being treated with chemotherapy.
Symptoms include fever, cough, and
shortness of breath
57-year-old woman with a history of
lymphoma, failed chemotherapy
induction, and shortness of breath
46-year-old woman with a history of
bilateral lung transplantation and
rapidly progressing shortness of
breath
29-year-old woman with a history of
systemic lupus erythematosus and
shortness of breath
IPF
active disease after tx
ALVEOLAR
PROTEINOSIS
• Idiopathic, but cases result
from silica
• filling of the alveolar spaces
with a periodic acid-Schiff-
positive (PAS-positive)
proteinaceous material, rich
in lipid
• Insidious onset
• Ground glass appearance
with “crazy paving”
• Consolidation suggests
superimposed infection,
• D/D pulm. oedem, blood,
viral, PCP
Interstitial pneumonias
• DIP-associated • LIP-uncommon,
with smoking, associated with
ususally no fibrosis aids, sjogren’s
• UIP-almost always • BIP-has been
has honeycombing/
fibrosis, poor renamed BOOP
prognosis • NSIP-dx of
• GIP-almost exclusion, but no
exclusively in hard honeycombing,
metal workers better prognosis
 CONSOLIDATION
• Obscures underlying vessels
• replacement of alveolar air
by fluid, cells, tissue, or
other material.
• air-bronchograms may be
present
• D/D PCP, BOOP, eosinophilic
pneumonia, aveolar CA,
lymphoma, ARDS, pulm.
Edema, aveolar proteinosis,
radiation, sarcoidosis, drugs
• Location, history may be
helpful
Chronic Eosinophilic
pneumonia
• Patchy peripheral,
subpleural upper
lobes
• Loeffler’s is
fleeting
• Infiltrates may last
for months
• Symptoms severe
• eosinophlia
BOOP
• Peripheral,
consolidation
• Centrilobular
nodules
• Lower lobes
• Subacute
presentation
• Associated with
prior infection,
drugs,
wegener’s
VIRAL PNEUMONIAS
CMV MYCOPLASMA
Diffuse
Calcification:

Case 1
Case 2 Case 3
Diffuse calcification

• Case 1: aveolar microlithiasis;

rare idiopathic
• Case 2: metastatic
calcification; seen in renal
failure, hyperparathyroidism
• Case 3: amyloidosis; diffuse
form, worse prognosis
[Link] DENSITY
CENTRILOBULAR
EMPHYSEMA
• Centrilobular lucencies
• Upper lobes
• Most common
• Associated with smoking
PANLOBULAR
EMPHYSEMA
• Lucency
involving entire
lung, with small,
few vessels
• Most severe in
lower lobes
• Associated with
1 anti trypsin
deficiency
PARAESEPTAL EMPHYSEMA

• Subpleural
• Associated with
centrilobular
• When larger
than 1cm
termed bullae
BULLOUS EMPHYSEMA

• Not specific
pathologic entity
• Centrilobular Or
paraseptal
emphysema with
large bullae
• Usually smokers
Centrilobular and paraseptal
emphysema with bullae
PCP with pnematocele
Bronchopulmonary papillomatosis

Cavitation and cyst formation is common

Nodules within the cysts is often
LYMPHANGIOMYOMATOSIS

• Diffuse distribution
• Thin walled cysts <4mm
• Only in women
• Chlyous effusions
• Pneumothorax
• Haemoptypsis
• Poor prognosis
LANGERHAN,S CELL
HISTIOCYTOSIS
• Eosinophilic
granuloma
• Early,
centrilobular
nodules
• Later, irreg.
Thick walled
cysts
• Upper lobes
• Almost always
in smokers
CYSTIC FIBROSIS WITH
BRONCHIECTASIS

• Bronchial wall
thickening with
dilatation, central
pattern
• Signet ring sign
• Most common
cause of
bronchiectasis is
prior infection
William campell
syndrome

• Rare, cystic brochiectasis, can be

fluid filled which diff. It from cysts,
patchy
• Defective cartilage
cylindrical varicose

cystic
Cystic fibrosis
 Mosaic Perfusion
Regardless of its cause, when mosaic
perfusion is present, pulmonary vessels in
the areas of decreased opacity often
appear smaller than vessels in relative
dense areas of lung This difference
reflects differences in regional blood flow,
and can be quite helpful in distinguishing
mosaic perfusion from "ground-glass"
opacity, which can otherwise have a
similar patchy appearance. In patients with
ground-glass opacity, vessels usually
appear of equal in size throughout the lung
Mosaic perfusion due to bronchiolitis
obliterans, cystic fibrosis, or other
airways diseases, gross abnormalities
of large bronchi (i.e. bronchiectasis) can
often be seen in the relatively lucent
areas of lung In patients with mosaic
perfusion occurring in association with
chronic pulmonary embolism,
enlargement of the main pulmonary
arteries may be visible, because of
pulmonary hypertension.
48-year-old woman with progressive
shortness of breath following bilateral lung
transplantation
45-year-old woman with progressive
shortness of breath following an upper
respiratory infection
BRONCHIOLITIS OBLITERANS
• Non specific
reaction
• Autoimmune, SJ,
Lung, heart
transplant, toxic
fumes, drugs
• Exp. Scans
extremely helpful
• Rarely idiopathic
53-year-old woman with
cough and asthma
46-year-old woman with progressive
shortness of breath following a bone marrow
transplant
THANKS