胸部CT诊断(大量实例CT片)课件

*,a,*,a,*,胸 部,CT,诊 断,第一节 胸部,CT,检查,一、胸部,CT,扫描方法,（一）普通扫描,（平扫,plain CT scan,）,1,a,胸 部 CT 诊 断1a,2,a,2a,3,a,3a,4,a,4a,（二）增强扫描,（,contrast enhancement,CE,）,1.,注药方法,团注法 （,bolus injection,）,静滴法,2.,扫描程序,静态,CT,扫描,动态,CT,扫描（,dynamic CT scan,）,5,a,（二）增强扫描5a,6,a,6a,（三）特殊扫描,1.,薄层扫描,2.,高分辨率,CT,扫描,（,High resolution CT, HRCT,）,3. CT,血管造影,（,CT angiography,CTA,）,4.,心电门控扫描,7,a,（三）特殊扫描7a,8,a,8a,9,a,9a,10,a,10a,11,a,11a,12,a,12a,13,a,13a,二、,CT,对胸部疾病的诊断价值与限度,（一）诊断价值,1.,肺部小病灶与早期病变,2.,咯血查因,3.,肺不张、肺实变,4.,肺肿瘤分期,5.,肺弥漫性病变,6.,肺气肿的诊断及功能评价,7.,肺血管性病变,8.,胸水查因,14,a,二、CT对胸部疾病的诊断价值与限度14a,（二）影响,CT,检出与诊断的因素,（主要为常规,CT,）,1.,运动伪影,2.,部分容积效应,3.,层厚与层间距,4.,大量胸水,5.,一病多像,一像多病,15,a,（二）影响CT检出与诊断的因素15a,16,a,16a,17,a,17a,18,a,18a,三、胸部正常,CT,解剖,（一）窗技术,1.,纵隔窗,:,窗位,30,60Hu,窗宽,300,500Hu,2.,肺窗：,窗位,-700-400Hu,窗宽,1000,1500Hu,（二）纵隔（,mediastinum,）,（三）肺（,lung,）,19,a,三、胸部正常CT解剖19a,20,a,20a,21,a,21a,22,a,22a,23,a,23a,24,a,24a,25,a,25a,26,a,26a,27,a,27a,28,a,28a,29,a,29a,30,a,30a,31,a,31a,32,a,32a,33,a,33a,34,a,34a,35,a,35a,36,a,36a,37,a,37a,38,a,38a,39,a,39a,40,a,40a,41,a,41a,42,a,42a,43,a,43a,44,a,44a,45,a,45a,46,a,46a,47,a,47a,48,a,48a,49,a,49a,50,a,50a,第二节 肺部疾病的,CT,诊断,一、先天性疾病,1.,肺隔离症（,pulmonary sequestration,）,某一肺段和正常肺组织及气管和支,气管树相互分离，无呼吸功能，血供来,自主动脉系统，分叶内型和叶外型两类。,51,a,第二节 肺部疾病的CT诊断51a,CT,表现：,部位：两下肺、脊柱旁。,形态：囊实性或囊性或实性，邻近肺,野斑片状影。,血供：体循环，病灶内血管异常。,鉴别诊断：,支气管源性囊肿、肺脓肿、先天性膈疝。,52,a,CT表现：52a,53,a,53a,54,a,54a,55,a,55a,56,a,56a,2.,支气管囊肿（,bronchogenic cyst,）,为支气管的先天发育异常，根据组,织学来源可分为支气管囊肿和支气管肺,囊肿,(pulmonary bronchogenic cyst),。,CT,表现,:,部位：纵隔与肺的任何部位，多见于,气 管隆突,5cm,范围内。,形态：圆形、椭圆形、边缘锐利，壁,菲薄。,密度：均匀，可有出血和液气平，壁,可强化。,57,a,2.支气管囊肿（bronchogenic cyst）57a,58,a,58a,59,a,59a,60,a,60a,61,a,61a,62,a,62a,63,a,63a,64,a,64a,65,a,65a,66,a,66a,二、支气管扩张症（,bronchiectasis,）,病因：先天性或后天性,病理：肉眼观，支气管呈柱状、囊状、静,脉曲张状或混合状扩张。,镜下观，粘膜柱状上皮呈急、慢性,炎性改变，伴弹力纤维、,平滑肌和软骨的损害。,67,a,二、支气管扩张症（bronchiectasis）67a,CT,表现：,病变支气管壁增厚，管腔,扩大，形态多样。,1.,柱状扩张,:,“,双轨,”,征、,“,印戒,”,征。,2.,囊状扩张,:,葡萄串状、卷发样。,3.,曲张形扩张,:,粗细不均的囊柱状。,4.,混合型,合并粘液栓时,腔内可见棒状,或结节状软组织密度影,咳痰后可,消失，同时可见肺野内出血,继发,感染等征象。,68,a,CT表现：病变支气管壁增厚，管腔68a,69,a,69a,70,a,70a,71,a,71a,72,a,72a,73,a,73a,74,a,74a,75,a,75a,76,a,76a,77,a,77a,78,a,78a,79,a,79a,三、肺感染性病变,1.,支气管肺炎,支气管肺炎（,bronchopneumonia,）,或小叶性肺炎（,lobular pneumonia,）,病 理：,小支气管壁充血、水肿、间,质炎性细胞浸润，小叶渗出、,实变、气肿或不张。,CT,表现：,两肺中下野中内带，支气管,血管束增粗，沿其分布小斑,片影及边缘模糊的小结节影。,80,a,三、肺感染性病变80a,81,a,81a,82,a,82a,83,a,83a,84,a,84a,85,a,85a,86,a,86a,2.,大叶性肺炎,大叶性肺炎（,lobar pneumonia,），,炎症累及整个肺叶，或呈肺段分布。,病理：充血期，,毛细血管充血，肺,泡内可有少量浆液性渗出。,红色肝样变期，,渗出液中含,较多红细胞。,灰色肝样变期，,渗出液中含,大量白细胞。,消散期，,渗出液溶解、吸收。,87,a,2. 大叶性肺炎87a,CT,表现：,渗出期表现为磨玻璃样影；实变,期呈叶、段的实变，可见空气支气管,征，叶间裂可向外膨出；消散期则呈,斑片状影。,鉴别诊断：,阻塞性肺炎，结核性大叶炎、,肺肿瘤（腺癌、肺泡癌或淋巴瘤）。,88,a,CT表现：88a,89,a,89a,90,a,90a,91,a,91a,3.,肺脓肿,肺脓肿（,lung abscess,），由化,脓性细菌引起的肺坏死性炎性病变，,分急性和慢性肺脓肿。,病理：,细支气管阻塞，小血管炎性栓塞，,肺组织坏死、液化，周围有纤维,组织增生。,92,a,3. 肺脓肿92a,CT,表现：,急性期：大片密实影，中心密度较,低，空洞形成后，壁厚而模糊，内有液,平；慢性期：洞壁清晰，内壁多不规整，,增强扫描洞壁强化，支气管、肺血管于,脓肿边缘截断。,鉴别诊断：,结核空洞、癌性空洞,93,a,CT表现：93a,94,a,94a,95,a,95a,96,a,96a,97,a,97a,98,a,98a,4.,肺结核,肺结核（,pulmonary tuberculosis,）,由人型或牛型结核杆菌引起的肺部慢性传,染病。,病理：,渗出结核性肺泡炎，增殖,结核性结节肉芽肿。继发改变：干酪样坏,死、液化、空洞、 播散；纤维化、钙化。,99,a,4.肺结核99a,CT,表现：,型：原发性肺结核,（,primary tuberculosis,）,纵隔、肺门淋巴结增大，增强扫描,多呈环形强化。肺内原发灶呈片影或段、,叶的实变，内可见低密度坏死、空洞。,可合并叶或段的不张。,100,a,CT表现：100a,101,a,101a,102,a,102a,103,a,103a,104,a,104a,105,a,105a,型：血行播散型肺结核,（,acute miliary tuberculosis and chronic,disseminated tuberculosis,）,急性血行播散型, CT,表现为双肺广泛,分布的,1,2mm,小点状阴影,密度均匀,边界,清,分布均匀,与支气管走行无关,以,HRCT,显示为佳。亚急性或慢性血行播散型,病灶,大小不一,密度不均,可有钙化,上中肺野分,布为主。,106,a,型：血行播散型肺结核106a,107,a,107a,108,a,108a,109,a,109a,110,a,110a,111,a,111a,112,a,112a,型：继发性肺结核,（,secondary pulmonary tuberculosis,）,肺尖后段、下叶背段常见，单发或多,发腺泡结节状影，小叶、肺段或肺叶,实变。,病变密度不均，可见钙化、坏死、空,洞，纤维索条影。,病灶邻近胸膜增厚。,113,a,型：继发性肺结核113a,114,a,114a,115,a,115a,116,a,116a,117,a,117a,caseous pneumonia:,大叶性实变，可见空气支气管征，,小空洞,下肺野可见支气管播散灶。,tuberculoma:,类圆形结节，可呈浅分叶，边缘,清晰，直径,2,4cm,，内可有坏死，结,节状、斑点状或层状钙化，周边常见,卫星灶，增强扫描结节多呈环形强化。,118,a,caseous pneumonia:118a,119,a,119a,120,a,120a,121,a,121a,122,a,122a,123,a,123a,124,a,124a,125,a,125a,126,a,126a,型：胸膜炎型（结核性胸膜炎）,可单独或与肺部结核合并存在，,表现为胸水，胸膜增厚或胸膜结节。,肺结核的鉴别诊断：,其它感染 肺癌 炎性假瘤 肉芽肿,127,a,型：胸膜炎型（结核性胸膜炎）127a,128,a,128a,129,a,129a,130,a,130a,131,a,131a,132,a,132a,肺癌,原发性支气管肺癌,（,primary bronchogenic carcinoma,）,是呼吸系统常见病，在全身恶性肿瘤,中居第二位。,病理：,肺癌起源于支气管上皮，腺体或细,支气管肺泡上皮。,组织学分型：,小细胞肺癌和非小细胞肺癌,（鳞癌、腺癌、大细胞未分化,癌、复合癌）。,按发生部位分：,中心型、外围型、细支气,管肺泡癌。,133,a,肺癌133a,CT,表现,:,（,1,）中心型肺癌：,肺门肿块，常伴肺不张或阻塞性肺炎,支气管异常,淋巴结转移及血行转移,纵隔侵犯,134,a,CT表现:134a,135,a,135a,136,a,136a,137,a,137a,138,a,138a,139,a,139a,左上肺非特异性炎症,140,a,左上肺非特异性炎症140a,（,2,）周围型肺癌,肺外周结节，多呈分叶状，可有细短,毛刺。,结节密度多不均匀，可有空泡征，支,气管气象，坏死、空洞、少数有钙化。,血管纠集、细支气管截断。,胸膜牵引征,增强扫描，,CT,值增加多在,20Hu,以上。,转移征象,141,a,（2）周围型肺癌141a,142,a,142a,143,a,143a,144,a,144a,145,a,145a,146,a,146a,147,a,147a,148,a,148a,149,a,149a,150,a,150a,151,a,151a,152,a,152a,153,a,153a,（,3,）细支气管肺泡癌,结节型：同周围型肺癌,弥漫型：双肺弥漫分布的腺胞结,节，可融合。,实变型（肺炎型）：肺段或叶的,实变，常合并腺泡结节。,154,a,（3）细支气管肺泡癌154a,155,a,155a,156,a,156a,157,a,157a,158,a,158a,159,a,159a,160,a,160a,161,a,161a,162,a,162a,（,4,）几种特殊类型的肺癌：,肺上沟癌（,Superior sulcus carcinoma,Pancoast tumor,）,纵隔型肺癌,肺炎型肺癌,重复癌,163,a,（4）几种特殊类型的肺癌：163a,164,a,164a,165,a,165a,166,a,166a,167,a,167a,168,a,168a,169,a,169a,170,a,170a,171,a,171a,172,a,172a,173,a,173a,174,a,174a,175,a,175a,第三节 纵隔疾病的,CT,诊断,一、胸内甲状腺,（,intrathoracic thyroid gland,）,病因：,甲状腺肿、腺瘤、囊肿、癌,CT,表现：,位置：,前上纵隔，气管和胸骨间，可,推压气管，上与甲状腺相连。,密度：,较高、常有囊变、钙化、强化,明显。,176,a,第三节 纵隔疾病的CT诊断176a,177,a,177a,178,a,178a,二、胸腺增生与胸腺瘤,（一）正常胸腺,位于前上纵隔，主动脉弓前，,呈三角形，新月形或箭头状，,20,岁以,后逐渐委缩，为脂肪替代。,正常胸腺大小；,1,月,14,岁厚,度,22mm,；厚度与主动脉弓直径之比：,1,岁以内,1.8,，,1,6,岁,1.2,，,6,14,岁,0.9,。,179,a,二、胸腺增生与胸腺瘤179a,180,a,180a,181,a,181a,（二）胸腺增生,（,thymic hyperplasia,）,弥漫性增生,结节状增生,182,a,（二）胸腺增生182a,183,a,183a,184,a,184a,185,a,185a,（三）胸腺瘤（,thymoma,）,病 理：,上皮细胞为主型、淋巴细胞为主型,和混合型。,CT,表现：,分非侵袭性和侵袭性胸腺瘤。前上,纵隔内结节影，向一侧或两侧突出，,边界清晰密度较均匀，可有囊变和,钙化，增强扫描明显强化。侵袭性,者弥漫浸润于大血管间，心包和胸,腔积液。,鉴别诊断：,胸腺增生与胸腺瘤 畸胎瘤 淋巴瘤,186,a,（三）胸腺瘤（thymoma）186a,187,a,187a,188,a,188a,189,a,189a,190,a,190a,191,a,191a,三、畸胎瘤（,teratoma,）,病理：,来源于原始生殖细胞，一种或多,种胚胎成分，有囊性和实质性,CT,表现：,前纵隔，边缘光滑之厚壁囊性肿块，,含脂肪、脂液分层、钙化、骨骼或牙齿、,囊性畸胎瘤壁常呈蛋壳状钙化。,192,a,三、畸胎瘤（teratoma）192a,193,a,193a,194,a,194a,四、淋巴瘤（,lymphoma,）,病理：,淋巴结或结外淋巴组织，分,Hodgkin disease, HD,和,non,Hodgkin lymphoma, NHL,CT,表现,:,纵隔肺门多组淋巴结肿大，可,融合成团，压迫或侵犯纵隔结构。,偶有坏死与钙化，强化程度较低。,鉴别诊断：,淋巴结结核 结节病,胸腺瘤 转移瘤,195,a,四、淋巴瘤（lymphoma）195a,196,a,196a,197,a,197a,198,a,198a,199,a,199a,200,a,200a,201,a,201a,202,a,202a,203,a,203a,204,a,204a,205,a,205a,五、心包囊肿（,pericardial cyst,）,多为单房,可发生于心包的任何,部位，以心膈区多见。 常位于右心,膈角区，呈边缘清晰锐利的囊状影。,鉴别诊断：,心包憩室 支气管囊肿,206,a,五、心包囊肿（pericardial cyst）206a,207,a,207a,208,a,208a,209,a,209a,210,a,210a,211,a,211a,212,a,212a,六、神经源性肿瘤,（,neurogenic tumor,）,是后纵隔最常见的肿瘤，多起源于肋,间神经内侧段或椎旁交感神经链。分神经,纤维瘤、神经鞘瘤、神经节细胞瘤、神经,母细胞瘤等。,CT,表现,:,后纵隔脊柱旁类圆形肿块，密度均匀，,部分呈哑铃状，椎间孔扩大，肋骨头和脊,椎受压，良性者边缘锐利，恶性者边缘不,清，侵蚀骨骼，增强扫描呈中等强化。,213,a,六、神经源性肿瘤（neurogenic tumor）21,214,a,214a,215,a,215a,216,a,216a,217,a,217a,218,a,218a,219,a,219a,220,a,220a,221,a,221a,222,a,222a,223,a,223a,224,a,224a,225,a,225a,226,a,226a,227,a,227a,The end,谢 谢 ！,228,a,The end谢 谢 ！228a,