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DOI: 10.1148/rg.256055037
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Right arrow Chest Radiology
Right arrow Computed Tomography

Multi–Detector Row CT and Postprocessing Techniques in the Assessment of Diffuse Lung Disease1

Catherine Beigelman-Aubry, MD, Catherine Hill, FRCR, Aymeric Guibal, MD, Julien Savatovsky, MD and Philippe A. Grenier, MD

1 From the Department of Radiology, Pitié-Salpêtrière Hospital, 47/83 Boulevard de l’Hôpital, 75013 Paris, France. Recipient of a Cum Laude award for an education exhibit at the 2004 RSNA Annual Meeting. Received March 4, 2005; revision requested March 29 and received May 16; accepted May 16. All authors have no financial relationships to disclose.


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  		Figure 1a.  Langerhans cell histiocytosis in a 51-year-old man with chronic dyspnea. (a) Axial CT scan demonstrates multiple irregular cysts in both upper lung lobes. (b) Coronal MPR image clearly shows that the cysts are located predominantly in the upper and middle lung zones. Note the normal size of the bronchi. MPR helped confirm the diagnosis in less time than it took to review the more numerous axial images.

 


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  		Figure 1b.  Langerhans cell histiocytosis in a 51-year-old man with chronic dyspnea. (a) Axial CT scan demonstrates multiple irregular cysts in both upper lung lobes. (b) Coronal MPR image clearly shows that the cysts are located predominantly in the upper and middle lung zones. Note the normal size of the bronchi. MPR helped confirm the diagnosis in less time than it took to review the more numerous axial images.

 


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  		Figure 2a.  Nonspecific interstitial pneumonitis in a 64-year-old woman with systemic sclerosis. (a) Axial CT scan of the lung bases shows ground-glass attenuation and reticular lines (arrows). (b, c) Longitudinal coronal (b) and sagittal (c) reformatted images clearly depict lesions in a subpleural location (arrows), with the sagittal image demonstrating their posterobasal location. These findings allowed immediate recognition of the craniocaudal and axial distribution of diffuse lung disease.

 


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  		Figure 2b.  Nonspecific interstitial pneumonitis in a 64-year-old woman with systemic sclerosis. (a) Axial CT scan of the lung bases shows ground-glass attenuation and reticular lines (arrows). (b, c) Longitudinal coronal (b) and sagittal (c) reformatted images clearly depict lesions in a subpleural location (arrows), with the sagittal image demonstrating their posterobasal location. These findings allowed immediate recognition of the craniocaudal and axial distribution of diffuse lung disease.

 


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  		Figure 2c.  Nonspecific interstitial pneumonitis in a 64-year-old woman with systemic sclerosis. (a) Axial CT scan of the lung bases shows ground-glass attenuation and reticular lines (arrows). (b, c) Longitudinal coronal (b) and sagittal (c) reformatted images clearly depict lesions in a subpleural location (arrows), with the sagittal image demonstrating their posterobasal location. These findings allowed immediate recognition of the craniocaudal and axial distribution of diffuse lung disease.

 


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  		Figure 3.  Diagram illustrates multiplanar VR averaging technique. The mean attenuation value of the voxels on each view throughout the volume is projected onto the 2D image. White cubes represent voxels with the highest attenuation value; black cubes represent voxels with the lowest attenuation value.

 


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  		Figure 4.  Diagram illustrates mIP technique. The lowest attenuation value of the voxels on each view throughout the volume is projected onto the 2D image. White cubes represent voxels with the highest attenuation value; black cubes represent voxels with the lowest attenuation value.

 


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  		Figure 5a.  Added clinical value of mIP. (a) Multivisceral Kaposi sarcoma in a 33-year-old man with human immunodeficiency virus (HIV) infection. Coronal mIP reformatted image (4.9-mm-thick slab) demonstrates ground-glass attenuation due to pulmonary hemorrhage in the left upper lobe. Note the normal difference in attenuation between air and lung parenchyma in the right upper lobe. Excellent visualization of air bronchograms helps the endoscopist select the optimal site for bronchoalveolar lavage. (b) Nonspecific interstitial pneumonitis due to systemic sclerosis in a 59-year-old woman. Oblique mIP–multiplanar VR image (10-mm-thick slab) clearly depicts small reticular opacities with concomitant, subtle bronchiolectasis.

 


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  		Figure 5b.  Added clinical value of mIP. (a) Multivisceral Kaposi sarcoma in a 33-year-old man with human immunodeficiency virus (HIV) infection. Coronal mIP reformatted image (4.9-mm-thick slab) demonstrates ground-glass attenuation due to pulmonary hemorrhage in the left upper lobe. Note the normal difference in attenuation between air and lung parenchyma in the right upper lobe. Excellent visualization of air bronchograms helps the endoscopist select the optimal site for bronchoalveolar lavage. (b) Nonspecific interstitial pneumonitis due to systemic sclerosis in a 59-year-old woman. Oblique mIP–multiplanar VR image (10-mm-thick slab) clearly depicts small reticular opacities with concomitant, subtle bronchiolectasis.

 


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  		Figure 6.  Diagram illustrates MIP technique. The highest attenuation value of the voxels on each view throughout the volume is projected onto the 2D image. White cubes represent voxels with the highest attenuation value; black cubes represent voxels with the lowest attenuation value.

 


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  		Figure 7.  Sarcoidosis in a 51-year-old man. Coronal MIP image (4.4-mm-thick slab) demonstrates the typical distribution of small nodules in the upper and middle lung zones seen in sarcoidosis.

 


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  		Figure 8.  Emphysema in a 52-year-old male smoker. Coronal VIP image (15.2-mm-thick slab) allows excellent evaluation of the rearrangement of the pulmonary vasculature, providing perspective information on the volumetric distribution of the remaining vessels.

 


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  		Figure 9a.  Waldenström macroglobulinemia in an 82-year-old woman. Coronal MPR (a) and VR (b) images demonstrate a "crazy-paving" pattern secondary to biopsy-proved hypersensitivity pneumonitis. Note that the VR image resembles the macropathologic view.

 


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  		Figure 9b.  Waldenström macroglobulinemia in an 82-year-old woman. Coronal MPR (a) and VR (b) images demonstrate a "crazy-paving" pattern secondary to biopsy-proved hypersensitivity pneumonitis. Note that the VR image resembles the macropathologic view.

 


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  		Figure 10.  Diagram illustrates the three main compartments of the pulmonary interstitium at the level of the secondary pulmonary lobule. The axial compartment surrounds the lobular artery and bronchiole, whereas the peripheral compartment is located at the level of the interlobular septum. These compartments are connected to each other by the intralobular interstitium.

 


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  		Figure 11a.  Pulmonary fibrosis caused by dermatomyositis in a 91-year-old woman. (a) Axial CT scan shows irregular thickened septal lines in the left lower lobe and focal subpleural honeycombing in the right lower lobe. (b) Coronal MPR image depicts diffuse distorted septal lines (arrows), which are characteristic of pulmonary fibrosis.

 


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  		Figure 11b.  Pulmonary fibrosis caused by dermatomyositis in a 91-year-old woman. (a) Axial CT scan shows irregular thickened septal lines in the left lower lobe and focal subpleural honeycombing in the right lower lobe. (b) Coronal MPR image depicts diffuse distorted septal lines (arrows), which are characteristic of pulmonary fibrosis.

 


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  		Figure 12.  Lymphangitis carcinomatosis in a 74-year-old man. Oblique mIP–multiplanar VR image (3.2-mm-thick slab) clearly delineates lesions with a perilymphatic distribution. Peribronchovascular thickening (arrows) and abnormal thickened nodular septal lines (arrowheads) are also well demonstrated.

 


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  		Figure 13a.  Pulmonary edema in a 64-year-old man who presented with breathlessness. (a) Axial CT scan (3-mm-thick slab) demonstrates thickened and nodular septal lines (arrow). (b) Sagittal MIP image (10-mm-thick slab) reveals enlarged pulmonary veins (arrows), thereby helping make the diagnosis of pulmonary edema.

 


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  		Figure 13b.  Pulmonary edema in a 64-year-old man who presented with breathlessness. (a) Axial CT scan (3-mm-thick slab) demonstrates thickened and nodular septal lines (arrow). (b) Sagittal MIP image (10-mm-thick slab) reveals enlarged pulmonary veins (arrows), thereby helping make the diagnosis of pulmonary edema.

 


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  		Figure 14a.  Lung fibrosis of unknown origin in a 71-year-old man. (a) Sagittal reformatted image shows small reticular opacities in the subpleural area of the left lower lobe (arrow) and focal honeycombing in the anterior subpleural region of the upper lobe (arrowheads). (b) Oblique mIP–multiplanar VR image (7.2-mm-thick slab) demonstrates apparent traction bronchiolectasis in the area of reticular opacities, a finding that was not evident on the sagittal image.

 


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  		Figure 14b.  Lung fibrosis of unknown origin in a 71-year-old man. (a) Sagittal reformatted image shows small reticular opacities in the subpleural area of the left lower lobe (arrow) and focal honeycombing in the anterior subpleural region of the upper lobe (arrowheads). (b) Oblique mIP–multiplanar VR image (7.2-mm-thick slab) demonstrates apparent traction bronchiolectasis in the area of reticular opacities, a finding that was not evident on the sagittal image.

 


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  		Figure 15a.  Sarcoidosis in a 41-year-old man. (a) Sagittal reformatted image demonstrates micronodules distributed predominantly in the upper and middle portions of the lungs. (b) MIP image (4.8-mm-thick slab) more clearly depicts the characteristic perilymphatic distribution of micronodules along the septa (arrows) and the major fissure (arrowhead). Note also the retraction of the major fissure, a finding that represents fibrosis.

 


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  		Figure 15b.  Sarcoidosis in a 41-year-old man. (a) Sagittal reformatted image demonstrates micronodules distributed predominantly in the upper and middle portions of the lungs. (b) MIP image (4.8-mm-thick slab) more clearly depicts the characteristic perilymphatic distribution of micronodules along the septa (arrows) and the major fissure (arrowhead). Note also the retraction of the major fissure, a finding that represents fibrosis.

 


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  		Figure 16a.  Miliary tuberculosis in a 45-year-old HIV-positive woman. (a) Axial CT scan demonstrates a few micronodules. (b) MIP image (6-mm-thick slab) shows a random distribution of nodules, which are much more clearly depicted than on the axial image.

 


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  		Figure 16b.  Miliary tuberculosis in a 45-year-old HIV-positive woman. (a) Axial CT scan demonstrates a few micronodules. (b) MIP image (6-mm-thick slab) shows a random distribution of nodules, which are much more clearly depicted than on the axial image.

 


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  		Figure 17.  Tuberculosis in a 56-year-old woman who was being evaluated for chronic fever. MIP–multiplanar VR images with increasing slab thickness (left to right) clearly depict the characteristic centrilobular location of micronodules seen in endobronchial spread of tuberculosis. The use of progressively increasing slab thickness improves the detection and assessment of the profusion of micronodules and allows progressive assessment of the margins of the secondary pulmonary lobule, which are recognized from pulmonary veins lying along the septa (arrows). Note that the fissure is free of nodules. Bronchoscopy helped confirm the diagnosis of tuberculosis.

 


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  		Figure 18a.  Drug-induced lung disease in a 59-year-old woman who was undergoing chemotherapy for a retroperitoneal malignancy. (a) Axial CT scan shows inhomogeneous lung attenuation. (b) mIP image (5.2-mm-thick slab) shows diffuse abnormal increased attenuation of the lung parenchyma compared with endobronchial air. This finding is characteristic of ground-glass attenuation, which in this case is secondary to drug-induced lung disease.

 


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  		Figure 18b.  Drug-induced lung disease in a 59-year-old woman who was undergoing chemotherapy for a retroperitoneal malignancy. (a) Axial CT scan shows inhomogeneous lung attenuation. (b) mIP image (5.2-mm-thick slab) shows diffuse abnormal increased attenuation of the lung parenchyma compared with endobronchial air. This finding is characteristic of ground-glass attenuation, which in this case is secondary to drug-induced lung disease.

 


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  		Figure 19a.  Pneumocystis carinii pneumonia in a 31-year-old HIV-positive man. (a) Axial CT scan shows ground-glass attenuation in the left upper lobe. (b) Sagittal MIP image (4.9-mm-thick slab) more clearly demonstrates the size of vessels in both the normal and abnormal areas. In this case, the similarity of vessel size in the two areas allowed a definite diagnosis of mosaic attenuation and the exclusion of mosaic perfusion. P carinii pneumonia was diagnosed by means of bronchoalveolar lavage directed to the left upper lobe.

 


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  		Figure 19b.  Pneumocystis carinii pneumonia in a 31-year-old HIV-positive man. (a) Axial CT scan shows ground-glass attenuation in the left upper lobe. (b) Sagittal MIP image (4.9-mm-thick slab) more clearly demonstrates the size of vessels in both the normal and abnormal areas. In this case, the similarity of vessel size in the two areas allowed a definite diagnosis of mosaic attenuation and the exclusion of mosaic perfusion. P carinii pneumonia was diagnosed by means of bronchoalveolar lavage directed to the left upper lobe.

 


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  		Figure 20a.  Hydrostatic pulmonary edema in a 73-year-old man who presented with acute breathlessness. (a) Axial CT scan demonstrates bilateral patchy areas of ground-glass attenuation associated with enlarged pulmonary vessels and right-sided pleural effusion. (b) Coronal mIP image (4.9-mm-thick slab) provides a simplified global display of the medullary distribution of ground-glass attenuation. (c) Coronal MIP image (12-mm-thick slab) clearly depicts enlarged pulmonary veins. All of these findings, in association with a pleural effusion, are characteristic of hydrostatic pulmonary edema.

 


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  		Figure 20b.  Hydrostatic pulmonary edema in a 73-year-old man who presented with acute breathlessness. (a) Axial CT scan demonstrates bilateral patchy areas of ground-glass attenuation associated with enlarged pulmonary vessels and right-sided pleural effusion. (b) Coronal mIP image (4.9-mm-thick slab) provides a simplified global display of the medullary distribution of ground-glass attenuation. (c) Coronal MIP image (12-mm-thick slab) clearly depicts enlarged pulmonary veins. All of these findings, in association with a pleural effusion, are characteristic of hydrostatic pulmonary edema.

 


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  		Figure 20c.  Hydrostatic pulmonary edema in a 73-year-old man who presented with acute breathlessness. (a) Axial CT scan demonstrates bilateral patchy areas of ground-glass attenuation associated with enlarged pulmonary vessels and right-sided pleural effusion. (b) Coronal mIP image (4.9-mm-thick slab) provides a simplified global display of the medullary distribution of ground-glass attenuation. (c) Coronal MIP image (12-mm-thick slab) clearly depicts enlarged pulmonary veins. All of these findings, in association with a pleural effusion, are characteristic of hydrostatic pulmonary edema.

 


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  		Figure 21a.  Emphysema in a 61-year-old man with exertional dyspnea. (a) Axial CT scan shows hypoattenuating areas and cystic lesions (arrows), findings that are best evaluated further with mIP in the optimal oblique plane. (b) On an oblique mIP image (5.2-mm-thick slab), the bronchiectatic nature of the cystic lesions in the left upper lobe becomes obvious (arrow). Note the presence of additional cystic lesions, which are related to emphysema.

 


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  		Figure 21b.  Emphysema in a 61-year-old man with exertional dyspnea. (a) Axial CT scan shows hypoattenuating areas and cystic lesions (arrows), findings that are best evaluated further with mIP in the optimal oblique plane. (b) On an oblique mIP image (5.2-mm-thick slab), the bronchiectatic nature of the cystic lesions in the left upper lobe becomes obvious (arrow). Note the presence of additional cystic lesions, which are related to emphysema.

 


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  		Figure 22.  Centrilobular emphysema in a 46-year-old male smoker. Multiplanar VR image (3.2-mm-thick slab) shows a centrilobular artery appearing as a central dot (arrow), a finding that is characteristic of centrilobular emphysema and helps differentiate it from cysts. Centrilobular emphysema is most clearly depicted with multiplanar VR averaging.

 


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  		Figure 23.  Idiopathic pulmonary fibrosis in a 45-year-old woman. Oblique multiplanar VR–mIP image (5.2-mm-thick slab) clearly demonstrates bronchiolectasis within areas of cysts (arrow). The juxtaposed areas of cysts with intervening walls (arrowheads) are characteristic of honeycombing.

 


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  		Figure 24a.  (a) Emphysema in a 52-year-old man. Coronal MIP image (6.8-mm-thick slab) shows a heterogeneous distribution of the remaining vessels within hypoattenuating areas. (b) Constrictive (obliterative) bronchiolitis related to vasoconstriction or remodeling secondary to hypoxia. Axial MIP image (5.6-mm-thick slab) shows harmonious reduction of vessels, a finding that is quite unlike that seen in a. Note the superimposed centrilobular nodules in the apical segment of the right lower lobe (arrow), which are related to acute infectious bronchiolitis.

 


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  		Figure 24b.  (a) Emphysema in a 52-year-old man. Coronal MIP image (6.8-mm-thick slab) shows a heterogeneous distribution of the remaining vessels within hypoattenuating areas. (b) Constrictive (obliterative) bronchiolitis related to vasoconstriction or remodeling secondary to hypoxia. Axial MIP image (5.6-mm-thick slab) shows harmonious reduction of vessels, a finding that is quite unlike that seen in a. Note the superimposed centrilobular nodules in the apical segment of the right lower lobe (arrow), which are related to acute infectious bronchiolitis.

 




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