There are no commercial supporters of this workship
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There are no conflict of interest
Julia Alegria MD Clinica Alemana UDD UDD Santiago - Chile 2
Imaging of the Diaphragm Learning Objetives Know Know the basis embriology anatomy Manifestation in images g the diaphragmatic p g pa pathology ogy Hernias Paralysis Eventration Tumors
Diaphragm The greek derivation of the words Dia : in between Phragma g : fence
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Embriology Develops during weeks 4-12 Composed of 4 components: Transverse septum Pleuroperitoneal fold Esophageal mesentery Muscular body wall RadioGraphics 2012; 32:E51E70
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Morgagni Hernia Constitute fewer than 10% of congenital diaphragmatic hernias
Morgagni Hernia
Morgagni hernia
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Morgagni hernia
Morgagni hernia
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Morgagni hernia
Morgagni g g hernia
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Bochdaleck Hernia 90% of congenital hernia more common on the left side
Bochdaleck Hernia
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Where the hernias usually goes?
B hd l k H Bochdaleck Hernia i
Anatomy
RadioGraphics 2012; 32:E51E70
Posterior attachments Cruras attach the diaphragm to the lumbar vertebral bodies and disks The crura are joined by a fibrous median arcuate ligament Lateral arcuate ligaments
RadioGraphics 2012; 32:E51E70
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Anatomyy
Anatomy
Median arcuate ligament syndrome.
Normal Lateral arcuate ligament
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Anatomy
Anterior lateral attachments
Inferior sternum Xiphoid process Lower six ribs Costal cartilage
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Anatomy y
Normal Anatomy
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Innervation
Hiatuses IVC Esophageal Aortic
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cervical nerves C3-C5 C3 C5 facilitate sensory and motor function
Function
Primary muscle of ventilation
E Emesis i
Urination
Defecation
Prevent gastro esophageal reflux
Disfunction Paralysis Weakness Eventration
Paralysis Synonyms
Paralysis Etiology
Diaphragmatic palsy
Traumatic : post surgical
Diaphragmatic paresis
Compression: malignancy compressing or invading phrenic nerve
Diaphragmatic weakness
Inflammatory Definitions Extreme form of diaphragmatic p g weakness Decreased strength of diaphragmatic musculature
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Neuropathic Idiopathic : minority of cases
Paralysis
Paralysis
Natural History and Prognosis Poor prognosis if bilateral when associated with
M t common signs/symptoms Most i / t
Unilateral; more common than bilateral
Myopathy
Asymptomatic in 50% Orthopnea, tachypnea, chest pain,, cough p g Inward motion of abdomen during inspiration
Bilateral ; more severe symptoms
Chronic demyelinating condition Coexistent COPD or pulmonary fibrosis
Exertional dyspnea, orthopnea
Treatment
Cor p pulmonale Increased incidence of pneumonia Decreased oxygenation & vital capacity on supine position, worse with bilateral paralysis
Unilateral: Usually no treatment required surgical plication and phrenic pacing in selected cases
Imaging Recommendations Chest fluoroscopy Normal diaphragmatic dome excursion 3-5 cm Sniff test Technique: Rapid forced inhalation through nose with closed mouth Normal: Sharp brief downward motion of both hemidiaphragms Paralysis: Absent or paradoxical upward motion
Paradoxical diaphragmatic movement on sniff test during M mode (motion mode)
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Paralysis
Paralysis MR Findings Real-time diaphragm imaging; only considered when other methods th d are iinconclusive l i
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May be useful for long-term follow-up and monitoring of therapeutic interventions
Eventration Congenital nonparalytic weakening and thinning of anterior portion and dome of hemidiaphragm
Eventration Clinical Issues Adults over 60 years of age Women typically affected
Pathology
Characteristic benign course with good prognosis
Congenital failure of fetal diaphragm to muscularize Thin diaphragmatic tendon and membranous muscle decreased muscle fibers Permanent diaphragmatic elevation Usually unilateral
Eventration
Treatment Asymptomatic adults do not require treatment Surgical repair in extreme cases symtomatic children
Eventration
Radiography Imaging
Lobular elevation or smooth hump-like p morphology of anteromedial hemidiaphragm
Preservation of posterior costophrenic angle
Right hemidiaphragm usually affected
Anteromedial portion of hemidiaphragm
CT
Useful when x ray is inconclusive or when mimics a mass
Location
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Disfunction
Disfunction
Usally unilateral Often asyntomatic Discovered i d incidentally d ll
Bilateral
Symptoms are more severe in patients with underlying y g pulmonary p y diseases
Ventilation failure Use of the accesory muscle
Syntomatic
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Mimics elevation Normal exhalation Increases intra abdominal preassure Obesity Ascitis Hepatoesplenomegaly Conditions cause lung volume loss Atelectasis Lung L resection ti Pulmonary fibrosis Pleural thickening Subpulmonic b l pleural l l effussion ff
Traumatic Hernia Traumatic hemidiaphragm laceration; may result in intrathoracic herniation of abdominal viscera Incidence 0 0.16% 16% to 5%
Traumatic Hernia General G l Features F t Best diagnostic clue Air Air-filled filled bowel above hemidiaphragm Increased accuracy with supradiaphragmatic enteric tube Location
More common with blunt than penetrating trauma
Equal q in blunt trauma Penetrating trauma
Up p to 7.2% of injuries j that are missed acutely y may y manifest delayed complications in a period that ranges from days to 50 years
Right side affected in12%-40% Left side is affected in 50%-88% Visceral herniation much more common on left (70-90%) Liver less likely to herniate through right-sided right sided lacerations
Radiol Clin N Am 44 (2006) 199211 Eur J Cardio- thorac Surg 1999;5:46974.
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Traumatic Hernia
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Traumatic Hernia
Traumatic Hernia
Size
Variable size of diaphragmatic tear:
Traumatic Hernia
Small in penetrating trauma, large in blunt trauma Prevalence P l off visceral i lh herniation i ti iincreases with ith llarger ttears
Morphology p gy
Blunt: Linear or radial tears typically at hemidiaphragm dome where tendon is thinnest Most commonly extend posterolaterally along embryonic closure of pleuroperitoneal membrane
Traumatic Hernia
Traumatic Hernia
The higher frequency of left-sided left sided BDR has been attributed to an area of congenital posterolateral weakness Radiographics 2002;22:S10318.
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Traumatic Hernia
Traumatic Hernia
Chest x-ray
Radiographic Findings Abnormal in 90% of cases left-sided sided tears Sensitivity 50% for left 20% for right-sided tears Often nonspecific p because of associated lower lobe atelectasis or contusion Abnormal diaphragmatic contour Hemidiaphragm elevation > 7 cm Positional change of hemidiaphragm contour/shape AJR Am J Roentgenol 1991; 156:517.
Intrathoracic location of abdominal viscera with /without collar sign
Nasogastric tube tip above the left hemidiaphragm.
Marked elevation of the left hemidiaphragm (>4 cm than the right) without associated atelectasis is another highly suggestive sign sign.
Obscuration or distortion of the diaphragm margin and diaphragm elevation with contralateral mediastinal shift
Elevation of the right diaphragm apex with shift of the apex to a point midway between the mediastinal margin and the lateral chest wall secondary to hepatic herniation is suggestive of right-sided BDR .
May mask the diaphragm injury
pulmonary contusion
atelectasis atelectasis,
pleural effusion,
Emerg Radiol 1994;1(5):2315.
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Traumatic Hernia
Traumatic Hernia CT signs
CT Findings CT CT d detection t ti off BDR sensitivity iti it off 71% tto 100%
Direct visualization of injury Segmental diaphragm non visualization
Specificity of 75% to 100%
Intrathoracic herniation of viscera Collar Collar sign sign
Sensitivity for left-sided injuries is greater (78100%) than for g injuries j ((5079%)) right-sided
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AJR Am J Roentgenol 2002;179:4517
Traumatic Hernia
Dependent viscera sign Diaphragm thickening, and peridiaphragmatic active contrast extravasation. Others
Traumatic Hernia
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Traumatic Hernia H i di Hernia diafragmática f áti iintra t pericárdica i á di
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First day
Ten days later
Hiatal Hernias
Sliding hiatus hernia
Sliding hiatus hernia
Paraesophageal hiatus hernia
Netter
Paraesophageal hiatus hernia
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Diaphragm Tumors
Diaphragm Tumors Primary :rare Metastases
AJR:200, January 2013
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Metastases
Summary
Development anomalies of the diaphragm comes : Morgagni hernia Bochdaleck hernia Eventration E t ti
Hernias can also due to trauma
g g modalities of study y Imaging Xray Fluoroscopy US with ith M mode d specially i ll iin children hild CT specially in trauma MR with cine images g