Imaging of the Diaphragm Julia Alegria, MD

Imaging of the Diaphragm Julia Alegria, MD Disclosures Imaging g g of the Diaphragm p g • There are no commercial supporters of this workship TUES...
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Imaging of the Diaphragm Julia Alegria, MD

Disclosures

Imaging g g of the Diaphragm p g

• 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:E51–E70

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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:E51–E70

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:E51–E70

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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

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E Emesis i

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Urination

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Defecation

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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

• Bilateral: – Mechanical ventilation &/or tracheostomy

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Paralysis

Paralysis

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

• False-positive sniff test: – COPD, weak, debilitated patients

Paralysis y • Video Diaphragm parlysis

Ultrasonographic Findings •

Absent caudal diaphragm movement on inspiration

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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

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Preservation of posterior costophrenic angle

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Right hemidiaphragm usually affected

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Anteromedial portion of hemidiaphragm

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CT

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Useful when x ray is inconclusive or when mimics a mass

Location

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REV. MED. CLIN. CONDES - 2009; 20(6) 776 - 781

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) 199–211 Eur J Cardio- thorac Surg 1999;5:469–74.

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Traumatic Hernia

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Traumatic Hernia

Traumatic Hernia •

Size

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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

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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:S103–18.

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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; 156:51–7.

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Intrathoracic location of abdominal viscera with /without ‘‘collar sign’’

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Nasogastric tube tip above the left hemidiaphragm.

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Marked elevation of the left hemidiaphragm (>4 cm than the right) without associated atelectasis is another highly suggestive sign sign.

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Obscuration or distortion of the diaphragm margin and diaphragm elevation with contralateral mediastinal shift

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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 .

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May mask the diaphragm injury

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pulmonary contusion

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atelectasis atelectasis,

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pleural effusion,

Emerg Radiol 1994;1(5):231–5.

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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 (78–100%) than for g injuries j ((50–79%)) right-sided

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AJR Am J Roentgenol 2002;179:451–7

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

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Hernias can also due to trauma

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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

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