Thoracic Imaging: Gross Sectional I S ti l Imaging of the Ch t i f th Chest an Overview

Department of Radiology, p gy, Vancouver General Hospital

Dr. Savvas Nicolaou Director of ER/Trauma Radiology savvas.nicolaou@vch.ca

Objectives
Be able to identify the following mediastinal structures on Chest CT: Esophagus Trachea and bifurcation into right and left main bronchi Pulmonary trunk and right and left pulmonary arteries Thoracic aorta Ascending Arch Descending Sinus of valsava

Objectives

Be able to identify the following mediastinal structures on Chest CT: y g Major branches of aorta Brachiocephalic artery Left common carotid artery Left subclavian artery Left and right subclavian and internal jugular veins Left and right brachiocephalic veins Superior and inferior vena cavae

Anatomy Review Anatom Re ie

LOOKING AT MEDIASTINUM
The mediastinum is the space between the spine at the back, the sternum at the front, and the lungs at the sides It is divided into the superior and inferior with subdivisions of the inferior into anterior, middle and posterior mediastinum

The Mediastinum

Radiological DIVISIONS OF THE MEDIASTINUM

Middle Anterior Posterior

RADIOLOGY Lecture 5 THORACIC IMAGING

PRE TEST PRE-TEST

RADIOLOGY Lecture 5 THORACIC IMAGING

Thymic mass in anterior mediastinum PRE TEST PRE-TEST

Anatomy Review
Esophagus

Esophagus

Anatomy Review

Trachea and bifurcation into right and left main bronchi At spinal level T4-T5

Anatomy Review
Pulmonary trunk and right and left pulmonary arteries

Anatomy Review
Thoracic aorta Ascending, transvserse Arch Descending, Sinus of valsalva (aka aortic sinuses)

Anatomy Review
Major branches of aorta: Brachiocephalic artery Left common carotid artery Left subclavian artery

Anatomy Review
Left and right subclavian and internal jugular veins Left and right brachiocephalic veins

Anatomy Review
Superior and inferior vena cavae

Axial (transverse) mediastinal structures: Gross vs CT

2 1

4 5

3 2 1 5

1. Esophagus 2. Trachea 3. Brachiocephalic A t 3 B hi h li Artery (Bif (Bifurcation i t Ri ht C ti into Right Common C tid A t Carotid Artery and d Right Subclavian Artery) 4. Left Common Carotid Artery y 5. Left Subclavian Artery

Axial (transverse) mediastinal structures: Gross vs CT

7 6

8 9

8 7 6 9

6. Right Subclavian Vein 7. Right Internal Jugular Vein

8. Left Internal Jugular Vein 9. Left Subclavian Vein

Full size axial CT with contrast

8 7 6 3 2 1 5 4 9

1. 1 Esophagus 2. Trachea 3. Brachiocephalic Artery (Bifurcation into Right Common Carotid Artery and Right Subclavian Artery) 4. Left Common Carotid Artery

5. 5 Left Subclavian Artery 6. Right Subclavian Vein 7. Right Internal Jugular Vein 8. 8 Left Internal Jugular Vein 9. Left Subclavian Vein

Axial (transverse) mediastinal structures: Gross vs CT

3 4

4 2 1 2 1

1. Esophagus 2. Trachea 2 T h

3. Brachiocephalic Artery 4. Left C 4 L ft Common Carotid A t C tid Artery

Axial (transverse) mediastinal structures: Gross vs CT

6 5

5. Left Subclavian Artery 6. Right Brachiocephalic Vein

7. Left Brachiocephalic Vein

Full size axial CT with contrast

6 4 2 1

1. Esophagus 2. Trachea 3. Brachiocephalic Artery 4. Left Common Carotid Artery

5. Left Subclavian Artery 6. Right Brachiocephalic Vein 7. Left Brachiocephalic Vein

Axial (transverse) mediastinal structures: Gross vs CT

4 3 2 3 1 2 1

1. Esophagus 2. 2 Trachea 3. Superior Vena Cava

4. Aortic Arch

Full size axial CT with contrast

2 1

1. Esophagus 1 E h 2. Trachea 3. Superior Vena Cava

4. Aortic Arch 4 A ti A h

Axial (transverse) mediastinal structures: Gross vs CT

4 3 2 1 2 1 3

1. Esophagus 3. Bifurcation into Left Main Bronchus 2. 2 Bifurcation into Right Main Bronchus 4 Pulmonary Trunk 4.

Axial (transverse) mediastinal structures: Gross vs CT

5 7

7
6

5. Ascending Aorta 6. Descending Thoracic Aorta

7. Superior Vena Cava

Full size axial CT with contrast

5 4 7

2 1

1. Esophagus 2. 2 Bifurcation into Right Main Bronchus 3. Bifurcation into Left Main Bronchus 4. Pulmonary Trunk

5. Ascending Aorta 6. 6 Descending Thoracic Aorta 7. Superior Vena Cava

Axial (transverse) mediastinal structures: Gross vs CT

2 1 2

1. Right Main Bronchus g

2. Left Main Bronchus

Axial (transverse) mediastinal structures: Gross vs CT

5 3

5 3

3. Esophagus 4. Pulmonary Trunk

5. Right Pulmonary Artery

Axial (transverse) mediastinal structures: Gross vs CT

8 7 8 7 6 9 9 6

6. Left Pulmonary Artery 7. Superior Vena Cava

8. Ascending Aorta 9. Descending Thoracic Aorta

Full size axial CT with contrast

4 8

7 6

1 5 2 3 9

1. Right Main Bronchus 2. Left Main Bronchus 3. Esophagus 3 E h 4. Pulmonary Trunk 5. Right Pulmonary Artery

6. Left Pulmonary Artery 7. Superior Vena Cava 8. Ascending A t 8 A di Aorta 9. Descending Thoracic Aorta

Axial (transverse) mediastinal structures: Gross vs CT

2 1 2

1. Esophagus g 2. Descending Thoracic Aorta 3. Sinus of Valsalva (Aortic Sinus)* j *Note the location of the aortic sinuses just distal to the aortic valve

Full size axial CT with contrast

1. 1 Esophagus 2. Descending Thoracic Aorta 3. Sinus of Valsalva (Aortic Sinus) -directly distal to aortic valve outlined-

Axial (transverse) mediastinal structures: Gross vs CT

3 3 1 2

1 2 (4)

1. Esophagus 2. Descending Thoracic Aorta

3. Inferior Vena Cava (4. Liver)

Full size axial CT with contrast

1 2

(4)

1. Esophagus 2. Descending Thoracic Aorta

3. Inferior Vena Cava (4. Liver)

Imaging of Lungs on Axial CT

Normal lung shows central, branching pulmonary arteries and bronchi Bronchus is a thin-walled, white circle with central air (black), and the adjacent artery appears as a solid, white circle solid More peripherally, numerous small "dots" and a few branching lines represent small pulmonary arteries and veins Major fissures (pleura) are visualized most frequently as lucent bands devoid of vascularity On high resolution CT: they may appear as lines or dense bands

Axial (transverse) mediastinal structures: Gross vs CT

5 3 5 3 1 4 2 6 2 1 4 6

1. 2. 2 3. 4. 5. 5 6.

Right Major (oblique) fissure Left major (olbique) fissure Right Upper Lobe Right Lower lobe Left Upper lobe Left lower lobe

3 2 4 6

5 1

Cross Sectional CT Imaging of Lungs g g g

3 5 1 6

4 7 3 5 2 8 6

7 2 8

1. 2. 2 3. 4. 5.

Right Major (oblique) fissure Left L ft major ( bli j (oblique) fi ) fissure Right minor (horizontal) fissure Right Upper Lobe Right Middle lobe Ri h Middl l b

6. 6 7. 8.

Right Lower l b Ri ht L lobe Left Upper lobe Left lower lobe

Coronal

Saggital

Transverse

Coronal mediastinal structures: Gross vs CT

1 1 5 5

3 4

3 2 4

1. Trachea 2. Pulmonary Trunk 3. Ascending Aorta

4. Aortic Sinus 5. Brachiocephalic Artery

Coronal mediastinal structures: Gross vs CT

7 6

6 (9) 9 ( ) (10) 10

6. 6 Superior Vena Cava 7. Right Brachiocephalic Vein 8. Left Brachiocephalic Vein

(9. (9 Right Atrium) (10. Left Ventricle)

Full size coronal CT with contrast

1 5

7 6 3 4 (9) 2

(10)

1. Trachea 2. Pulmonary Trunk 3. 3 Ascending Aorta 4. Aortic Sinus 5. Brachiocephalic Artery

6. Superior Vena Cava 7. Right Brachiocephalic Vein 8. 8 Left Brachiocephalic Vein (9. Right Atrium) (10. Left Ventricle)

Coronal mediastinal structures: Gross vs CT

1 4 4

3 3 2 2

1. Trachea 2. Pulmonary Trunk

3. Aortic Arch 4. Brachiocephalic Artery

Coronal mediastinal structures: Gross vs CT

5 5

6 8

6 8

5. 5 Left Common Carotid Artery 6. Right Brachiocephalic Vein 7. Left Brachiocephalic Vein

8. 8 Superior Vena Cava 9. Inferior Vena Cava

Full size coronal CT with contrast

1 5 4 6 3 8 2 7

1. Trachea 2. Pulmonary Trunk 3. 3 Aortic Arch 4. Brachiocephalic Artery 5. Left Common Carotid Artery

6. Right Brachiocephalic Vein 7. Left Brachiocephalic Vein 8. 8 Superior Vena Cava 9. Inferior Vena Cava

Coronal mediastinal structures: Gross vs CT

2 3 3

1. Esophagus 1 E h 2. Trachea

3. Aortic A h 3 A ti Arch

Coronal mediastinal structures: Gross vs CT

4 4

5 6 5 6

4. Left Subclavian Artery 5. Right Pulmonary Artery

6. Left Pulmonary Artery

Full size coronal CT with contrast

4 3

6 5

1. Esophagus 2. 2 Trachea 3. Aortic Arch 4. Left Subclavian Artery

5. Right Pulmonary Artery 6. 6 Left Pulmonary Artery

Coronal mediastinal structures: Gross vs CT

1 2 2

3 4 4

1. Esophagus 2. Trachea

3. Right Main Bronchus 4. Left Main Bronchus

Coronal mediastinal structures: Gross vs CT

5 5 7 7

5. Descending Thoracic Aorta 6. Right Pulmonary Artery

7. Left Pulmonary Artery

Full size coronal CT with contrast

1 2 5 3 7

1. Esophagus 2. 2 Trachea 3. Right Main Bronchus 4. Left Main Bronchus

5. Descending Thoracic Aorta 6. 6 Right Pulmonary Artery 7. Left Pulmonary Artery

Coronal mediastinal structures: Gross vs CT

1 2

1. Esophagus p g

2. Descending Thoracic Aorta g

Full size coronal CT with contrast

1. Esophagus

2. Descending Thoracic Aorta

Coronal CT Imaging of Lungs

4 7 3 5 8 2 1 6 8

3 5 1 6

1. 2. 3. 4.

Right Major (oblique) fissure Left major (oblique) fissure g (horizontal) fissure ) Right minor ( Right Upper Lobe

5. 6. 7. 8.

Right Middle lobe Right Lower lobe Left Upper lobe pp Left lower lobe

Sagittal mediastinal structures: Gross vs CT

4 5 2 5 3 1 1 2 3 4

1. Left Main Bronchus 2. 2 Aortic Arch 3. Descending Thoracic Aorta

4. 4 Left Subclavian Artery 5. Left Brachiocephalic Vein

Full size sagittal CT with contrast

1. 1 Left Main Bronchus 2. Aortic Arch 3. Descending Thoracic Aorta

4. 4 Left Subclavian Artery 5. Left Brachiocephalic Vein

Sagittal mediastinal structures: Gross vs CT

1 1

3 2

1. Trachea 2. Right Pulmonary Artery

3. Ascending Aorta

Sagittal mediastinal structures: Gross vs CT

(5)

( ) (5)

(6) (6)

4. Left Brachiocephalic Vein (5. (5 Brachiocephalic Artery)

(6. Left Atrium)

Full size sagittal CT with contrast

(5)

4 1

3 2

( ) (6)

1. 1 Trachea 2. Right Pulmonary Artery 3. Ascending Aorta

4. 4 Left Brachiocephalic Vein (5. Brachiocephalic Artery) (6. Left Atrium)

Post Test

Arrow indicates malpositioned tube. Normally, the ET tube should be at least over 3cm above level of carina.

TRAUMATIC AORTIC DISSECTION

Traumatic aortic pseudo aneurysm

Aortic Angiogram