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Chest X ray

Mediastinum

COHS February 2014

Goals

To understand the basic terminology and techniques

of chest x-rays To gain familiarity with "the normal chest x-ray“

To learn and practice a standardized sequence of

chest x-ray interpretation

To learn and be able to recognize several common chest x-ray abnormalities

Lung zones

Pulmonary arteries

Mediastinum

Many structures can be identified within the mediastium;

Heart, blood vessels, main airways,

esophagus, lymph nodes, thymus

..

Mediastinum • Many structures can be identified within the mediastium; • Heart, blood vessels, main airways,
DISTANT STRUCTURES TWO SHADOWS/MAGNIFICATION

DISTANT STRUCTURES

TWO SHADOWS/MAGNIFICATION

ADJACENT STRUCTURES

SHADOWS MERGE

How many structures can you identify?

Aortic pulmonary Vascular SVC Aortic recess pedicle arch Right pulmonary Left artery LA Right pulmonary artery
Aortic pulmonary
Vascular
SVC
Aortic
recess
pedicle
arch
Right
pulmonary
Left
artery
LA
Right
pulmonary
artery
(lower lobe)
RA
LV
RV

Postero-Anterior (PA) View

SVC IVC
SVC
IVC

Postero-Anterior (PA) View

RA
RA

Postero-Anterior (PA) View

RV
RV

Postero-Anterior (PA) View

PA
PA

Postero-Anterior (PA) View

LA
LA

Postero-Anterior (PA) View

LV
LV

Postero-Anterior (PA) View

Aorta
Aorta

Postero-Anterior (PA) View

Postero-Anterior (PA) View

Postero-Anterior (PA) View

Postero-Anterior (PA) View • Right border Superior vena cava Right atrium Inferior vena cava – –

Right border

Superior vena cava Right atrium Inferior vena cava

Postero-Anterior (PA) View • Right border Superior vena cava Right atrium Inferior vena cava – –

Postero-Anterior (PA) View

Postero-Anterior (PA) View • • Right border – Superior vena cava – Right atrium – Inferior

•

Right border

Superior vena cava

Right atrium

Inferior vena cava

Left border

Aortic knob

Main pulmonary trunk

Left ventricle

Postero-Anterior (PA) View

Postero-Anterior (PA) View • Pulmonary Arteries – Right

Postero-Anterior (PA) View • Pulmonary Arteries – Right

Pulmonary Arteries Right

Postero-Anterior (PA) View

 Pulmonary Arteries  Right  Left
Pulmonary Arteries
Right
Left

Postero-Anterior (PA) View

LA
LA

Pulmonary Arteries

Right

Left

Pulmonary Veins

How many structures can you identify?

Brachiocephalic

vessels

Brachiocephalic Trachea Pulmonary outflow tract RV Aorta LPA RPA LA IVC Right upper lobe bronchus lobe
Brachiocephalic Trachea Pulmonary outflow tract RV Aorta LPA RPA LA IVC Right upper lobe bronchus lobe

Trachea

Pulmonary outflow tract
Pulmonary
outflow
tract

RV

Aorta LPA RPA
Aorta
LPA
RPA
LA
LA

IVC

Right upper

lobe bronchus

Brachiocephalic Trachea Pulmonary outflow tract RV Aorta LPA RPA LA IVC Right upper lobe bronchus lobe

lobe

Brachiocephalic Trachea Pulmonary outflow tract RV Aorta LPA RPA LA IVC Right upper lobe bronchus lobe

Left upper

bronchus

Confluence of pulmonary veins

LV

Right

hemidiaphragm

Brachiocephalic Trachea Pulmonary outflow tract RV Aorta LPA RPA LA IVC Right upper lobe bronchus lobe
Gastric air bubble
Gastric air
bubble

Left

hemidiaphragm

Lateral View SVC RA IVC
Lateral View
SVC
RA
IVC

Lateral View

RV
RV

Lateral View

Lateral View

Lateral View

LA
LA

Lateral View

LV
LV

Lateral View

Aorta
Aorta
Lateral View Aorta

Lateral View

LV
LV

Lateral View

Lateral View • Aorta • Main Pulmonary Artery • Inferior vena cava

Aorta

Main Pulmonary Artery

Inferior vena cava

Lateral View

Lateral View • Pulmonary Arteries Left – – Right • Pulmonary Veins

Pulmonary Arteries Left

Right

•

Pulmonary Veins

Which valve has been replaced?

Which valve has been replaced?

Which valve has been replaced? Aortic valve Note the orientation of the valve perpendicular to the

Aortic valve

Which valve has been replaced? Aortic valve Note the orientation of the valve perpendicular to the

Note the orientation of the valve perpendicular to the

plane of the PA film.

Which valve has been replaced?

Which valve has been replaced?

Pulmonic
Pulmonic

The pulmonary outflow tract is more superior and lateral than many

people think.

Last one, name the valves…

Last one, name the valves…

Aortic

Last one, name the valves… Aortic Tricuspid Mitral Tricuspid Aortic

Tricuspid

Last one, name the valves… Aortic Tricuspid Mitral Tricuspid Aortic

Mitral

Tricuspid

Last one, name the valves… Aortic Tricuspid Mitral Tricuspid Aortic

Aortic

Last one, name the valves… Aortic Tricuspid Mitral Tricuspid Aortic

Mitral

Last one, name the valves… Aortic Tricuspid Mitral Tricuspid Aortic

The Vascular Pedicle

Found in the superior mediastinum.

Right and left margins are normally formed by the

superior vena cava and the descending portion of the aortic arch, respectively.

A widened vascular pedicle can have several

etiologies including elevated intravascular volume, aortic trauma, or pericardial effusion.

Aortic arch Vascular pedicle Superior vena cava
Aortic
arch
Vascular
pedicle
Superior
vena cava

Intravascular volume depletion

vs.

Intravascular volume elevation

Intravascular volume depletion

vs.

Intravascular volume elevation

Vascular pedicle Superior vena cava
Vascular
pedicle
Superior
vena cava

Aorta

Vascular pedicle Superior vena cava
Vascular
pedicle
Superior
vena cava

Aorta

Intravascular volume elevation resulting in an expanded SVC should not be mistaken for hematoma, which would have a less distinct border and more opacified appearance.

Trauma patient with an aortic transection

Trauma patient with an aortic transection Note the vascular pedicle’s “fuzzy”, opacified right border.

Note the vascular pedicle’s “fuzzy”, opacified right border.

What is happening here?

What is happening here?

What is happening here?

What is happening here? Can you follow the heart borders?

Can you follow the heart borders?

What is happening here? The wide vascular pedicle here results from a pericardial effusion If you
What is happening here?
The wide vascular
pedicle here results
from a pericardial
effusion
If you look closely you can
make out the superior
pericardial border
The pacemaker
wires roughly
outline the right
atrium border
effusion
The left heart border
can be seen within the
effusion
effusion

Comparing this with older films can also help make the diagnosis.

Other Mediastinal Structures

Esophagus Thyroid Thymus Lymph nodes

These are generally not seen unless there is pathology

What could be the source of this anterior mediastinal mass?

What could be the source of this anterior mediastinal mass?

What could be the source of this anterior mediastinal mass? Ddx: Lymphoma/leukemia, germ cell tumors (e.g.,
What could be the source of this anterior mediastinal mass? Ddx: Lymphoma/leukemia, germ cell tumors (e.g.,

Ddx: Lymphoma/leukemia, germ cell tumors (e.g., teratoma), thymic mass (e.g., thymoma, cyst), enlarged thyroid, vascular (e.g., hematoma, aortic aneurysm).

This patient has a thymoma.

How about this one?

How about this one?
How about this one?

How about this one?

How about this one? This patient has a an enlarged thyroid gland.
How about this one? This patient has a an enlarged thyroid gland.

This patient has a an enlarged thyroid gland.

Case 1. 68/M

Traumatic Aortic Rupture

A

B
B

A. Anteriorposterior chest radiograph obtained on supine position shows mediastinal widening with enlarged and indistinct aortic knob and aortopulmonary window opacification (a).

C

  • B. Contrast-enhanced axial

CT scan shows a rupture of the aorta with a

pseudoaneurysm (star)

Traumatic Aortic Rupture A B A. Anteriorposterior chest radiograph obtained on supine position shows mediastinal

projecting anteromedially. Also noted are mediastinal hematoma and bilateral hemothoraces.

  • C. 3-D volume rendering

image well demonstrates a pseudoaneurysm (arrow) of the aorta at isthmic portion.

Case 1. 49/M

Fracture of the left 1 st Costal Cartilage

A B
A
B
C D
C
D

A. Chest radiograph appears normal.

B. Tc 99m MDP scan shows hot uptake at junction between left 1 st rib and manubrium. C and D. Axial (C) and 3-D reconstruction (D) CT

scans reveal fracture of calcified left 1 st costal cartilage, just lateral to sternocostal joint.