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Cxr revised 24 11-91

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normal chest X-ray

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Cxr revised 24 11-91

  1. 1. CXR Normal Anatomy A. Almasi MD Iran University of Medical Science Department of Radiology
  2. 2. PA CXR • • • • • • • • • • Quality Control Trachea Mediastinum& Heart Diaphragms Pleural space including fissures Lungs Hidden Areas of the Lungs Hila Below Diaphragm Bones
  3. 3. PA view
  4. 4. Quality Control • Inspiration: • Ant. end of 5th - 6th or post. end of 10th rib above the diaphragm • Centering: • Medial end of the clavicles equidistant from T4-5 spinous process • Exposure: • Vertebral bodies and disc spaces behind the heart must be barely visible and bronchovascular marking should be visible through the heart
  5. 5. PA view
  6. 6. Rotation Effect • Anterior structures (e.g. heart) shift to the side farther from the film • The lung farther from the film appears more lucent and the ipsilateral hemithorax appears wider • In this rotated film skin folds can be mistaken for a tension pneumothorax (blue arrows)
  7. 7. Expiratory Film • • • • Increased heart size More prominent bronchovascular markings Basal opacities Tracheal deviation to the right
  8. 8. Expiratory Film • • • • Increased heart size More prominent bronchovascular markings Basal opacities Tracheal deviation to the right inspiration expiration
  9. 9. Respiration and Rotation Effect Inspiration Expiration& Leftwards Rotation
  10. 10. Improper Exposure Underexposed Overexposed
  11. 11. Trachea • Exact midline in the upper part& deviating to the right around the aortic knob • Even diameter up to M:25mm F:21mm • Right paratracheal stripe <4-5mm • Azygos vein at the anlge between the RMB& trachea (less than 10mm in diameter) • Carina at T6-7 angle: 60-75
  12. 12. Trachea in Superior Mediastinum • Left side of the trachea is not border forming on CXR it is not surrounded by aerated lung
  13. 13. right brachiocephalic artery right paratracheal stripe SVC carina Normal PA View
  14. 14. Right Paratracheal Stripe Hodjkin’s Disease Normal after Radiotherapy
  15. 15. cephalization Wide Carina left atrial in Mitral appendage Malady left atrium
  16. 16. The Heart • 1/3(1/5-1/2) to the right& 2/3 to the left of midline • CT ratio 50% on PA and 60% on AP view • Diameter up to F:14.5cm M:15.5cm • 1-1.5cm increase on two consecutive films is significant • Enlarges in expiration& when diaphragm is high
  17. 17. Cardiothoracic (CT) Ratio
  18. 18. Normal PA View
  19. 19. Mediastinal Borders Right  Superior  Brachiocephalic A&V  SVC  Tortuous or dilated ascending aorta may contribute  Inferior  Rt atrium  IVC (probable) Left  Subclavian A  Aortic knob  Pulmonary A  Lt atrial appendage  Lt ventricle
  20. 20. 1.1 Mediastinal Borders 1.1.BraciocephalicA&V 1.SVC 2.RA 3.SubclavianA 4.Aortic Knob 5.Descending Aorta 6.Pulmonary Trunk 7.LA Auricle 8.LV
  21. 21. Normal PA View
  22. 22. Prominent Pulmonary Trunk Is normal in young women& children
  23. 23. Tortuous Aorta & Prominent Lt Cardiophrenic Angle Fat Pad Ascending A Fat Pad
  24. 24. Cardiophrenic Angle Fat Pad on Lateral CXR
  25. 25. Tortuous Aorta& Brachiocephalic Aneurysm
  26. 26. PA CXR • • • • • • • • • • Quality Control Trachea Mediastinum& Heart Diaphragms Pleural space including fissures Lungs Hidden Areas of the Lungs Hila Below Diaphragm Bones
  27. 27. Diaphragm • Right hemidiaphragm is usually higher • More than 3cm difference between heights of the hemidiaphragms may be abnormal • Dome of the hemidiaphragms is usually posteriorly located but on the right it may be anterior 40% of the times • Contour should be sharp except where heart lies on the diaphragm
  28. 28. PA view
  29. 29. Anterior right diaphragm dome
  30. 30. High Hemidiaphragm DDx • Normal esp. when there is much gas in the bowel, normal motion on fluoroscopy or sonography • Diaphragmatic Paralysis esp. after thoracic surgery, paradoxical motion of the diaphragm • Eventration usu.paradoxical motion on fluoroscopy
  31. 31. High Hemidiaphragm
  32. 32. Diaphragmatic Scalloping
  33. 33. Diaphragmatic Slipping in flat diaphragms • Athletes • Emphysema
  34. 34. Hump of Diaphragm
  35. 35. Hump Sonography rules out subdiaphragmatic mass
  36. 36. Pleural Space • Lateral Costophrenic Angles should be acute, blunting indicate effusion (250ml at least), flattening or thickening • Posterior Costophrenic Angles can become blunted by as little as 75ml fluid on lateral view • Fissures are double layered pleura separating lobes
  37. 37. Fissures • Oblique (major) visible only on lateral view From T4-5 to just posterior to costophrenic angel on the right and 5cm posterior on the left • Horizontal (minor) visible on both PA& lateral views From right hilum to the 6th rib at axillary line
  38. 38. Fissures
  39. 39. Fluid-filled fissures • • The patient below has a pleural effusion extending into the fissure. Which fissure is which? What is the bright loop near the center of the films?
  40. 40. Segmental Lung Anatomy • Lung lobes are separated by fissures which are composed of two adjacent layers of parietal pleura • A lung segment is the lung parenchyma surrounding a segmental bronchus
  41. 41. Lobar& Segmental Anatomy of the Lungs
  42. 42. Lobar& segmental anatomy
  43. 43. Minor Fissure From right hilum to the 6th rib at axillary line
  44. 44. Minor Fissure
  45. 45. Major Fissures From T4-5 crossing the hilum and terminating behind costophrenic angel on the right and 5cm more posteriorly on the left
  46. 46. minor Fissures left major right major
  47. 47. The Lungs • Opacity • Symmetry in marking& lucency • Vasculature – Inferior vessels are more prominent – No vessel>3mm in diameter in the 1st anterior intercostal space – Concave lateral border of Rt descending pulmonary A • Hidden Areas – Apex – Posterior Recess – Areas superimposed by mediastinum, hila& bones
  48. 48. Normal PA View
  49. 49. Lung Hila • • • • Left hilum higher 97% Symmetric in size and density Concave lateral border Contour made up of superior pulmonary vein& descending branch of main pulmonary artery • Descending branch of main pulmonary artery on the Rt has concave lateral contour and measures less than 16mm in diameter • Normal LNs not visible
  50. 50. Hilar Anatomy
  51. 51. Hila on PA View
  52. 52. Hila on Lateral View
  53. 53. Lt Main Pul. A Hila on Lateral View * Rt Main Pul. A * Rt Sup Bronchus Lt Sup Bronchus
  54. 54. Hilar Adenopathy
  55. 55. Hilar Adenopathy
  56. 56. Prominent Hila-Vascular (Pulmonary Venous HTN)
  57. 57. Prominent Hila Pulmonary Arterial HTN
  58. 58. Prominent Hila Pulmonary Arterial HTN
  59. 59. Hilar Enlargement Vascular vs Adenopathy
  60. 60. Below diaplragm, Soft tissue& Bones • Gas shadows (stomach, bowel, surgical emphysema, etc.) • Symmetric axillary lines, Mastectomy • Bone lesions
  61. 61. Normal PA View
  62. 62. Normal PA
  63. 63. Prominent skin fold vs pneumothorax
  64. 64. Calcified Costal Cartilage
  65. 65. Hypertrophied 1st Costochondral Junction
  66. 66. Hypertrophied 1st Costochondral Junction
  67. 67. Lateral CXR • Clear Spaces • Vretebral Translucency • Diaphragm Outline • The fissures • The lung Hila • The Trachea& Upper Lobe Bronchi • The Sternum
  68. 68. Clear Spaces& Vertebral Translucency • Ant. Clear Space – Ant. medistinal masses, LNs& aortic aneurysm may fill this space – In emphysema it widens (>3cm) • Post. Clear Space – Vertebral translucency increases progressively downward in this space
  69. 69. CXR Lateral View
  70. 70. PE on lateral view (effect on vertebral translucency)
  71. 71. PE
  72. 72. minor Fissures left major right major
  73. 73. Lt Main Pul. A Hila on Lateral View * Rt Sup Bronchus Rt Main Pul. A * Lt Sup Bronchus
  74. 74. Hilar Adenopathy
  75. 75. LLL Consolidation
  76. 76. Lateral Decubitus Films • • • • • To differentiate pleural effusion from thickening in case of a blunt costophrenic angle To assess the volume of pleural effusion Demonstrates whether a pleural effusion is mobile or loculated Detection of a pneumothorax in the nondependent hemithorax in a patient who could not be examined erect The dependant lung should increase in density due to atelectasis from the weight of the mediastinum putting pressure on it. Failure to do so indicates air trapping
  77. 77. PA versus AP CXR
  78. 78. PA versus AP CXR
  79. 79. Recommended order of reading a CXR • It is recommended to start from the regions of least radiologic interest to decrease the likelihood of missing details. 1- Abdomen 2- Thorax (soft tissues and bones) 3- Mediastinum 4- Lung-unilateral 5- Lungs-bilateral This order can be memorized by the breviation ATMLL
  80. 80. Abdomen • The recommended path is shown, beginning at the right lower corner.
  81. 81. Thorax (soft tissues and bones) • The path again starts from the right lower corner of the x-ray
  82. 82. Mediastinum • Mediastinum can be assessed in two consecutive runs one for the trachea And bronchi and the other for the soft-tissue structures and pulmonary hila
  83. 83. Lung • It is recommended to look at the lungs one by one at first and then a look that compares the two lungs
  84. 84. Lateral Film • The same order that was mentioned (ATMLL) is applicable to lateral films too
  85. 85. Proposed reading order for a CXR • • • • • • • • • • • • • Turn off stray lights, optimize room lighting, view images in order Patient Data (name history #, age, sex, old films) Routine Technique: AP/PA, exposure, rotation, supine or erect Trachea: midline or deviated, caliber, mass Lungs: abnormal shadowing or lucency Pulmonary vessels: artery or vein enlargement Hila: masses, lymphadenopathy Heart: thorax: heart width > 2:1 ? Cardiac configuration? Mediastinal contour: width? mass? Pleura: effusion, thickening, calcification Bones: lesions or fractures Soft tissues: don’t miss a mastectomy ICU Films: identify tubes first and look for pneumothorax
  86. 86. Atelectasis vs Lobar Pneumonia Atelectasis • Volume Loss Associated Ipsilateral Shift • Linear, Wedge-Shaped • Apex at Hilum Pneumonia • Normal or Increased Volume No Shift, or if Present Contralateral • Consolidation, Air Space Process • Not Centered at Hilum