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Awad Bessar, MD
Professor of Radiodiagnosis
Zagazig University
Clinical Approach
 Imaging of Acute Chest Pain
 Cardiogenic acute chest pain
 Non-Cardiogenic acute chest pain:
 Aortic
 Pulmonary infa...
 Calcium Scoring: provide a quantitative
assessment of subclinical atherosclerotic
coronary artery disease
52-year-old woman with chest pain. (A) Curved planar
reconstruction from a coronary CTA demonstrates no evidence
of corona...
83-year-old man with chest pain.
(A) Curved planar reconstructed
image of the right coronary artery
from a coronary CTA
de...
A
An 8 mm thick
maximum intensity
projection in a
slightly oblique para-
axial projection (a)
and 3-D
reconstruction (b) i...
B
An 8 mm thick
maximum intensity
projection in a
slightly oblique para-
axial projection (a)
and 3-D
reconstruction (b) i...
C
An 8 mm thick
maximum intensity
projection in a
slightly oblique para-
axial projection (a)
and 3-D
reconstruction (b) i...
A B
Noncalcified
plaque (arrow)
in the
proximal left
anterior
descending
coronary
artery
associated
with
significant
luminal
s...
Noncalcified plaque
(arrows) of the
proximal left
anterior descending
coronary artery
associated with
(subtotal) occlusion...
Densely calcified plaque
in the proximal and mid
left anterior descending
coronary artery (arrow)
in a 65-year-old female
...
Mixed plaque with calcified (arrow) and noncalcified
components (arrowhead) in the mid left anterior descending
coronary a...
Coronary artery stenosis. Coronary CTA shows a high-grade stenosis
(arrow) due to non-calcified plaque (arrowheads) in the...
Chest radiography usually represents the first
imaging modality performed in patients presenting
with acute chest pain.
 Pneumothorax
 Pneumomediastinum
 Rib fractures
 Acute infections.
 Aortic aneurysms or dissections (lower
sensitivit...
 Widening of the superior mediastinum
 Displacement of aortic wall calcifications
 In Aortic dissection an intima flap ...
 Stanford Type A
lesions involve
the ascending
aorta and aortic
arch and may or
may not involve
the descending
aorta.
 S...
 type I= ascending, arch and descending aorta:
 type II= only ascending aorta
 type III= only descending aorta.
The Sta...
 Classic Aortic Dissection is the most common
entity causing an acute aortic syndrome (70%).
 Incidence: 1-10 : 100.000
...
LEFT: Type A dissection with clear intimal flap seen
within the aortic arch.
RIGHT: Type B dissection. Entry point distal ...
True lumen:
-Surrounded by
calcifications (if present)
-Smaller than false lumen
Usually origin of celiac
trunk, SMA and r...
False lumen:
• Flow or occluded by
thrombus (chronic).
• Delayed enhancement
• Wedges around true lumen
(beak-sign)
• Coll...
Collageneous media-remnants (cobwebs) are only seen in
the false lumen.
• The compressed true lumen is seen on the inner side
and is brighter than the false lumen.
• Thrombus formation within th...
Aortic dissection in a 72-
year-old patient. Non-
contrast CT scan
 (a) shows displacement
of some calcifications
toward ...
Massive hematoma
caused by rupture
of the dissected
aorta into the
mediastinum and
pleural cavity, no
pericaldial
hematoma.
Imminent rupture of AAA. Axial CTA shows a large outpouching (arrow)
near the bifurcation of the abdominal aorta into the ...
 It can be difficult to differentiate an aneurysm with thrombus
from a dissection with a thrombosed false lumen.
 If the...
 Endoluminal clot: This is seen as a partial
intravascular central or marginal filling defect
surrounded by contrast form...
 Other non-specific signs: Peripheral wedge-
shaped consolidation represents a pulmonary
infarction especially if it is n...
Acute PE. CTA chest
shows large globular
filling defects within
the distal right main
pulmonary artery
(arrow) and filling...
Chronic PE. CTA chest shows non-occlusive intraluminal filling defects
(arrows) adherent to the wall and multiple peripher...
Septic emboli. Axial CT chest of an intravenous drug abuse patient shows
multiple peripheral cavitary nodules (arrows) due...
 Hampton Hump Sign
 Westermark sign
 Pulmonary infarction secondary to pulmonary
embolism produces an abnormal area of
opacification on the chest radiograph,...
Lung window shows a focal subpleural area of consolidation in the left
lower lobe (arrows). This hump-shaped area of opaci...
CT with mediastinal windowing shows low-attenuation filling defect,
which represents a saddle embolus (arrows) bridging th...
 This sign refers to oligemia of the lung beyond
an occluded vessel in a patient with pulmonary
embolism
PA chest radiograph shows oligemia of the right lung, the so-called
Westermark sign. Note how the vessels on the right are...
CT with lung windowing better shows the diminution of vessels on
the right compared with the left. There is also a right p...
CT with mediastinal windowing shows thrombus expanding
and filling the main and right pulmonary arteries (arrows).
 Pulmonary infarction (usually haemorrhagic) is
most commonly caused by pulmonary
embolism (PE) in combination with chron...
 Wedge shaped (less often rounded) pleurally
based opacification (Hampton hump) without
air bronchiograms.
 More often i...
Pulmonary infarction. (A) Chest film made 3 days after open-heart surgery
demonstrates a very irregular opacity at the rig...
 Like on CXR, wedge shaped (less often rounded)
pleural based opacification (Hampton hump)
without air bronchograms and o...
A large right-sided
spontaneous
pneumothorax (left in the
image). An arrow indicates
the edge of the collapsed
lung
CT scan of the chest showing a pneumothorax on the person's left side
(right side on the image). A chest tube is in place ...
Chest X-ray of left-
sided
pneumothorax
(seen on the right
in this image). The
left thoracic cavity
is partly filled with
...
CTA image shows a
main pulmonary
artery aneurysm
(arrow) with
resultant
significant
compression of the
left main stem
coro...
Esophageal perforation.
Axial CECT shows a large
amount of oral contrast
layering posteriorly in the
right hemithorax (sma...
SVC thrombosis. Venous
phase CTA shows partial
enhancement of
(arrowhead) a large low-
density thrombus (arrow)
in the sup...
On a chest radiograph the cardiac outline appears bulging in the region
of the aneurysm, and there may be associated compe...
2D transthoracic echo of pericardial effusion
Water bottle-
shaped heart
This image is from a patient with malignant pericardial effusion. Note
the "water-bottle" appearance of the cardiac silhou...
 A pleural effusion is a collection of fluid within
the pleural cavity.
 There are many causes of pleural effusion that
...
CXR (erect):
 Blunting of the costophrenic angle
 Occasionally, blunting of the cardiophrenic angle
 Fluid within the h...
 Ultrasound allows the detection of small amounts
of pleural locular fluid, with positive identification
of amounts as sm...
Right pleural effusion. Sagittal image of the right upper
quadrant demonstrates an anechoic fluid collection above
the rig...
Empyema.
Ultrasound image of
a large
parapneumonic
effusion
demonstrates thick
septations (white
arrows) within the
fluid ...
Free pleural effusion. Posteroanterior chest radiograph
demonstrates the meniscus sign (arrows) in a large free right
pleu...
Empyema. Axial CECT shows a peripherally enhancing elliptical-shaped
pleural collection with an airfluid level (arrow). No...
 Pneumomediastinum is the presence of
extraluminal gas within the mediastinum. Gas
may come from lungs, trachea, central ...
-Blunt chest trauma
-Secondary to chest, neck, or
retroperitoneal surgery
-Esophageal perforation:
 o Boerhaave syndrome
...
 Subcutaneous emphysema
 Elevated thymus: Thymic wing sign
 Air anterior to pericardium: Pneumopericardium
 Air around...
Loculated pneumomediastinum in an infant with respiratory distress syndrome.
Frontal chest radiograph obtained 5 days afte...
Pneumomediastinum in acute respiratory distress syndrome. High-resolution
CT scan shows diffuse bilateral areas of ground-...
 This is a rare but serious condition due to acute
infection of the mediastinum. Chest CT is the
best imaging modality of...
Mediastinitis. Axial
CECT shows a small
pocket of enhancing
loculated abscess
(arrow) within the
peripherally
enhancing fl...
 Percutaneous Indwelling Central Catheter
 Central venous catheter
 Pulmonary artery catheter
 Venovenous or venoarter...
Normal position of a percutaneous intravascular central catheter (PICC)
line. A. Standard posteroanterior chest radiograph...
Normal position of
central venous
catheters. Catheter
entering from right
internal jugular vein
with tip in the distal
rig...
Complications Secondary to Central Venous
Catheters:
1. Malposition
2. Pneumothorax
3. Vascular laceration (hemothorax, ch...
Malpositioned central venous catheters. Posteroanterior and lateral
radiographs demonstrate a central venous catheter in t...
Neck hematoma (asterisk) after right internal jugular line placement
attempt. Note the endotracheal tube tip is in the rig...
Fatal right hemothorax after right internal jugular line placement
attempt in a patient with undiagnosed idiopathic thromb...
Posteroanterior and (D) lateral radiographs demonstrate a right
subclavian catheter with tip overlaying the right clavicul...
Normal position of a
pulmonary artery
catheter placed
through the right
internal jugular vein,
with tip in the
proximal ri...
Pulmonary artery pseudoaneurysm secondary to peripheral placement of a
pulmonary artery catheter. Bright red blood in endo...
Pulmonary artery pseudoaneurysm secondary to peripheral placement of a
pulmonary artery catheter. Bright red blood in endo...
Pulmonary artery pseudoaneurysm secondary to peripheral placement of a
pulmonary artery catheter. Bright red blood in endo...
Venoarterial extracorporeal
life support in a patient
with acute respiratory
distress syndrome
secondary to streptococcal
...
Wire-mesh stent in the superior vena cava as seen on (A)
posteroanterior and (B) lateral radiographs
 Intraaortic balloon pump
 Venoarterial extracorporeal life support
 Stents
Normal position of an
intraaortic balloon pump with
metallic tip at the inferior
aspect of the aortic knob
(arrow). Note t...
Abnormal intraaortic
balloon pump position,
with tip in the left
subclavian artery (white
arrow). Note the
pulmonary arter...
 Pacemaker
 Implantable cardiac defibrillator
 Left venticular assist device
 Atrial septal defect closure device
Temporary transvenous
pacemaker placed
through the common
femoral vein at the groin,
through the inferior vena
cava, right...
Dual-chamber pacemaker as demonstrated on (A) posteroanterior and
(B) lateral radiographs. Device was placed for syncope a...
Biventricular pacemaker in a patient with ischemic cardiomyopathy
Two examples of broken pacemaker leads. A. Lead broken beneath
the left clavicular head (arrow). B. Lead broken (arrow) in...
Twiddler syndrome. Single lead pacemaker with lead tip in right ventricle. A.
Note the generator position and the adjacent...
Pacemaker and
implantable cardiac
defibrillators.
Pacemaker in the
right chest wall with
lead tip in the right
ventricle (...
Epicardial implantable cardiac defibrillator patches (arrows) that required
thoracotomy to implant, with epicardial leads ...
HeartMate left ventricular assist system
Large wire coronary artery bypass graft markers (arrows) as seen on (A)
posteroanterior and (B) lateral radiographs.
 Endotracheal tube
 Tracheostomy tube
 Intratracheal oxygen catheter
 Stents
Abnormal endotracheal tube with
balloon inflated positioned within
the pharynx. High position of an
endotracheal tube may ...
 Feeding tube
 Nasogastric or oral-gastric tubes
 Intraesophageal manometer
 Temperature probe
 pH probe
 Stent
 An...
Correct position of feeding tubes
Incorrect
position of
esophageal
tubes
Coil-type stent in the esophagus as seen on (A) posteroanterior and (B)
lateral radiographs.
Gastric banding for morbid obesity
 Chest tubes
Two chest tubes. One punctured the lung, with resulting large pulmonary
hematoma. A. Chest radiograph shows ...
Emergency cadiopulmonary imaging
Emergency cadiopulmonary imaging
Emergency cadiopulmonary imaging
Emergency cadiopulmonary imaging
Emergency cadiopulmonary imaging
Emergency cadiopulmonary imaging
Emergency cadiopulmonary imaging
Emergency cadiopulmonary imaging
Emergency cadiopulmonary imaging
Emergency cadiopulmonary imaging
Emergency cadiopulmonary imaging
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Emergency cadiopulmonary imaging

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Emergency cadiopulmonary imaging

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Emergency cadiopulmonary imaging

  1. 1. Awad Bessar, MD Professor of Radiodiagnosis Zagazig University Clinical Approach
  2. 2.  Imaging of Acute Chest Pain  Cardiogenic acute chest pain  Non-Cardiogenic acute chest pain:  Aortic  Pulmonary infarction and embolism  Non-thoracic causes  Imaging of thoracic fluid and gas collection  Pericardial effusion  Pulmonary effusion  Pneumothorax  Mediastinum  Monitoring and Support Devices; Tubes and Lines
  3. 3.  Calcium Scoring: provide a quantitative assessment of subclinical atherosclerotic coronary artery disease
  4. 4. 52-year-old woman with chest pain. (A) Curved planar reconstruction from a coronary CTA demonstrates no evidence of coronary artery disease. (B) Straightened coronary artery view allows measure of caliber along the length of the artery (arrow). Crosssectional view (arrowhead) shows the arterial wall and lumen in a projection similar to intravascular ultrasound.
  5. 5. 83-year-old man with chest pain. (A) Curved planar reconstructed image of the right coronary artery from a coronary CTA demonstrates multiple areas of proximal stenosis (arrows). (B) Coronary angiogram with injection of the right coronary artery shows similar areas of stenosis (arrows).
  6. 6. A An 8 mm thick maximum intensity projection in a slightly oblique para- axial projection (a) and 3-D reconstruction (b) in a patient with left anterior descending coronary artery stenosis (arrow). Corresponding coronary angiography (c).
  7. 7. B An 8 mm thick maximum intensity projection in a slightly oblique para- axial projection (a) and 3-D reconstruction (b) in a patient with left anterior descending coronary artery stenosis (arrow). Corresponding coronary angiography (c).
  8. 8. C An 8 mm thick maximum intensity projection in a slightly oblique para- axial projection (a) and 3-D reconstruction (b) in a patient with left anterior descending coronary artery stenosis (arrow). Corresponding coronary angiography (c).
  9. 9. A B
  10. 10. Noncalcified plaque (arrow) in the proximal left anterior descending coronary artery associated with significant luminal stenosis in a 65-year-old male patient
  11. 11. Noncalcified plaque (arrows) of the proximal left anterior descending coronary artery associated with (subtotal) occlusion in a 48-year-old male patient presenting with a vague history of recent episodes of chest pain.
  12. 12. Densely calcified plaque in the proximal and mid left anterior descending coronary artery (arrow) in a 65-year-old female patient presenting with chronic angina pectoris
  13. 13. Mixed plaque with calcified (arrow) and noncalcified components (arrowhead) in the mid left anterior descending coronary artery associated with mild luminal narrowing in a 55-year-old female patient presenting with atypical angina pectoris.
  14. 14. Coronary artery stenosis. Coronary CTA shows a high-grade stenosis (arrow) due to non-calcified plaque (arrowheads) in the proximal LAD
  15. 15. Chest radiography usually represents the first imaging modality performed in patients presenting with acute chest pain.
  16. 16.  Pneumothorax  Pneumomediastinum  Rib fractures  Acute infections.  Aortic aneurysms or dissections (lower sensitivity)  Pulmonary embolism (lower sensitivity)
  17. 17.  Widening of the superior mediastinum  Displacement of aortic wall calcifications  In Aortic dissection an intima flap is seen in only 70% of cases. Typical Aortic Dissection, Intramural Hematoma and Penetrating Aortic Ulcer.
  18. 18.  Stanford Type A lesions involve the ascending aorta and aortic arch and may or may not involve the descending aorta.  Stanford Type B lesions involve the thoracic aorta distal to the left subclavian artery.
  19. 19.  type I= ascending, arch and descending aorta:  type II= only ascending aorta  type III= only descending aorta. The Stanford classification has replaced the DeBakey classification
  20. 20.  Classic Aortic Dissection is the most common entity causing an acute aortic syndrome (70%).  Incidence: 1-10 : 100.000  mostly men  rarely < 60 year (etiology = media degeneration)  hypertension > 70%  Type A mortality 1-2% per hour after onset of symptoms, total up to 90% non-treated, 40% when treated.  1 year survival Type B up to 85% if medically treated (5 year > 70%)
  21. 21. LEFT: Type A dissection with clear intimal flap seen within the aortic arch. RIGHT: Type B dissection. Entry point distal to left subclavian artery.
  22. 22. True lumen: -Surrounded by calcifications (if present) -Smaller than false lumen Usually origin of celiac trunk, SMA and right renal artery
  23. 23. False lumen: • Flow or occluded by thrombus (chronic). • Delayed enhancement • Wedges around true lumen (beak-sign) • Collageneous media- remnants (cobwebs) • Larger than true lumen • Circular configuration (persistent systolic pressure) • Outer curve of the arch • Usually origin of left renal artery • Surrounds true lumen in Type A dissection
  24. 24. Collageneous media-remnants (cobwebs) are only seen in the false lumen.
  25. 25. • The compressed true lumen is seen on the inner side and is brighter than the false lumen. • Thrombus formation within the false lumen. • The true lumen usually is smaller as the false lumen
  26. 26. Aortic dissection in a 72- year-old patient. Non- contrast CT scan  (a) shows displacement of some calcifications toward the aortic lumen.  The contrast-enhanced CT scan at the same level (b) clearly demonstrates an intimal flap in the aortic arch with calcifications along it
  27. 27. Massive hematoma caused by rupture of the dissected aorta into the mediastinum and pleural cavity, no pericaldial hematoma.
  28. 28. Imminent rupture of AAA. Axial CTA shows a large outpouching (arrow) near the bifurcation of the abdominal aorta into the iliac arteries. Note the small crescent-shaped area of hyperdensity (arrowhead) within the large thrombus anteriorly.
  29. 29.  It can be difficult to differentiate an aneurysm with thrombus from a dissection with a thrombosed false lumen.  If there are intima calcifications this will be very helpfull.  A false lumen displaces the intimal calcifications. • LEFT: Dissection with a thrombosed false lumen. • RIGHT: Aneurysm with thrombus on the inner side of the intimal calcifications.
  30. 30.  Endoluminal clot: This is seen as a partial intravascular central or marginal filling defect surrounded by contrast forming an acute angle with the vessel wall (“polo mint” or “tram line” sign). A complete intravascular filling defect occupies the entire vessel, without rim enhancement.  Dilated pulmonary artery proximal to the clot.
  31. 31.  Other non-specific signs: Peripheral wedge- shaped consolidation represents a pulmonary infarction especially if it is non-enhancing and displays a thick vessel running towards the bubbly consolidation (vascular sign).  Pleural effusion and right-heart dilation. The central pulmonary arteries may be dilated in subacute PE.
  32. 32. Acute PE. CTA chest shows large globular filling defects within the distal right main pulmonary artery (arrow) and filling defects within segmental pulmonary arteries in the left lower lobe (arrowheads) and a large rightsided pleural effusion.
  33. 33. Chronic PE. CTA chest shows non-occlusive intraluminal filling defects (arrows) adherent to the wall and multiple peripheral cavitary infarcts (arrowhead).
  34. 34. Septic emboli. Axial CT chest of an intravenous drug abuse patient shows multiple peripheral cavitary nodules (arrows) due to septic emboli. Echocardiography demonstrated tricuspid valve vegetations.
  35. 35.  Hampton Hump Sign  Westermark sign
  36. 36.  Pulmonary infarction secondary to pulmonary embolism produces an abnormal area of opacification on the chest radiograph, which is always in contact with the pleural surface.  The opacification may assume a variety of shapes. When the central margin is rounded, a hump•is produced, as described by Hampton and Castleman.
  37. 37. Lung window shows a focal subpleural area of consolidation in the left lower lobe (arrows). This hump-shaped area of opacification represents pulmonary infarction secondary to pulmonary embolism. there are also small bilateral pleural effusions, which are commonly seen with acute pulmonary emboli.
  38. 38. CT with mediastinal windowing shows low-attenuation filling defect, which represents a saddle embolus (arrows) bridging the lingular and left lower lobe pulmonary arteries
  39. 39.  This sign refers to oligemia of the lung beyond an occluded vessel in a patient with pulmonary embolism
  40. 40. PA chest radiograph shows oligemia of the right lung, the so-called Westermark sign. Note how the vessels on the right are diminutive compared with those on the left. As a result, the right hemithorax appears hyperlucent.
  41. 41. CT with lung windowing better shows the diminution of vessels on the right compared with the left. There is also a right pleural effusion
  42. 42. CT with mediastinal windowing shows thrombus expanding and filling the main and right pulmonary arteries (arrows).
  43. 43.  Pulmonary infarction (usually haemorrhagic) is most commonly caused by pulmonary embolism (PE) in combination with chronic left heart failure.  It occurs in the minority (10 - 15%) of patients with PE
  44. 44.  Wedge shaped (less often rounded) pleurally based opacification (Hampton hump) without air bronchiograms.  More often in the lower lobes.  In the case of pulmonary hemorrhage without infarction the opacities resolve, usually within a week, by maintaining their shape (the so called "melting sign").  In the case of infarction it requires months to heal and will leave a linear scar.  Elevation of the ipsilateral hemidiaphragm.
  45. 45. Pulmonary infarction. (A) Chest film made 3 days after open-heart surgery demonstrates a very irregular opacity at the right base (pneumonia versus pulmonary embolization with infarction). (B) On a film made 5 days later, the consolidation is seen to have reduced in size yet to have retained the same general configuration as on the initial view. The diagnosis of pulmonary embolism was confirmed by a radionuclide lung scan
  46. 46.  Like on CXR, wedge shaped (less often rounded) pleural based opacification (Hampton hump) without air bronchograms and often occurs in the costophrenic sulcus.  Convex borders with a halo sign due to adjacent hemorrhage.  Feeding vessel with visualization of the thrombus.  Sometimes scattered areas of low attenuation within the lesion (necrosis) and sometimes enhancement of the perimeter of the infarct.  Cavitation is seen in septic embolism and in infection of a bland infarct.
  47. 47. A large right-sided spontaneous pneumothorax (left in the image). An arrow indicates the edge of the collapsed lung
  48. 48. CT scan of the chest showing a pneumothorax on the person's left side (right side on the image). A chest tube is in place (small black mark on the right side of the image), the air-filled pleural cavity (black) and ribs (white) can be seen. The heart can be seen in the center
  49. 49. Chest X-ray of left- sided pneumothorax (seen on the right in this image). The left thoracic cavity is partly filled with air occupying the pleural space. The mediastinum is shifted to the opposite side.
  50. 50. CTA image shows a main pulmonary artery aneurysm (arrow) with resultant significant compression of the left main stem coronary artery (arrowhead).
  51. 51. Esophageal perforation. Axial CECT shows a large amount of oral contrast layering posteriorly in the right hemithorax (small arrow), with some contrast and air seen within and adjacent to the esophagus (arrow).
  52. 52. SVC thrombosis. Venous phase CTA shows partial enhancement of (arrowhead) a large low- density thrombus (arrow) in the superior vena cava, representing tumor thrombus
  53. 53. On a chest radiograph the cardiac outline appears bulging in the region of the aneurysm, and there may be associated compensatory hypertrophy or pulmonary oedema. Cardiac aneurysms tend to involve the left ventricle because the blood there is under greatest pressure.
  54. 54. 2D transthoracic echo of pericardial effusion
  55. 55. Water bottle- shaped heart
  56. 56. This image is from a patient with malignant pericardial effusion. Note the "water-bottle" appearance of the cardiac silhouette in the anteroposterior (AP) chest film.
  57. 57.  A pleural effusion is a collection of fluid within the pleural cavity.  There are many causes of pleural effusion that are broadly split into transudates and exudates. This categorization relies upon the protein concentration of the pleural fluid: a protein concentration > 30g/l suggests an exudate.
  58. 58. CXR (erect):  Blunting of the costophrenic angle  Occasionally, blunting of the cardiophrenic angle  Fluid within the horizontal or oblique fissures  With large volume effusions, mediastinal shift occurs away from the effusion  With underlying collapse, mediastinal shift may occur towards the effusion CXR (supine):  Fluid is dependant and collects posteriorly  There is no meniscus and only a veil-like appearance to the hemithorax
  59. 59.  Ultrasound allows the detection of small amounts of pleural locular fluid, with positive identification of amounts as small as 3 to 5 ml, which cannot be identified by x-rays as it is only capable of detecting volumes above 50 ml of liquid.  Allows an easy differentiation of pleural locular liquid and thickened pleura.  Efficient in pinpointing thoracocentesis, even in small fluid collections.  The ultrasound image of pleural effusion is characterized by an echo-free space between the visceral and parietal pleura.
  60. 60. Right pleural effusion. Sagittal image of the right upper quadrant demonstrates an anechoic fluid collection above the right hemidiaphragm consistent with a pleural effusion (arrow)
  61. 61. Empyema. Ultrasound image of a large parapneumonic effusion demonstrates thick septations (white arrows) within the fluid in keeping with an exudate. Frank pus was aspirated during thoracentesis
  62. 62. Free pleural effusion. Posteroanterior chest radiograph demonstrates the meniscus sign (arrows) in a large free right pleural effusion
  63. 63. Empyema. Axial CECT shows a peripherally enhancing elliptical-shaped pleural collection with an airfluid level (arrow). Note the thickening of the extrapleural subcostal fat (arrowhead), seen with chronic empyemas.
  64. 64.  Pneumomediastinum is the presence of extraluminal gas within the mediastinum. Gas may come from lungs, trachea, central bronchi, oesophagus, and the neck or abdomen.
  65. 65. -Blunt chest trauma -Secondary to chest, neck, or retroperitoneal surgery -Esophageal perforation:  o Boerhaave syndrome  o Endoscopic intervention  o Esophageal carcinoma -Tracheobronchial perforation:  o Laceration  o Bronchial stump dehiscence  o Bronchoscopy  o Tracheostomy  o Laryngeal fracture -Vigorous exercise:  o Childbirth  o Weightlifting  o Valsalva maneuver -Asthma -Barotrauma:  Diving  Ventilator : most commonly secondary to ards with positive pressure ventilation -Subcutaneous emphysema, pulmonary interstitial emphysema -Stab wound -Infection:  Tuberculosis  Histoplasmosis  Dental or retropharyngeal infection  Mediastinitis -Idiopathic
  66. 66.  Subcutaneous emphysema  Elevated thymus: Thymic wing sign  Air anterior to pericardium: Pneumopericardium  Air around pulmonary artery and main branches: Ring around artery sign  Air outlining major aortic branches: Tubular artery sign  Air outlining bronchial wall: Double bronchial wall sign  Continuous diaphragm sign: Due to air trapped posterior to pericardium  Air between parietal pleura and diaphragm: Extrapleural sign  Air in pulmonary ligament
  67. 67. Loculated pneumomediastinum in an infant with respiratory distress syndrome. Frontal chest radiograph obtained 5 days after birth shows a rounded radiolucent opacity over the mediastinal area (arrows). This image was not present in a previous radiographic study done 48 hours before (not shown)
  68. 68. Pneumomediastinum in acute respiratory distress syndrome. High-resolution CT scan shows diffuse bilateral areas of ground-glass opacity with a superimposed linear (“crazy-paving”) pattern consistent with acute respiratory distress syndrome. Irregular hyperlucent areas, representing focal areas of pulmonary laceration, are seen in the right upper lobe (white arrows). Extensive pneumomediastinum (black arrows) and small bilateral pleural effusions also are seen.
  69. 69.  This is a rare but serious condition due to acute infection of the mediastinum. Chest CT is the best imaging modality of choice, which aids the diagnosis and guides percutaneous drainage of the mediastinal collection.  Causes include esophageal/pharyngeal perforation, post-sternotomy, extension of infection from elsewhere and may be associated with empyema
  70. 70. Mediastinitis. Axial CECT shows a small pocket of enhancing loculated abscess (arrow) within the peripherally enhancing fluid collection (arrow head) in the anterior mediastinum. A small right pleural effusion and moderate left loculated pleural collection
  71. 71.  Percutaneous Indwelling Central Catheter  Central venous catheter  Pulmonary artery catheter  Venovenous or venoarterial extracorporeal life support  Stents
  72. 72. Normal position of a percutaneous intravascular central catheter (PICC) line. A. Standard posteroanterior chest radiograph demonstrates the left upper extremity PICC with tip in the distal left brachiocephalic vein. B. Note the greater conspicuity of the same percutaneous intravascular central catheter on the right anterior oblique radiograph at low kVp technique
  73. 73. Normal position of central venous catheters. Catheter entering from right internal jugular vein with tip in the distal right brachiocephalic vein, and catheter (double lumen) entering from left subclavian vein with tip in the superior vena cava illustrates location of venous anatomy
  74. 74. Complications Secondary to Central Venous Catheters: 1. Malposition 2. Pneumothorax 3. Vascular laceration (hemothorax, chest wall/neck/mediastinal hematoma) 4. Infection (possible source of septic emboli) 5. Catheter fragmentation and embolization 6. Venous thrombosis 7. Venous stenosis
  75. 75. Malpositioned central venous catheters. Posteroanterior and lateral radiographs demonstrate a central venous catheter in the azygos vein (arrowheads).
  76. 76. Neck hematoma (asterisk) after right internal jugular line placement attempt. Note the endotracheal tube tip is in the right main bronchus.
  77. 77. Fatal right hemothorax after right internal jugular line placement attempt in a patient with undiagnosed idiopathic thrombocytopenic purpura
  78. 78. Posteroanterior and (D) lateral radiographs demonstrate a right subclavian catheter with tip overlaying the right clavicular head (arrow), as well as catheter fragments in both the right and left pulmonary arteries (arrowheads).
  79. 79. Normal position of a pulmonary artery catheter placed through the right internal jugular vein, with tip in the proximal right pulmonary artery (arrowhead). Note the right chest wall port (large arrow) with tip in the superior vena cava (small arrow).
  80. 80. Pulmonary artery pseudoaneurysm secondary to peripheral placement of a pulmonary artery catheter. Bright red blood in endotracheal tube immediately after inflation of the pulmonary artery balloon. Focal hemorrhage in the right lower lung (asterisk).
  81. 81. Pulmonary artery pseudoaneurysm secondary to peripheral placement of a pulmonary artery catheter. Bright red blood in endotracheal tube immediately after inflation of the pulmonary artery balloon. Pulmonary angiogram after embolization with several 2- to 4-mm Gianturco coils demonstrates absent blood flow in the pseudoaneurysm
  82. 82. Pulmonary artery pseudoaneurysm secondary to peripheral placement of a pulmonary artery catheter. Bright red blood in endotracheal tube immediately after inflation of the pulmonary artery balloon. Selective pulmonary angiogram of the right middle lobe demonstrates a 2-cm pseudoaneurysm arising from a subsegmental artery.
  83. 83. Venoarterial extracorporeal life support in a patient with acute respiratory distress syndrome secondary to streptococcal pneumonia. The tip of the venous cannula (arrowheads) is in the right atrium (arrow) and the tip of the arterial cannula (open arrowheads) is in the distal common carotid artery (large arrow).
  84. 84. Wire-mesh stent in the superior vena cava as seen on (A) posteroanterior and (B) lateral radiographs
  85. 85.  Intraaortic balloon pump  Venoarterial extracorporeal life support  Stents
  86. 86. Normal position of an intraaortic balloon pump with metallic tip at the inferior aspect of the aortic knob (arrow). Note the radiolucency of the inflated balloon (arrowheads).
  87. 87. Abnormal intraaortic balloon pump position, with tip in the left subclavian artery (white arrow). Note the pulmonary artery catheter in correct position in the right descending pulmonary artery (black arrow) and the endotracheal tube in correct position with tip 4 cm above the carina (arrowheads).
  88. 88.  Pacemaker  Implantable cardiac defibrillator  Left venticular assist device  Atrial septal defect closure device
  89. 89. Temporary transvenous pacemaker placed through the common femoral vein at the groin, through the inferior vena cava, right atrium across the tricuspid valve and into the right ventricle with tip in the right ventricular outflow tract (arrow). There is an adjacent pulmonary artery catheter, also placed from a femoral approach, with tip in the left pulmonary artery (arrowhead). The patient had complete heart block that later required a permanent pacemaker.
  90. 90. Dual-chamber pacemaker as demonstrated on (A) posteroanterior and (B) lateral radiographs. Device was placed for syncope and bradycardia 14 years earlier. Generator is in the left anterior chest wall with lead tips in the right atrium (arrowheads) and right ventricle (arrows).
  91. 91. Biventricular pacemaker in a patient with ischemic cardiomyopathy
  92. 92. Two examples of broken pacemaker leads. A. Lead broken beneath the left clavicular head (arrow). B. Lead broken (arrow) in the chest wall near the generator.
  93. 93. Twiddler syndrome. Single lead pacemaker with lead tip in right ventricle. A. Note the generator position and the adjacent redundant lead after initial insertion. B. Three years later the generator has migrated inferiorly and medially, and the redundant lead in the chest wall has unwound.
  94. 94. Pacemaker and implantable cardiac defibrillators. Pacemaker in the right chest wall with lead tip in the right ventricle (large arrow, top) and the larger implantable cardiac defibrillator in the left chest wall with lead tips in the right atrium (arrow) and right ventricle (arrowhead). Note the right pneumothorax, a complication of pacemaker placement
  95. 95. Epicardial implantable cardiac defibrillator patches (arrows) that required thoracotomy to implant, with epicardial leads that extend to a device in the anterior abdominal wall, as demonstrated on (A) posteroanterior and (B) lateral radiographs.
  96. 96. HeartMate left ventricular assist system
  97. 97. Large wire coronary artery bypass graft markers (arrows) as seen on (A) posteroanterior and (B) lateral radiographs.
  98. 98.  Endotracheal tube  Tracheostomy tube  Intratracheal oxygen catheter  Stents
  99. 99. Abnormal endotracheal tube with balloon inflated positioned within the pharynx. High position of an endotracheal tube may cause vocal cord injury
  100. 100.  Feeding tube  Nasogastric or oral-gastric tubes  Intraesophageal manometer  Temperature probe  pH probe  Stent  Antireflux devices  Gastric banding
  101. 101. Correct position of feeding tubes
  102. 102. Incorrect position of esophageal tubes
  103. 103. Coil-type stent in the esophagus as seen on (A) posteroanterior and (B) lateral radiographs.
  104. 104. Gastric banding for morbid obesity
  105. 105.  Chest tubes Two chest tubes. One punctured the lung, with resulting large pulmonary hematoma. A. Chest radiograph shows a large hematoma in the right lung. B. Computed tomography demonstrates the high attenuation hematoma surrounding the intraparenchymal chest tube, and a second chest tube in the pleural space posteromedially

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