Chest X-ray anatomy
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  • 1. Living Anatomy of the Chest for 1st year Medical Students Original version compiled by Dr. Gillian Lieberman forthe Harvard Medical School Human Body Lecture Series. Adapted here for Independent Study. 1
  • 2. Living AnatomyRadiology is ideally suited to image anatomy in the living patient.Labeled plain film Chest X-Rays (CXR), Angiograms, Bronchograms,Computed Tomography (CT) and Magnetic Resonance Images (MRI)follow, accompanied by anatomic diagrams to help familiarize you withchest anatomy.Areas covered include:The Heart: Chambers, valves, great vessels, coronary arteriesThe Lungs: Lobes, pulmonary arteries, bronchial treeThe PleuraThe Azygos-Hemiazygos venous systemBasic Radiologic principles are outlined to facilitate plain film interpretation. 2
  • 3. CXR-PA Anatomy on 1 2 2 4 Normal Chest X-Ray 13 Key: • Right 1st rib 3• Right 2nd rib 5 6 • Scapula 7 7 • Trachea 9 8 • Carina • Bronchus seen end on • Bilateral hila • Branch of right main descending pulmonary artery • Right minor (horizontal fissure) • Right hemi diaphragm 10 • Left hemi diaphragm 11 • Gastric air bubble 12 • Left clavicle 3
  • 4. CXR-Left LAT Anatomy on 6 Normal Chest 6 T2 T3 1b 1a 5 X-Ray 4a 4b Key: T5 1a. Manubrium sternum 8 1b. Body of sternum T6 4. Right hemi diaphragm T7 5. Left hemi diaphragm 4a. Right scapula T8 4b. Left scapula 8. Trachea T9 9a 9. Soft tissue of the arms 9b T10 10. Major fissure 11. Minor fissure-little higher in this 3 T11 patient than the usual 9a. 9th left rib 2 9b. 9th right rib T2-11 Thoracic vertebrae 4
  • 5. Radiologic Principles: IRight Upper Lobe Pneumonia withPartial Volume Loss Pneumoperitoneum This film is helpful to demonstrate some basic radiologic principles which are essential to understanding x-ray 1 interpretation. 2 Key: 2. Denser and smaller right upper lobe due to pneumonia 3. Elevated minor fissure 5 4. Top surface of liver 4 7 3 5. Undersurface of diaphragm 5 4 6. Top surface of diaphragm 6 7 7. Top surface of spleen 8. Free air in the abdominal cavity = pneumoperitoneum 5
  • 6. Radiologic Principles: IIFat The plain films are made up of four densities- Bone Black Air e.g. in lungs,stomach Fat Soft tissue which include muscle, organs e.g. liver, fluid e.g. blood Air White Bone heavy metal e.g. calcium, iron Soft Tissue A line or border is seen only when there is an interface between two of these densities. E.g. The right heart outline is usually seen because soft tissue density of the heart is next to air density of the right middle lobe of the lung. 6
  • 7. Radiologic Principles: III Pneumoperitoneum Free air in the abdomen (always abnormal) Pneumonia (pneumoperitoneum) rises to a position under the diaphragm when the patient is upright. It therefore outlines the top of the liver on the right, the top of the spleen on the left, and undersurfaces on both hemi diaphragms. These are usually hot seen because liver, spleen and diaphragm are all soft tissue and therefore no interface is present. The upper border of the diaphragms are usually seen because air in the lower lung lobes abut the soft tissues of the diaphragm. Pneumonia In pneumonia, the air in the lung getsPneumoperitoneum replaced with fluid which shows up soft tissue density on x-ray. The lung lobe often also gets smaller or consolidated so the fissures move. Bacterial infection commonly respects the lobar boundaries as in this case. 7
  • 8. Lobes of the Lung Lobes and Fissures of the Lung (from the front) IMPORTANT FACTS: The right lung has 3 lobes (separated by the major Oblique fissure & minor Horizontal fissure) -Right upper lobe -Right middle lobe -Right lower lobe The left lung has 2 lobes separated by major (oblique) fissure -Left upper lobe (medial portion is called the lingula) -Left lower lobe“Man’s Anatomy” by Tobias & Arnold 8
  • 9. The PleuraThe pleura is the lining of the lungs.There are 2 layers -1. The visceral pleura hugs the lung lobes -2. The parietal pleura hugs the chest wallThe pleural space is a potential space between the two.A pneumothorax is the presence of air (always abnormal) in the pleural space.A pleural effusion is the presence of detectable fluid (always abnormal) in the pleural space.A hydropneumothorax is air and fluid in the pleural space. Coronal Section of Pleural Sacs (schematic)“Man’s Anatomy”by Tobias &Arnold 9
  • 10. Right Tension Pneumothorax Lobes of the Lung This film is included because it helps demonstrate the 3 lobes of the right lung, the pleura and the pleural space. 4 Key: 2. Normal pointy left costophrenic angle 3 3. Blunted denser right costophrenic angle 5 due to fluid in pleural space = pleural 2 effusion 7 4. Air in pleural space = pneumothorax 5. … partially collapsed right upper lobe 6 6. ---partially collapsed right middle lobe 7. -.-partially collapsed right lower lobe 2 8. Visceral pleura of right middle lobe 9. (Position of parietal pleura – not seen) 9 1 10. Left breast shadow. (Notice the rightCommon causes for hydropneumothorax include rib fractures breast has been removed = rightpenetrating chest wounds e.g. stab or bullet wounds and mastectomy)iatrogenic causes e.g. lung biopsies or effusion drainages. 10 Pneumothorax and pleural effusion = hydropneumothorax
  • 11. Anatomy on Normal Chest X-RayHeart borders and chambers of the heart on PA and lateral views. 11
  • 12. Heart Chambers and ValvesThe heart is made up of 4 chambers. The right side which handles deoxygenated blood isseparated from the left side which handles oxygenated blood by septa, the top is separatedfrom the bottom by valves.Simplistic view: 1 12
  • 13. Venous Return to the Heart The atria receives blood from the body and lungs. The SVC and IVC bring deoxygenated (blue) blood to the right atrium from the body. The pulmonary veins bring oxygenated (red) blood to the left atrium from the lungs.Simplistic view: 2 13
  • 14. Arterial Output from the Heart The ventricles receive blood from their respective atria. The right ventricle pumps deoxygenated blood via the pulmonary artery to the lungs. The left ventricle pumps oxygenated blood via the aorta to the body. The entrance to the aorta and the pulmonary artery have aortic and pulmonary valves respectively.Simplistic view: 3 Pulmonary valve Aortic valve 14
  • 15. Heart Valves This patient had a malfunctioning mitral valve (between left atrium and left ventricle) and aortic valve (between left ventricle and aorta) and prosthetic valves were inserted (better seen on lateral)Frontal CXR LAT CXR Key: 2. Suture material used for repair 1 of vertical incision thru sternum (median sternotomy) 1 2 3. Aortic valve 2 prosthesis 3 4. Mitral valve 3 prosthesis 5. Left hemi diaphragm 6. Right hemi diaphragm 5 4 4 5 15
  • 16. Schema of great vessels connected to the heart The pulmonary artery and aorta cross one another in the mediastinum. 16“Man’s Anatomy by Tobias & Arnold
  • 17. The Aortic arch 17“Man’s Anatomy by Tobias & Arnold
  • 18. Great Neck Vessels 18“Man’s Anatomy by Tobias & Arnold
  • 19. Angiograms-Aortic arch angiogram 10 9 6 An angiogram is an x-ray examination of blood vessels following contrast administration. 5 Arteriogram = Arterial Study 4 7 Venogram = Venous Study 8 2 1 3 19
  • 20. Angiograms-Pulmonary arteriogram (PA gram) Pulmonary Art #1 Key: 2. Right main pulmonary artery branch 3. Right upper lobe pulmonary artery branch 4. Right middle lobe pulmonary artery branch 2 5 2 7 5. Right lower lobe pulmonary artery branch 1 6. Left main pulmonary artery 3 7. Left upper lobe pulmonary artery branch 8. Left lower lobe pulmonary artery branch 9. Pulmonary veins 10. Left atrium 11. Left ventricle 12. Ascending aorta 13. Descending aorta 20
  • 21. Angiograms-Pulmonaryarteriogram (PA gram) Pulmonary Art #2 Key: 2. Right main pulmonary artery branch 3. Right upper lobe pulmonary artery branch 4. Right middle lobe pulmonary artery branch11 5. Right lower lobe pulmonary artery branch 12 6. Left main pulmonary artery 7. Left upper lobe pulmonary artery branch 9 8. Left lower lobe pulmonary artery branch 9. Pulmonary veins 10. Left atrium 10 11. Left ventricle 12. Ascending aorta 13. Descending aorta 21
  • 22. Angiograms-Pulmonaryarteriogram (PA gram) Pulmonary Art #3 Key: 2. Right main pulmonary artery branch 3. Right upper lobe pulmonary artery branch 4. Right middle lobe pulmonary artery branch 11 12 5. Right lower lobe pulmonary artery branch 6. Left main pulmonary artery 7. Left upper lobe pulmonary artery branch 8. Left lower lobe pulmonary artery branch 9. Pulmonary veins 10 10. Left atrium 11. Left ventricle 12. Ascending aorta 13. Descending aorta 22
  • 23. Heart and VesselsCardiomegaly plus early Congestive Heart Failure (CHF) Key: 2. Inferior vena cava (IVC) 3. Superior vena cava (SVC) *3. Azygos vein 7 5 7 7 5. Carina 7 2 6. Trachea 4 3 7. Right main stem bronchus 8. Prominent pulmonary vessels Any and or all heart chambers may enlarge when the heart becomes diseased. Cardiomegaly = a big heart. A patient’s heart enlarges due to a number of diseases e.g. valve disease, high blood pressure, congestive heart failure. 1 If the heart fails, the lung often become congested. Early on the pulmonary vessels appear more prominent as in this case. More advanced failure can result in a condition of pulmonary edema which is fluid flooding into the alveoli of the lungs causing the patient marked shortness of breath. 23
  • 24. Azygos-Hemiazygos venous system The Azygos vein receives tributaries from intercostal veins as outlined. It is seen as an oval density to the right of the trachea just above the right main stem bronchus on all chest x-rays (*3 on the earlier film) This is the portion that travels forward to join the SVC. In CHF, the Azygos vein dilates and this density becomes prominent as seen on the previous patient’s CXR. 24“Man’s Anatomy by Tobias & Arnold
  • 25. Coronary arteries 25“Man’s Anatomy by Tobias & Arnold
  • 26. Coronary artery anatomy LCX)“Man’s Anatomy by Tobias & Arnold 26
  • 27. Coronary Angiograms LT Coronary Art LAO Left main coronaryLAO artery Diagonal The coronary arteries can be artery outlined in the living patient by Left circumflex artery injecting contrast into them. A catheter (tube) is threaded Obtuse through the Patients vessels to the Marginal heart, to gain access- called Artery “cardiac catheterization” 27
  • 28. Coronary Angiograms LT Coronary Art LAO Left main coronary arterySinus Node Artery LAD AV Diagonal Groove artery Left IV Groove circumflex Obtuse artery marginal Septal artery perforator 28
  • 29. Coronary Angiograms RT Coronary Art LAOConusBronch RCA AV Node A AV Crux GrooveAcute Posterior LVmarginal Bronchartery 29
  • 30. Coronary Angiograms RT Coronary Art RAOAcuteMarginalArteries 30
  • 31. Bronchial segmental anatomy “Man’s Anatomy by Tobias & Arnold 31
  • 32. Normal BronchogramFrontal CXR Contrast agent can be instilled or inhaled into the bronchial tree Lateral CXR outlining the walls of the trachea, main stem bronchi, segmental and even subsegmental bronchi 32
  • 33. Abnormal Bronchogram: Bronchiectasis Bronchiectasis = localized irreversible dilatation of the bronchial tree Contrast agent can be instilled or inhaled into the bronchial tree outlining the walls of the trachea, main stem bronchi, segmental and even subsegmental bronchi 33
  • 34. Computed TomographyComputer tomography (CT) scanning obtains multiple cross sectional images through a patientusing x-rays and computer enhancement. (Imagine slicing a sausage crosswise into many roundequal thickness slices and then looking at these to see what’s in the sausage)CT, ultrasound and magnetic resonance imaging (MRI) all allow imaging of the body in differentplanes.TERMINOLOGY:The following description considers the body in the anatomical positionAxial plane (=cross section) a plane of the body parallel to the horizonMedian/Midline Sagittal plane – the vertical plane which passes through the sagittal suture of theskull and through the midline of the body dividing the body into right and left halves.ParaSagittal plane –any vertical plane parallel to the median sagittal plane.Coronal plane –any vertical plane perpendicular to the median sagittal plane and parallel to thevertical plane through the coronal suture of the skull.With CT scanning, factors can be altered for better resolution of different body parts.e.g. Referring to the images enclosed, the scanner was set to optimally visualize mediastinalstructures (1-4A), and lung parenchyma in (1-4B) 34
  • 35. Normal Chest anatomy onKey: Axial Computed Tomography2. Pectoralis major muscle 16. Superior vena cava (SVC 29. Diaphragm3. Pectoralis minor muscle • Aortic arch • Liver4. Sternum • Ascending aorta 3. Spleen5. Clavicle • Descending aorta 4. Stomach6. Rib • Azygos vein 5. Kidney7. Humeral head * Carina (tracheal bifurcation) 6. Lung –upper lobe8. Scapula 7. Pulmonary artery 7. Lung –right middle lobe9. Vertebral body 8. Main stem bronchus 8. Lung –lower lobe10. Thyroid gland 9. Right ventricular outflow 9. Major (oblique) fissure tract11. Trachea 10. Minor (horizontal) fissure 10. Left atrium12. Esophagus 11. Segmental bronchus 11. Right atrium13. Subclavian artery 12. Left ventricle14. Carotid artery 13. Right ventricle15. Innominate (brachialcephalic) artery 28A. Pulmonary veins 3516. Innominate vein 28B. Inferior vena cava (IVC)
  • 36. Computed Tomography 1A 1 1 2 2 13 13 11 12 12Key: 8. Vertebral body2. Pectoralis major muscle 9. Thyroid gland3. Pectoralis minor muscle 10. Trachea4. Sternum 11. Esophagus5. Clavicle 12. Subclavian artery6. Rib 13. Carotid artery7. Humeral head 14. Innominate (brachialcephalic) artery 368. Scapula 15. Innominate vein
  • 37. Computed Tomography 1B 10 10 11 11 Key: 10. Trachea 11. Esophagus 37
  • 38. Computed Tomography 2A 3 1 5 2 15 13 7 7Key: 8. Vertebral body 16. Superior vena cava (SVC)2. Pectoralis major muscle 9. Thyroid gland 17. Aortic arch3. Pectoralis minor muscle 10. Trachea4. Sternum 11. Esophagus5. Clavicle 12. Subclavian artery6. Rib 13. Carotid artery7. Humeral head 14. Innominate (brachialcephalic) artery 388. Scapula 15. Innominate vein
  • 39. Computed Tomography 2A 11 20 5 11Key:2. Pectoralis major muscle 1. Aortic arch3. Pectoralis minor muscle 2. Ascending aorta4. Sternum 3. Descending aorta5. Rib 4. Azygos vein6. Esophagus 21. Pulmonary artery7. Superior vena cava (SVC) 39
  • 40. Computed Tomography 2B 10 3434 10 11 37 11 37 36 36 Key: 10. Trachea 3. Esophagus 4. Lung-upper lobe 5. Lung-lower lobe 6. Major (oblique) fissure 40
  • 41. Computed Tomography 2B * 39 22 22 39 37 37Key:* Carina (tracheal bifurcation)3. Main stem bronchus4. Major (oblique) fissure39. Segmental bronchus 41
  • 42. Computed Tomography 3 23 5 11 7 75Key:3. Sternum 19. Descending aorta3. Rib 20. Azygos vein7. Scapula 3. Pulmonary artery8. Vertebral body 23. Right ventricular outflow11. Esophagus tract 4216. Superior vena cava (SVC) 24. Left atrium
  • 43. Computed Tomography 3A 3 23 28 28 7 5Key: 18. Ascending aorta3. Sternum 19. Descending aorta3. Rib 3. Right ventricular outflow tract7. Scapula 4. Left atrium16. Superior vena cava (SVC) 28A. Pulmonary veins 43
  • 44. Computed Tomography 34 34 3835 11 37 37 36 36 Key: 11. Esophagus 34. Lung –upper lobe 35. Lung –right middle lobe 36. Lung –lower lobe 37. Major (oblique) fissure 38. Minor (horizontal) fissure 44
  • 45. Computed Tomography 3B 34 35 37 37 36 36 Key: 34. Lung –upper lobe 35. Lung –right middle lobe 36. Lung –lower lobe 37. Major (oblique) fissure 38. Minor (horizontal) fissure 45
  • 46. Computed Tomography 3 25 11Key: 24. Left atrium3. Sternum 25. Right atrium5. Rib 26. Left ventricle8. Vertebral body 27. Right ventricle5. Esophagus 28A. Pulmonary veins6. Descending aorta 28B. Inferior vena cava (IVC) 46 7. Diaphragm
  • 47. Computed Tomography 4A 26 29Key:19. Descending aorta 29. Diaphragm26. Left ventricle 30. Liver28A. Pulmonary veins 31. Spleen28B. Inferior vena cava (IVC) 33. Kidney 47
  • 48. Computed Tomography 35 37 37 11 36 36 Key: 2. Esophagus 3. Diaphragm 4. Lung- right middle lobe 5. Lung- lower lobe 48 6. Major (oblique) fissure
  • 49. Computed Tomography 4B 32 Key: 32. Stomach 49
  • 50. Normal MRI Chest Magnetic Resonance Imaging (MRI) utilizes changing magnetic and electrical fields to obtain images of a patient. Factors can be altered to enhance resolution of different structures thus blood for example can look bright white or dark black. Among the advantages of MRI are: 1. X-rays and the attendant hazards of ionizing radiation are not present. 2. Scans in multiple different projections e.g. oblique, sagittal, coronal, axial can be obtained with ease.Refer to films:Film 1 -Sagittal oblique MRI angiogram chosen to best demonstrate the aortic arch.Film 2&3 -Axial sectionsFilm 4&5 -Sagittal oblique MRI angiogram chosen to best demonstrate the coronary arteries 50
  • 51. Normal Sagittal MRI ChestMRI 1 3 51
  • 52. Normal Axial MRI ChestMRI 2a 52
  • 53. Normal MRI ChestMRI 2b 53
  • 54. Normal MRI ChestMRI 3a 16 15 54
  • 55. Normal MRI ChestMRI 3b 55
  • 56. Normal Parasagittal MRI ChestMRI 4 12 6 56
  • 57. Normal MRI ChestMRI 4 57
  • 58. Normal MRI ChestMRI 4 12 13 11 58
  • 59. MRI 5 Normal MRI Chest 12 11 59
  • 60. Normal MRI Chest 60
  • 61. Normal MRI ChestMRI 5 61
  • 62. Conclusion of Living anatomy of the chest Congratulations! You have completed this module. You worked through many anatomic diagrams and labeled chest x-rays, bronchograms, angiograms, CT scans & MRI images. You saw the normal and also some Abnormal images to peak your interest. Radiology is ideally suited to image not only normal anatomy, but more importantly from a clinical diagnostic standpoint, abnormal anatomy & pathology. Wishing you a joy-filled career and life long love of learning.  GillWith grateful thanks to Pamela Lepkowski, Education Coordinator, HarvardMedical School & Assistant extraordinaire for her outstanding work on this 62Independent study module.