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Cxr revised 24 11-91

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normal chest X-ray

normal chest X-ray

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  • 1. CXR Normal Anatomy A. Almasi MD Iran University of Medical Science Department of Radiology
  • 2. PA CXR • • • • • • • • • • Quality Control Trachea Mediastinum& Heart Diaphragms Pleural space including fissures Lungs Hidden Areas of the Lungs Hila Below Diaphragm Bones
  • 3. PA view
  • 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. PA view
  • 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. Expiratory Film • • • • Increased heart size More prominent bronchovascular markings Basal opacities Tracheal deviation to the right
  • 8. Expiratory Film • • • • Increased heart size More prominent bronchovascular markings Basal opacities Tracheal deviation to the right inspiration expiration
  • 9. Respiration and Rotation Effect Inspiration Expiration& Leftwards Rotation
  • 10. Improper Exposure Underexposed Overexposed
  • 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. Trachea in Superior Mediastinum • Left side of the trachea is not border forming on CXR it is not surrounded by aerated lung
  • 13. right brachiocephalic artery right paratracheal stripe SVC carina Normal PA View
  • 14. Right Paratracheal Stripe Hodjkin’s Disease Normal after Radiotherapy
  • 15. cephalization Wide Carina left atrial in Mitral appendage Malady left atrium
  • 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. Cardiothoracic (CT) Ratio
  • 18. Normal PA View
  • 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. 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. Normal PA View
  • 22. Prominent Pulmonary Trunk Is normal in young women& children
  • 23. Tortuous Aorta & Prominent Lt Cardiophrenic Angle Fat Pad Ascending A Fat Pad
  • 24. Cardiophrenic Angle Fat Pad on Lateral CXR
  • 25. Tortuous Aorta& Brachiocephalic Aneurysm
  • 26. PA CXR • • • • • • • • • • Quality Control Trachea Mediastinum& Heart Diaphragms Pleural space including fissures Lungs Hidden Areas of the Lungs Hila Below Diaphragm Bones
  • 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. PA view
  • 29. Anterior right diaphragm dome
  • 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. High Hemidiaphragm
  • 32. Diaphragmatic Scalloping
  • 33. Diaphragmatic Slipping in flat diaphragms • Athletes • Emphysema
  • 34. Hump of Diaphragm
  • 35. Hump Sonography rules out subdiaphragmatic mass
  • 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. 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. Fissures
  • 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. 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. Lobar& Segmental Anatomy of the Lungs
  • 42. Lobar& segmental anatomy
  • 43. Minor Fissure From right hilum to the 6th rib at axillary line
  • 44. Minor Fissure
  • 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. minor Fissures left major right major
  • 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. Normal PA View
  • 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. Hilar Anatomy
  • 51. Hila on PA View
  • 52. Hila on Lateral View
  • 53. Lt Main Pul. A Hila on Lateral View * Rt Main Pul. A * Rt Sup Bronchus Lt Sup Bronchus
  • 54. Hilar Adenopathy
  • 55. Hilar Adenopathy
  • 56. Prominent Hila-Vascular (Pulmonary Venous HTN)
  • 57. Prominent Hila Pulmonary Arterial HTN
  • 58. Prominent Hila Pulmonary Arterial HTN
  • 59. Hilar Enlargement Vascular vs Adenopathy
  • 60. Below diaplragm, Soft tissue& Bones • Gas shadows (stomach, bowel, surgical emphysema, etc.) • Symmetric axillary lines, Mastectomy • Bone lesions
  • 61. Normal PA View
  • 62. Normal PA
  • 63. Prominent skin fold vs pneumothorax
  • 64. Calcified Costal Cartilage
  • 65. Hypertrophied 1st Costochondral Junction
  • 66. Hypertrophied 1st Costochondral Junction
  • 67. Lateral CXR • Clear Spaces • Vretebral Translucency • Diaphragm Outline • The fissures • The lung Hila • The Trachea& Upper Lobe Bronchi • The Sternum
  • 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. CXR Lateral View
  • 70. PE on lateral view (effect on vertebral translucency)
  • 71. PE
  • 72. minor Fissures left major right major
  • 73. Lt Main Pul. A Hila on Lateral View * Rt Sup Bronchus Rt Main Pul. A * Lt Sup Bronchus
  • 74. Hilar Adenopathy
  • 75. LLL Consolidation
  • 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. PA versus AP CXR
  • 78. PA versus AP CXR
  • 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. Abdomen • The recommended path is shown, beginning at the right lower corner.
  • 81. Thorax (soft tissues and bones) • The path again starts from the right lower corner of the x-ray
  • 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. Lung • It is recommended to look at the lungs one by one at first and then a look that compares the two lungs
  • 84. Lateral Film • The same order that was mentioned (ATMLL) is applicable to lateral films too
  • 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. 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