This Presentation is basically image collection from chapter 9 of GRAINGER & ALLISON’S DIAGNOSTIC RADIOLOGY. This is an effort to present the most authentic images.

1. 9
The Normal Chest
DR MUHAMMAD BIN ZULFIQAR
PGR III FCPS Services institute of Medical
Sciences/ Services Hospital Lahore
GRAINGER & ALLISON’S DIAGNOSTIC RADIOLOGY

2. • FIGURE 9-1 ■ The position and shape of the major
fissures (arrows) in the lower and the upper zones is
best shown by CT. Note that above the hila, the major
fissures bow backwards (B, C)
• The images are high-resolution 0.625-mm-thin CT
sections from a 64-row multislice CT study.

3. • FIGURE 9-1 ■ The position and shape of the major fissures
(arrows) in the lower and the upper zones is best shown
by CT. Note that above the hila, the major fissures bow
backwards (B, C), whereas below the hila, the major
fissures bow forwards (D to H).
• The images are high-resolution 0.625-mm-thin CT sections
from a 64-row multislice CT study.

4. • FIGURE 9-1 ■ The position and shape of the major fissures (arrows) in
the lower and the upper zones is best shown by CT. Note below the hila,
the major fissures bow forwards (D to H). The minor fissure (F, G) is
apparent as an area of avascularity anterior to the major fissure. In this
example the slightly bowed horizontal fissure undulates through the plane
of the slice (asterisks). The images are high-resolution 0.625-mm-thin CT
sections from a 64-row multislice CT study.
• The images are high-resolution 0.625-mm-thin CT sections from a 64-row
multislice CT study.

5. • FIGURE 9-1 ■ The position and shape of the major fissures
(arrows) in the lower and the upper zones is best shown
by CT. below the hila, the major fissures bow forwards. The
minor fissure (F, G) is apparent as an area of avascularity
anterior to the major fissure. In this example the slightly
bowed horizontal fissure undulates through the plane of
the slice (asterisks). The images are high-resolution 0.625-
mm-thin CT sections from a 64-row multislice CT study.

6. • FIGURE 9-2 ■ The position of fissures is often
best shown in additional sagittal reformats
(arrows) taken of the right lung (A, B) and the
left lung (C, D). Note the course of the major and
minor fissures together with an accessory cardiac
fissure on the right (arrowhead), and the major
fissure on the left (arrows).

7. • FIGURE 9-2 ■ The position of fissures is often
best shown in additional sagittal reformats
(arrows) taken of the right lung (A, B) and the
left lung (C, D). Note the course of the major and
minor fissures together with an accessory cardiac
fissure on the right (arrowhead), and the major
fissure on the left (arrows).

8. • FIGURE 9-3 ■ Azygos lobe fissure (A, C, arrows) and
azygos vein (B to D, asterisk). The azygos vein in the
lower end of the fissure is well seen on the coronal
reformats (C, D). In the early arterial contrast perfusion
phase the vein is not filled with contrast media (D)
displaying a soft-tissue-like attenuation. Occasionally
on conventional plain film radiography (E) the course of
the azygos vein from the mediastinum to the lower end
of the fissure (arrowhead) can be appreciated as a
vascular band (asterisk).

9. • FIGURE 9-3 ■ Azygos lobe fissure (A, C, arrows) and azygos
vein (B to D, asterisk). The azygos vein in the lower end of
the fissure is well seen on the coronal reformats (C, D). In
the early arterial contrast perfusion phase the vein is not
filled with contrast media (D) displaying a soft-tissue-like
attenuation. Occasionally on conventional plain film
radiography (E) the course of the azygos vein from the
mediastinum to the lower end of the fissure (arrowhead)
can be appreciated as a vascular band (asterisk).

10. • FIGURE 9-3 ■ Azygos lobe fissure (A, C, arrows) and azygos vein (B to D, asterisk).
The azygos vein in the lower end of the fissure is well seen on the coronal
reformats (C, D). In the early arterial contrast perfusion phase the vein is not filled
with contrast media (D) displaying a soft-tissue-like attenuation. Occasionally on
conventional plain film radiography (E) the course of the azygos vein from the
mediastinum to the lower end of the fissure (arrowhead) can be appreciated as a
vascular band (asterisk).

11. • FIGURE 9-4 ■ Intersegmental bilateral septa deep to
the inferior pulmonary ligament (A). Note the
bifurcated T-shape of the septum on the right
indicating the boundaries of the segments 9 and 10
(arrowheads). The function of the inferior pulmonary
ligament fixating the lower lobe to the
paraoesophageal mediastinum (asterisk) is well
appreciated in another patient with pneumothorax (B).

12. • FIGURE 9-5 ■ Diagram illustrating the anatomy of the
main bronchi and segmental divisions. The
nomenclature is that approved by the British Thoracic
Society. (Courtesy of the Editors of Thorax.)

13. • FIGURE 9-5 ■ Diagram illustrating the anatomy
of the main bronchi and segmental divisions.
The nomenclature is that approved by the British
Thoracic Society. (Courtesy of the Editors of
Thorax.)

14. • FIGURE 9-6 ■ Ring shadows (arrowheads) due to end-
on bronchial projection as a normal finding on chest
radiography. Note the delicate appearance in a patient
without interstitial oedema.

15. RUL, 4 = lateral segment of right middle lobe (RML), 5 = medial segment of RML, 6 = apical
posterior segment of left upper lobe (LUL), 7 = anterior segment of LUL, 8 = superior segment of
lingula, 9 = inferior segment of lingula, 10 = apical (superior) segment of right lower lobe (RLL),
11 = medial basal segment of RLL, 12 = anterior basal segment of RLL, 13 = lateral basal segment
of RLL, 14 = posterior basal segment of RLL, 15 = apical (superior) segment of left lower lobe
(LLL), 16 = anterior basal segment of LLL, 17 = lateral basal segment of LLL, 18 = posterior basal
segment of LLL.
• FIGURE 9-7 ■ Diagrams of position of segments
seen on plain frontal and lateral chest
radiographs. There is substantial overlap of the
projected images of the segments in both views;
this overlap is worse in the frontal than the
lateral projection. (A) shows only the segments
in the upper lobes and the middle lobe; (B)
shows only the segments in the lower lobes; (C,
D) show all the segments in the right and left
lung, respectively, in the lateral view. H = hila, 1 =
apical segment of right upper lobe (RUL), 2 =
posterior segment of RUL, 3 = anterior segment
of

16. • FIGURE 9-8 ■ Pulmonary angiography. Conventional digital subtraction
angiography using selective right and left injections (A, B). Composed
image obtained during (A) the arterial phase and (B) the venous phase.
Note the difference in arrangement of the central arteries and veins,
whereas anatomic differences are not perceptible in the lung periphery.
Also note the biventricular ICD device overlying the projection in this
patient with cardiac arrhythmia. On CT pulmonary angiography the
anatomical relation of arterial and venous systems can be appreciated
interactively on one image using volume rendering (C) or thick-slab
maximum intensity imaging (D).

17. • FIGURE 9-8 ■ Pulmonary angiography. Conventional digital subtraction
angiography using selective right and left injections (A, B). Composed image
obtained during (A) the arterial phase and (B) the venous phase. Note the
difference in arrangement of the central arteries and veins, whereas anatomic
differences are not perceptible in the lung periphery. Also note the biventricular
ICD device overlying the projection in this patient with cardiac arrhythmia. On CT
pulmonary angiography the anatomical relation of arterial and venous systems can
be appreciated interactively on one image using volume rendering (C) or thick-slab
maximum intensity imaging (D).

18. • FIGURE 9-9 ■ Diagrams of the relationships
between the hilar blood vessels and bronchi.
(A) Frontal view. (B) Right posterior oblique
view of right hilum. (C) Left posterior oblique
view of left hilum.

19. • FIGURE 9-9 ■ Diagrams of the relationships
between the hilar blood vessels and bronchi. (A)
Frontal view. (B) Right posterior oblique view of
right hilum. (C) Left posterior oblique view of left
hilum.

20. Lateral chest radiograph
with major blood vessels
drawn in. IPV = inferior
pulmonary vein—only one
has been drawn in since they
are superimposed, LPA = left
pulmonary artery, LSPV = left
superior pulmonary vein,
RPA = right pulmonary
artery, RSPV = right superior
pulmonary vein. (Diagrams
drawn by Ron Ervin and
reproduced with permission
from Armstrong P (ed) 1983
Critical problems in
diagnostic radiology.
Lippincott, Philadelphia.)
• FIGURE 9-9, Continued ■

21. • FIGURE 9-10 ■ Normal
digital PA chest
radiograph
demonstrating position
and density of the hilar
structures. Arrows
indicate the hilar points
where the superior
pulmonary vein crosses
the descending lower
lobe artery, the left
normally being level with
or slightly higher than
the right.

22. • FIGURE 9-11 ■ Frontal view of the hila in a
plain chest radiograph. The measurement
points for the diameter of the right lower lobe
artery are indicated.

23. • FIGURE 9-12 ■ CT of normal hila. High-resolution CT images (0.625 mm) have
been obtained through the hilar structures during contrast medium injection and
displayed on lung windows (L-500, W 1500). (A) Section just below the tracheal
carina at the origin of the right upper lobe bronchus, immediately posterior to the
upper lobe vein (v). (B) Section through level of right main pulmonary artery (RPA)
and bronchus intermedius (arrowhead). Note the tongue of lung that contacts the
left main bronchus between the aorta (B) and the left lower lobe artery (black
arrowhead). Note also that the right lung contacts the posterior wall of the
bronchus intermedius as it extends into the azygo-oesophageal recess. (C) Section
through the level of the middle lobe bronchus (long arrow) at the point of origin of
the bronchus to the superior segment of the right lower lobe. Note that the
middle lobe bronchus separates the right lower lobe artery from the right superior
pulmonary vein as it enters the left atrium (LA). The lung contacts the posterior
wall of the right lower lobe bronchus as it extends into the azygo-oesophageal
recess. (D) Section through the level of the inferior pulmonary veins (arrows). At
this level the lower lobe arteries have bilaterally divided into basal segmental
divisions; each are less than 10 mm in diameter.

24. • FIGURE 9-12 ■ CT of normal hila. High-resolution CT images (0.625 mm)
have been obtained through the hilar structures during contrast medium
injection and displayed on lung windows (L-500, W 1500). Section through
the level of the middle lobe bronchus (long arrow) at the point of origin of
the bronchus to the superior segment of the right lower lobe. Note that
the middle lobe bronchus separates the right lower lobe artery from the
right superior pulmonary vein as it enters the left atrium (LA). The lung
contacts the posterior wall of the right lower lobe bronchus as it extends
into the azygo-oesophageal recess. (D) Section through the level of the
inferior pulmonary veins (arrows). At this level the lower lobe arteries
have bilaterally divided into basal segmental divisions; each are less than
10 mm in diameter.

25. • FIGURE 9-13 ■ Lateral view of the hila
showing normal thickness of the posterior
wall of the bronchus intermedius (arrows).

26. • FIGURE 9-14 ■ MRI of normal mediastinum and hila. Four transverse and four
coronal sections have been chosen to show the important anatomical features:
(A–D, G, H) gradient echo post gadolinium iv; (E, F) T1-weighted gradient echo
sequence). (A) is 1 cm above the tracheal carina; (B) is just below (A); (C) is at the
level of the right main pulmonary artery; (D) is at the level of the mid left atrium.
A.Ao = ascending aorta; AV = azygos vein; BI = bronchus intermedius; D.Ao =
descending aorta; LA = left atrium; LCA = left carotid artery; LMB = left main
bronchus; LPA = left pulmonary artery; LV = left ventricle; MPA = main pulmonary
artery; Oes = oesophagus; RA = right atrium; RMB = right main bronchus; RSPV =
right superior pulmonary vein; SVC = superior vena cava;

27. • FIGURE 9-14 ■ MRI of normal mediastinum and hila. Four transverse and four
coronal sections have been chosen to show the important anatomical features:
(A–D, G, H) gradient echo post gadolinium iv; (E, F) T1-weighted gradient echo
sequence). (A) is 1 cm above the tracheal carina; (B) is just below (A); (C) is at the
level of the right main pulmonary artery; (D) is at the level of the mid left atrium.
A.Ao = ascending aorta; AV = azygos vein; BI = bronchus intermedius; D.Ao =
descending aorta; LA = left atrium; LCA = left carotid artery; LMB = left main
bronchus; LPA = left pulmonary artery; LV = left ventricle; MPA = main pulmonary
artery; Oes = oesophagus; RA = right atrium; RMB = right main bronchus; RSPV =
right superior pulmonary vein; SVC = superior vena cava; T = trachea.

28. • FIGURE 9-14 ■ MRI of normal mediastinum and hila. Four transverse and
four coronal sections have been chosen to show the important anatomical
features: (A–D, G, H) gradient echo post gadolinium iv; (E, F) T1-weighted
gradient echo sequence). (A) is 1 cm above the tracheal carina; (B) is just
below (A); (C) is at the level of the right main pulmonary artery; (D) is at the
level of the mid left atrium. A.Ao = ascending aorta; AV = azygos vein; BI =
bronchus intermedius; D.Ao = descending aorta; LA = left atrium; LCA = left
carotid artery; LMB = left main bronchus; LPA = left pulmonary artery; LV =
left ventricle; MPA = main pulmonary artery; Oes = oesophagus; RA = right
atrium; RMB = right main bronchus; RSPV = right superior pulmonary vein;
SVC = superior vena cava; T = trachea.

29. • FIGURE 9-14 ■ MRI of normal mediastinum and hila. Four transverse and
four coronal sections have been chosen to show the important anatomical
features: (A–D, G, H) gradient echo post gadolinium iv; (E, F) T1-weighted
gradient echo sequence). (A) is 1 cm above the tracheal carina; (B) is just
below (A); (C) is at the level of the right main pulmonary artery; (D) is at the
level of the mid left atrium. A.Ao = ascending aorta; AV = azygos vein; BI =
bronchus intermedius; D.Ao = descending aorta; LA = left atrium; LCA = left
carotid artery; LMB = left main bronchus; LPA = left pulmonary artery; LV =
left ventricle; MPA = main pulmonary artery; Oes = oesophagus; RA = right
atrium; RMB = right main bronchus; RSPV = right superior pulmonary vein;
SVC = superior vena cava; T = trachea.

30. • FIGURE 9-15 ■ CT of normal mediastinum. (A–I) Five 1-cm-
thick sections have been selected to show the important
anatomical features. The level of each section is illustrated in
the diagram. A.Ao = ascending aorta; AoA = aortic arch; AV =
azygos vein; D.Ao = descending aorta; IA = innominate artery;
LA = left atrium; LCA = left carotid artery; LIV = left innominate
vein; LPA = left pulmonary artery; LSA = left subclavian artery;
MPA = main pulmonary artery; OES = oesophagus; RA = right
atrium; RIV = right innominate vein; RPA = right pulmonary
artery; RVO = right ventricular outflow tract; SPV = superior
pulmonary vein; SVC = superior vena cava; T = trachea.

31. • FIGURE 9-15 ■ CT of normal mediastinum. (A–I) Five 1-cm-thick
sections have been selected to show the important anatomical
features. The level of each section is illustrated in the diagram. A.Ao
= ascending aorta; AoA = aortic arch; AV = azygos vein; D.Ao =
descending aorta; IA = innominate artery; LA = left atrium; LCA =
left carotid artery; LIV = left innominate vein; LPA = left pulmonary
artery; LSA = left subclavian artery; MPA = main pulmonary artery;
OES = oesophagus; RA = right atrium; RIV = right innominate vein;
RPA = right pulmonary artery; RVO = right ventricular outflow tract;
SPV = superior pulmonary vein; SVC = superior vena cava; T =
trachea.

32. • FIGURE 9-15 ■ CT of normal mediastinum. (A–I) Five 1-cm-thick
sections have been selected to show the important anatomical
features. The level of each section is illustrated in the diagram. A.Ao
= ascending aorta; AoA = aortic arch; AV = azygos vein; D.Ao =
descending aorta; IA = innominate artery; LA = left atrium; LCA =
left carotid artery; LIV = left innominate vein; LPA = left pulmonary
artery; LSA = left subclavian artery; MPA = main pulmonary artery;
OES = oesophagus; RA = right atrium; RIV = right innominate vein;
RPA = right pulmonary artery; RVO = right ventricular outflow tract;
SPV = superior pulmonary vein; SVC = superior vena cava; T =
trachea.

33. • FIGURE 9-15 ■ CT of normal mediastinum. (A–I) Five 1-cm-thick
sections have been selected to show the important anatomical
features. The level of each section is illustrated in the diagram.
A.Ao = ascending aorta; AoA = aortic arch; AV = azygos vein; D.Ao
= descending aorta; IA = innominate artery; LA = left atrium; LCA
= left carotid artery; LIV = left innominate vein; LPA = left
pulmonary artery; LSA = left subclavian artery; MPA = main
pulmonary artery; OES = oesophagus; RA = right atrium; RIV =
right innominate vein; RPA = right pulmonary artery; RVO = right
ventricular outflow tract; SPV = superior pulmonary vein; SVC =
superior vena cava; T = trachea.

34. • FIGURE 9-15 ■ CT of normal mediastinum. (A–I) Five 1-cm-thick
sections have been selected to show the important anatomical
features. The level of each section is illustrated in the diagram.
A.Ao = ascending aorta; AoA = aortic arch; AV = azygos vein; D.Ao
= descending aorta; IA = innominate artery; LA = left atrium; LCA
= left carotid artery; LIV = left innominate vein; LPA = left
pulmonary artery; LSA = left subclavian artery; MPA = main
pulmonary artery; OES = oesophagus; RA = right atrium; RIV =
right innominate vein; RPA = right pulmonary artery; RVO = right
ventricular outflow tract; SPV = superior pulmonary vein; SVC =
superior vena cava; T = trachea.

35. • FIGURE 9-16 ■ CT of normal thymus (arrow)
in a young adult man.

36. • FIGURE 9-17 ■ Thymic residues (curved
arrows) shown by CT.

37. • FIGURE 9-18 ■ The International Association for the
Study of Lung Cancer (IASLC) lymph node map
grouping the lymph node stations into ‘zones’ for
purpose of prognostic analysis (from:
<http://www.radiologyassistant.nl/en/4646f1278c26f>
). Please see explanations in Table 9-1.

38. • FIGURE 9-18 ■ The International Association for the
Study of Lung Cancer (IASLC) lymph node map
grouping the lymph node stations into ‘zones’ for
purpose of prognostic analysis (from:
<http://www.radiologyassistant.nl/en/4646f1278c26f>
). Please see explanations in Table 9-1.

39. • FIGURE 9-19 ■ The IASLC lymph node map can be applied to clinical staging by
computed tomography in axial (A–C) views. The border between the right and left
paratracheal region is shown in (A) and (B). Ao = aorta; Az = azygos vein; MB =
main bronchus; Eso = oesophagus; IV = innominate vein; LtInV = left innominate
vein; LtSCA = left subclavian artery; PA = pulmonary artery; SPV = superior
pulmonary vein; RtInV = right innominate vein; SVC = superior vena cava; T =
trachea. (With permission from Rusch VW, Asamura H, Watanabe H et al 2009 The
IASLC lung cancer staging project. J Thorac Oncol 4: 568–577.)

40. • FIGURE 9-19 ■ The IASLC lymph node map can be applied to clinical staging by
computed tomography in axial (A–C) views. The border between the right and left
paratracheal region is shown in (A) and (B). Ao = aorta; Az = azygos vein; MB =
main bronchus; Eso = oesophagus; IV = innominate vein; LtInV = left innominate
vein; LtSCA = left subclavian artery; PA = pulmonary artery; SPV = superior
pulmonary vein; RtInV = right innominate vein; SVC = superior vena cava; T =
trachea. (With permission from Rusch VW, Asamura H, Watanabe H et al 2009 The
IASLC lung cancer staging project. J Thorac Oncol 4: 568–577.)

41. • FIGURE 9-20 ■ Diagrams
illustrating the mediastinal
boundaries and junction
lines. The visualisation of the
junction lines on a plain chest
radiograph is variable,
depending on how much fat is
present in the mediastinum
and on how closely the two
lungs approximate to one
another. (A) Section just
above the level of the aortic
arch; (B) section through the
aortic arch; (C) section
through the heart. (D) Axial
CT and (E) chest plain X-ray
showing the anterior junction
line (arrowheads). (F, G) Axial
CT showing the supra-aortic
and lower posterior junction
line (arrows).

42. • FIGURE 9-20 ■ Diagrams illustrating the mediastinal
boundaries and junction lines. The visualisation of the
junction lines on a plain chest radiograph is variable,
depending on how much fat is present in the mediastinum
and on how closely the two lungs approximate to one
another. (A) Section just above the level of the aortic arch;
(B) section through the aortic arch; (C) section through the
heart. (D) Axial CT and (E) chest plain X-ray showing the
anterior junction line (arrowheads). (F, G) Axial CT showing
the supra-aortic and lower posterior junction line (arrows).

43. • FIGURE 9-20 ■ Diagrams illustrating the mediastinal boundaries
and junction lines. The visualisation of the junction lines on a plain
chest radiograph is variable, depending on how much fat is present
in the mediastinum and on how closely the two lungs approximate
to one another. (A) Section just above the level of the aortic arch;
(B) section through the aortic arch; (C) section through the heart.
(D) Axial CT and (E) chest plain X-ray showing the anterior junction
line (arrowheads). (F, G) Axial CT showing the supra-aortic and
lower posterior junction line (arrows).

44. • FIGURE 9-20 ■ Diagrams illustrating the mediastinal boundaries
and junction lines. The visualisation of the junction lines on a plain
chest radiograph is variable, depending on how much fat is present
in the mediastinum and on how closely the two lungs approximate
to one another. (A) Section just above the level of the aortic arch;
(B) section through the aortic arch; (C) section through the heart.
(D) Axial CT and (E) chest plain X-ray showing the anterior junction
line (arrowheads). (F, G) Axial CT showing the supra-aortic and
lower posterior junction line (arrows).

45. • FIGURE 9-21 ■ Right tracheal stripe (straight
arrows) and pleurooesophageal line (curved
arrows) demonstrated on (A) plain radiograph
and (B) unenhanced CT.

46. • FIGURE 9-22 ■ Lateral view of trachea and
major bronchi. (A) In this example, the
posterior wall of the trachea is outlined by
lung posterior to it (arrow). (B) In this
example, the collapsed oesophagus is
between the lung and the trachea (arrow).

47. • FIGURE 9-23 ■ Bulge behind manubrium
representing normal left innominate
(brachiocephalic) vein (arrow).

48. • FIGURE 9-24 ■ Azygo-oesophageal line
(arrows).

49. • FIGURE 9-25 ■ Patterns of pleural reflection along the
left border of the great vessels and heart. The heavy
line indicates the visible pleural interface. (Adapted
from Blank N, Castellino R A 1972 Patterns of pleural
reflections of the left superior mediastinum: normal
anatomy and distortions produced by adenopathy.
Radiology 102: 585–589, with permission from the
Radiological Society of North America.)

50. • FIGURE 9-26 ■ Retrosternal stripe
(arrowheads) and inferior vena cava in lateral
projection (arrows).

51. • FIGURE 9-27 ■ (A) Right phrenic nerve as it
passes over the surface of the right
hemidiaphragm (arrows). (B, C) Coronal
secondary reformat and volume rendering
showing the nerve as delicate structure crossing a
lymph node in the mediastino-diaphragmatic
angle (arrowheads).

52. • FIGURE 9-27 ■ (A) Right phrenic nerve as it
passes over the surface of the right
hemidiaphragm (arrows). (B, C) Coronal
secondary reformat and volume rendering
showing the nerve as delicate structure crossing a
lymph node in the mediastino-diaphragmatic
angle (arrowheads).