5. ROTATION
īThe medial ends of both clavicles
should be equidistant from the
spinous process of the vertebral
body projected between the
clavicles
6. The increase in blackness
(radiolucency) of one
hemithorax is always on
the side to which the
patient is rotated,
irrespective of whether the
CXR has been taken PA or
AP
7. DEGREE OF INSPIRATION
īIt is ascertained by counting either the
number of visible anterior or posterior
ribs
īAdequate inspiratory effort â five to
seven complete anterior or ten posterior
ribs are visible
īPoor inspiratory effort - fewer than five
anterior ribs
īHyperinflated lung-more than seven
anterior ribs
8. IMPORTANCE OF AN INSPIRATORY FILM
POOR INSPIRATORY FILM NORMAL INSPIRATORY FILM
1
2
3
1. Mediastinal Widening 2.Cardiomegaly 3.Lower lobe patchy opacification
9. PROJECTION OF X-RAY
īProjection is defined as the direction of x-ray with
relation to the patient
īIf the direction of x-ray projection is from front â AP
projection
īIf the direction of x-ray projection is from behind âPA
projection
11. PA VIEW AP VIEW
īIn erect patients
īVertebral spines more
prominent
īScapulae clear of lungs
īClavicles are horizontal
īIn supine patients
īVertebral bodies clear
īApparent cardiomegaly
īScapulae overlap
īClavicles are oblique
12. ERECT SUPINE
ī Gas bubble in fundus with a
clear air fluid level
ī Gas bubble in antrum
ī Apparent cardiomegaly
13. EXPOSURE OF X-RAY
Normal exposure - the vertebral bodies should just be
visible at the lower part of cardiac shadow
Underexposed -If the vertebral bodies are not visible ,
insufficient number of x-ray photons have passed
through the patient to reach the x-ray film
Similarly, if the film appears too âblackâ, then too many
photons have resulted in overexposure of the x-ray film.
15. SYSTEMATIC APPROACH
īTechnical factors
īSkeletal abnormalities and hardware
īSitus: gastric air bubble, cardiac apex, and aortic knob
īHeart: position, size, and shape
īGreat vessels: position, size, and shape
īLung fields and vascularity by zone
īSearch for calcifications
26. HOW TO MEASURE MAIN PULMONARY ARTERY
If we draw a
tangent line from the apex
of the left
ventricle to the
aortic knob(red line)
and measure along
a perpendicular
to that tangent
line (yellow line)
The distance between the
tangent and the main
pulmonary artery
(between two small green
arrows) falls in a range
between 0 mm (touching
the tangent line) to as
much as 15 mm away from
the tangent line
32. CARDIOMEGALY
īThe cardiothoracic ratio should be less
than 0.55 on PA view. i.e. A+B/C<0.55
ī A cardiothoracic ratio > 0.55 suggests
cardiomegaly in adults
īA cardiothoracic ratio > 0.6 suggests
cardiomegaly in newborn
33. CTR is more than 50% but heart is normal
Spurious causes of cardiac enlargement
ī Portable AP films
ī Obesity
ī Pregnant
ī Ascites
ī Straight back syndrome
īPectus excavatum
34. ī CTR is less than 50% but heart is
abnormal
Obstruction to outflow of the
ventricles
ī Ventricular hypertrophy
īMust look at cardiac contours
< 50%
ASCENDING AORTA DILATED LV CONTOUR
35. CRITERIA'S FOR CARDIOMEGALY
īCardiothoracic ratio >0.55 in adults on PA view
īCardiothoracic ratio >0.6 in newborn on PA view
īAny increase in transcardiac diameter > 2 cm compared
to old x-ray
īIn old age and emphysema a transcardiac diameter
more than 15.5 cm in males &>12.5 cm in females
37. CRITERIA FOR RA ENLARGEMENT
īRt. Cardiac border becomes more
convex > 50% of right border
īRt. Atrial border extends >3
intercostal spaces
īMeasurement from mid vertical line
to max. convexity in rt. Border>5 cm
in adult & >4cm in children
īLateral view â fullness in space
between sternum and front of
upper part of cardiac silhouette
38. CRITERIA FOR LA ENLARGEMENT
ī Widening of carina( normal 45-75 degree)
ī Elevation of left bronchus
ī Straightening of left border
ī Double atrial shadow( shadow within shadow)
ī Grade 1 âdouble cardiac contour
ī Grade2 - LA touches RA border
ī Grade 3 â LA overshoots the Rt. Cardiac border
ī Displaces the descending aorta to the left and esophagus to
right seen in barium swallow
40. LEFT ATRIAL ENLARGEMENT
DOUBLE ATRIAL SHADOW
WIDENING OF CARINA
ELEVATION OF LEFT
BRONCHUS
Left atrial appendage
enlargement
41.
42. Widening of carina
Elevation of lt.
bronchus
Aneurysmal LA
Aneurysmal LA â When La enlarges to left and right and approaches within
an inch of lateral chest wall
44. LEFT VENTRICULAR ENLARGEMENT
ī PA view
ī (a)Left cardiac border gets enlarged and becomes more convex
resulting in cardiomegaly
ī (b)Lt. cardiac border dips into lt. dome of diaphragm
ī (c) rounded apical segment
ī (d) cardiophrenic angle is obtuse
45. LEFT VENTRICULAR ENLARGEMENT
Lateral view
ī(a) Left ventricle enlarges inferiorly and posteriorly
ī(b)Riglerâs measurement A is >17 mm
ī(c)Rigler,s measurement B is< 7.5 mm
ī(d) Eyelerâs ratio becomes > 0.42
46. RIGLERâS MEASUREMENT
īRiglerâs A & B used to differentiate left
ventricular and right ventricular
enlargement
ī Possible only when IVC shadow is
present
īJn. Of IVC with Lt. Atrium â J point
īRiglerâs A- from J point along line of IVC
draw a line of 2 cm above and mark the
point X.
47. īDraw a horizontal line from pt. A to posterior
Cardiac border and mark that pt. y
īDistance between points x & y is Riglerâs
measurement A
īNORMAL<17 mm
īRiglerâs B-from the pt. J drop a perpendicular
line to the dome and this distance is Riglerâs
measurement B
īNORMAL>7.5 mm
RIGLERâS MEASUREMENT
48. īWhen LV enlarges,
īPosterior cardiac border gets displaced
posteriorly & IVC shadow gets included in
cardiac shadow, without getting displaced
posteriorly
ī Riglerâs measurement A >17 mm in lt.
ventricular enlargement
RIGLERâS MEASUREMENT
49. EYELERâS RATIO
īTo differentiate lt. & rt. Ventricular
enlargement
ī Valid when IVC shadow is absent or cannot
be visualised
īMark the point of jn. where postero inferior
cardiac border meets the dome as B
ī From this point B draw a horizontal line to
the posterior border of sternum-AB
50. īFrom pt.B - draw another horizontal line
posteriorly to the inner border of the rib-
BC
īRatio of AB/BC is Eyelerâs ratio < 0.42
EYELERâS RATIO
51. LA Oblique view
ī There is a retrocardiac space( prevertebral)
(a)Mild lt. Ventricular enlargement-obliteration
of retrocardiac space
(b) mod. Lt.ventricular enlargement-cardiac
shadow overlaps vertebral column
(c)Marked Lt.ventricular enlargement-cardiac
shadow overshoots vertebral column
52. Chest X ray shows left ventricular
enlargement.
Left heart border is displaced
leftward, inferior and posteriorly.
Rounding of the cardiac apex.
53. RV ENLARGEMENT
PA VIEW
Cardiophrenic angle is acute
Clockwise rotation of heart causes RV to form
the middle portion of the left heart border.
RIGHT LATERAL VIEW
Obliteration of retrosternal spac
54. RV ENLARGEMENT
LEFT LATERAL VIEW
Riglerâs measurement will be17mm or less
Riglerâs measurement will be 7.5mm or more
Eyelerâs ratio is 0.42 or less
55. PERICARDIAL EFFUSION
īNarrow vascular pedicle
īCardiomegaly directly proportional to severity of pericardial
effusion
īThis shadow has a rounded, globular appearance with no
particular chamber enlargement
īCardiophrenic angle become more and more acute
īOligaemic pulmonary vascular markings
īMarked change in cardiac silhouette in decubitus posture
īâEpicardial fat pad signâ- anterior pericardial strip bordered
by epicardial fat post. and mediastinal fat ant.>2mm
57. DILATED CARDIOMYOPATHY VS
PERICARDIAL EFFUSION
īChambers can be identified
īCardiophrenic angle is obtuse
īIncreased pulmonary venous hypertension
īNo change in cardiac silhouette in decubitus
īVascular pedicle is dilated or normal
īFluoro shows cardiac pulsation
58. CONSTRICTIVE PERICARDITIS
1.Straightening of the right
border
2.Pericardial thickening > 4
mm
3.Pericardial calcification (50%
cases)
4.Dilatation of SVC and
azygous vein
Pericardial calcification
59. CONGENITAL ABSENCE OF PERICARDIUM
īFocal bulge in area of main pulmonary
artery
ī Sharply marginated
ī Absent right cardiac border
ī Increased distance between sternum
and heart due to absence of sterno
pericardial ligament
63. PULMONARY VENOUS HYPERTENSION
īLARRY ELLIOTâS CLASSIFICATION OF PVH
RADIOGRAPHIC
GRADE OF PVH
ACUTE DISEASE
PCWP
CHRONIC DISEASE
PCWP
1 13-17 MMHG 13-17 MMHG
2 18-25 MMHG 18-30 MMHG
3 >25 MMHG >30 MM HG
4 HEMOSIDEROSIS
AND OSSIFICATION
LONG STANDING
PVH
64. GRADE 0 -PCWP< 12 MM HG
ī Upper lobe pulmonary veins are less prominent than lower lobe veins
GRADE 1- PCWP 13-17MMHG
Redistribution of blood flow with cephalization-âANTLER SIGNâ
ī 1) increased resistance to flow due to interstitial odema
ī 2) alveolar hypoxia in lower lobes causes reflex vasoconstriction
ī 3) vasoconstriction of the arterioles due to LA or pulmonary vein reflex
PULMONARY VENOUS HYPERTENSION
66. KERLEY A LINES
īDistended lymphatic channels within
edematous septa coursing from
peripheral lymphatics to central hilar
nodes
ī Towards the hilum
ī Less specific for Pulmonary venous
hypertension
KERLEY A LINES
67. KERLEY B LINES
īHorizontal lines
ī1-3 mm thick
īPerpendicular to pleural surface
īTowards the costophrenic angle
īAccumulation of fluid in interlobular
septa and lymphatics
īHighly specific for PVH
KERLEY B
68. īCrisscross lines seen between A &B
īGRADE 3 â pcwp > 25mm hg
Alveolar odema
Bilateral diffuse patchy
cotton wool opacities
KERLEY C LINES
69.
70. Pulmonary circulation
Pulmonary plethora â features
ī Enlargement of central pulmonary artery , lobar and segmental
artery
ī Prominent nodular vascular shadows in frontal CXR- shunt vessels
that course ventral to dorsal
ī Upper & lower lobe vessels prominent
ī RPDA > 17mm
ī Right descending pulmonary artery> tracheal diameter Ratio of
RPDA to diameter of trachea > 1
ī Plethora seen if shunt size >2:1
72. īDecreased flow proximal to orgin of main pulmonary artery
īSmall pulmonary artery
īEmpty pulmonary bay
īPulmonary vessels small
īLung hypertranslucent
īLateral view shows diminution of hilar vessels
Pulmonary oligaemia
74. īHigh pressure left to right shunts are associated with
obliterative changes in the smaller pulmonary arteries &
arterioles
īLarge main & large central pulmonary arteries taper down
rapidly to very small vessels
īSeen in Eisenmengerâs syndrome
īPrecapillary PAH
Pruning
86. īLinear or railroad track
calcification at site of ductus may
be seen in adults with PDA
PROMINENT
MPA
LV APEX
PLETHORA
AORTIC KNOB
PDA
87. âĸ âFIGURE OF 3â in CXR
âĸ âREVERSE 3â or âE signâ in Barium
meal
COARCTATION OF AORTA
88. DD OF INFERIOR RIB NOTCHING
1)Aortic obstruction- Takayasu arteritis
Coarctation of aorta
2) Subclavian artery obstruction âClassic BT shunt
Takayasu arteritis
3)Chronic Svc obstruction
4)Intercostal Av fistula
5)Neurofibromatosis
89. ī Cyanosis With Decreased
Vascularity
Tetralogy of Fallot
Truncus-type IV
Tricuspid atresia
Transposition of great arteries
Ebsteinâs anomaly
ī Cyanosis With Increased
Vascularity
Truncus types I, II, III
TAPVC
Tricuspid atresia
Transposition
Single ventricle
Cyanotic Congenital Heart Disease
92. īâfigure of 8â âsnowmanâ
īRt border-SVC
īUpper border-left innominate
īLeft border-left vertical vein
īBody of snowman-RA
CYANOTIC CHDâTAPVC (supracardiac)
93. īThe scimitar sign is produced
by an anomalous pulmonary
vein that drains any or all of
the lobes of the right lung.
ī Scimitar vein empties into the
inferior vena cava
CYANOTIC CHDâPAPVC(Scimitar sign)
95. īLV apex
īRt pulmonary artery has a superior
orgin (20%)
īâwaterfall signâ
īâHilar comma signâ
īAssociated right aortic arch (33%)
īConcave PA segment
ELEVATED
RIGHT HILUM
CYANOTIC CHDâTRUNCUS ARTERIOSUS
96. CYANOTIC CHD
Eisenmengerâs syndrome
âĸ Chest xray show dilation of central
pulmonary arteries and pruning of peripheral
pulmonary arteries, right ventricular and
atrial enlargement. Left heart would return
to normal size.
âĸ Left to right shunts such as atrial septal
defect, ventricular septal defect and patent
ductus arteriosus, cause increased
pulmonary blood flow. With time, high
pulmonary vascular resistance will
develop, ultimately causing right to left
shunt.
106. PERICARDIAL VS MYOCARDIAL CALCIFICATION
PERICARDIAL
ī SEEN IN BOTH SIDES OF HEART MOST
COMMONLY IN AV GROOVE
ī DIFFUSE CALCIFICATION AROUND THE
HEART
ī CALCIFICATION IS CHUNKY & UGLY
MYOCARDIAL
ī SEEN IN ONLY LEFT SIDE
ī MOST COMMON SITE IS ANT.
WALL
ī LOCALIZED TO THE LEFT
ī CALCIFICATION IS FINE &
CURVILINEAR
115. MISCELLENOUS X-RAYS
īLEFT SVC
ī Occurs in less than 0.5% of people
ī Failure of regression of L common
and Ant. Cardinal veins
ī Drains left jugular and left subclavian
vein
ī Most patients also have right sided
SVC
ī Drains into dilated coronary sinus
LEFT SVC
116. RIGHT AORTIC ARCH
ī Leftward displacement of barium filled
esophagus
īRt. Indentation of trachea
ī Aortic knob is absent from left side
ī Aorta descends on right
īAssociated with TOF
īTruncus arteriosus
117. AORTIC NIPPLE
Left superior intercostal vein
ī Seen in 5% of cases
īTo be differentiated from a mass
īAlso called pseudo dissection
īIt drains into hemiazygous vein
Hartman T .Pearls & Pitfalls in Thoracic imaging,Variants and other difficult diagnosis
118. CERVICAL AORTIC ARCH
īLeft sided cervical aortic arch
īAortic knob at apex of lung
īDescend on the left
CERVICAL AORTIC ARCH
123. BIBLIOGRAPHY
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(5) Ramesh M. Gowda,Lawrence M. Boxt. Calcifications of the heart.North American Clinics of Radiology 2004;4
(6) Martin J. Lipton, Lawrence M. Boxt. How to approach cardiac diagnosis from the chest radiograph.North American Clinics
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Radiology 2004;6
(8) Radiology imaging â sutton 6th edition
(9) Pediatric cardiology- Perloffâs clinical recognition of congenital heart disease
(10)Radiology of congenital heart disease-Amplatz
(11)Grainger & Allisons- diagnostic radiology vol1 , 4th edition
(12)Cardiac Xrays- v.Chockalingam
(13)Braunwald heart diseases 9th edition
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