This document discusses various imaging approaches for evaluating acute chest pain and thoracic abnormalities. It begins by outlining how cardiac CT angiography can be used to assess coronary artery disease and causes of non-cardiac chest pain such as aortic disorders, pulmonary embolism, and other thoracic issues. Examples of CT and MRI images are provided to illustrate different pathologies. The document then focuses on specific conditions like aortic dissection, pulmonary embolism, pneumothorax, and pleural effusions. Imaging findings and diagnostic criteria for each condition are summarized.

1. Awad Bessar, MD
Professor of Radiodiagnosis
Zagazig University
Clinical Approach

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

5.  Calcium Scoring: provide a quantitative
assessment of subclinical atherosclerotic
coronary artery disease

6. 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.

7. 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).

8. 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).

9. 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).

10. 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).

11. A B

12. Noncalcified
plaque (arrow)
in the
proximal left
anterior
descending
coronary
artery
associated
with
significant
luminal
stenosis in a
65-year-old
male patient

13. 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.

14. 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

15. 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.

16. Coronary artery stenosis. Coronary CTA shows a high-grade stenosis
(arrow) due to non-calcified plaque (arrowheads) in the proximal LAD

17. Chest radiography usually represents the first
imaging modality performed in patients presenting
with acute chest pain.

18.  Pneumothorax
 Pneumomediastinum
 Rib fractures
 Acute infections.
 Aortic aneurysms or dissections (lower
sensitivity)
 Pulmonary embolism (lower sensitivity)

20.  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.

21.  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.

22.  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

23.  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%)

24. LEFT: Type A dissection with clear intimal flap seen
within the aortic arch.
RIGHT: Type B dissection. Entry point distal to left
subclavian artery.

26. True lumen:
-Surrounded by
calcifications (if present)
-Smaller than false lumen
Usually origin of celiac
trunk, SMA and right
renal artery

27. 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

28. Collageneous media-remnants (cobwebs) are only seen in
the false lumen.

29. • 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

30. 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

31. Massive hematoma
caused by rupture
of the dissected
aorta into the
mediastinum and
pleural cavity, no
pericaldial
hematoma.

32. 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.

33.  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.

36.  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.

37.  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.

38. 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.

39. Chronic PE. CTA chest shows non-occlusive intraluminal filling defects
(arrows) adherent to the wall and multiple peripheral cavitary infarcts
(arrowhead).

40. 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.

41.  Hampton Hump Sign
 Westermark sign

42.  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.

43. 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.

44. CT with mediastinal windowing shows low-attenuation filling defect,
which represents a saddle embolus (arrows) bridging the lingular and
left lower lobe pulmonary arteries

45.  This sign refers to oligemia of the lung beyond
an occluded vessel in a patient with pulmonary
embolism

46. 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.

47. CT with lung windowing better shows the diminution of vessels on
the right compared with the left. There is also a right pleural effusion

48. CT with mediastinal windowing shows thrombus expanding
and filling the main and right pulmonary arteries (arrows).

49.  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

50.  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.

51. 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

52.  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.

53. A large right-sided
spontaneous
pneumothorax (left in the
image). An arrow indicates
the edge of the collapsed
lung

54. 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

55. 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.

57. CTA image shows a
main pulmonary
artery aneurysm
(arrow) with
resultant
significant
compression of the
left main stem
coronary artery
(arrowhead).

58. 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).

59. SVC thrombosis. Venous
phase CTA shows partial
enhancement of
(arrowhead) a large low-
density thrombus (arrow)
in the superior vena cava,
representing tumor
thrombus

60. 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.

61. 2D transthoracic echo of pericardial effusion

62. Water bottle-
shaped heart

63. 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.

65.  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.

68. 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

69.  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.

70. 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)

71. 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

72. Free pleural effusion. Posteroanterior chest radiograph
demonstrates the meniscus sign (arrows) in a large free right
pleural effusion

73. 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.

74.  Pneumomediastinum is the presence of
extraluminal gas within the mediastinum. Gas
may come from lungs, trachea, central bronchi,
oesophagus, and the neck or abdomen.

75. -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

76.  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

77. 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)

78. 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.

79.  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

80. 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

82.  Percutaneous Indwelling Central Catheter
 Central venous catheter
 Pulmonary artery catheter
 Venovenous or venoarterial extracorporeal life
support
 Stents

83. 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

84. 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

85. 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

86. Malpositioned central venous catheters. Posteroanterior and lateral
radiographs demonstrate a central venous catheter in the azygos vein
(arrowheads).

87. Neck hematoma (asterisk) after right internal jugular line placement
attempt. Note the endotracheal tube tip is in the right main bronchus.

88. Fatal right hemothorax after right internal jugular line placement
attempt in a patient with undiagnosed idiopathic thrombocytopenic
purpura

89. 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).

90. 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).

91. 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).

92. 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

93. 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.

94. 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).

95. Wire-mesh stent in the superior vena cava as seen on (A)
posteroanterior and (B) lateral radiographs

96.  Intraaortic balloon pump
 Venoarterial extracorporeal life support
 Stents

97. 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).

98. 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).

99.  Pacemaker
 Implantable cardiac defibrillator
 Left venticular assist device
 Atrial septal defect closure device

100. 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.

101. 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).

102. Biventricular pacemaker in a patient with ischemic cardiomyopathy

103. 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.

104. 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.

105. 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

106. 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.

107. HeartMate left ventricular assist system

108. Large wire coronary artery bypass graft markers (arrows) as seen on (A)
posteroanterior and (B) lateral radiographs.

109.  Endotracheal tube
 Tracheostomy tube
 Intratracheal oxygen catheter
 Stents

110. Abnormal endotracheal tube with
balloon inflated positioned within
the pharynx. High position of an
endotracheal tube may cause vocal
cord injury

111.  Feeding tube
 Nasogastric or oral-gastric tubes
 Intraesophageal manometer
 Temperature probe
 pH probe
 Stent
 Antireflux devices
 Gastric banding

112. Correct position of feeding tubes

113. Incorrect
position of
esophageal
tubes

114. Coil-type stent in the esophagus as seen on (A) posteroanterior and (B)
lateral radiographs.

115. Gastric banding for morbid obesity

116.  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