Cxr

1. CARDIAC X-RAY

2.  R – ROTATION
 I -- INSPIRATION
 P -- PROJECTION
 E -- EXPOSURE

3.  The medial ends of both clavicles should be equidistant
from the spinous process of the vertebral body projected
between the clavicles

4. The increase in blackness 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

5.  It is ascertained by counting either the number
of visible anterior or posterior ribs
 Adequate inspiratory effort - six complete
anterior or ten posterior ribs are visible
 Poor inspiratory effort - fewer than six anterior
ribs
 Hyperinflated lung-more than six anterior ribs

7. POOR INSPIRATORY FILM NORMAL INSPIRATORY FILM
1
2
3
1.MEDIASTINAL WIDENING 2.CMGLY 3.LOWER LOBE PATCHY OPACIFICN

8.  Projection is defined as the direction of x-ray
with relation to the patient
 If the direction of x-ray projection is from
front – AP projection
 If the direction of x-ray projection is from
behind –PA projection

10.  In erect patients
 Vertebral spines more
prominent
 Scapulae clear of
lungs
 Clavicles are
horizontal
 In supine patients
 Vertebral bodies clear
 Apparent cardiomegaly
 Scapulae overlap
 Clavicles are oblique

11. 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 ‘black’, then
too many photons have resulted in overexposure
of the x-ray film.

12. UNDERPENETRATION
NORMAL
OVERPENETRATION

13.  Ascending aorta normally lies within the
cardiac silhoutte and is superimposed on the
SVC which forms convex border above the
RA.
 Dilated ascending aorta is visualised in
frontal view in following situations
 Aortic regurgitation
 Marfan syndrome
 Aortic aneurysm
 Poststenotic dilatation in AS.

14. Aortic knob is the junction formed by the arch and descending aorta

15.  It is the prominent aortic arch, which is
wider and higher than normal with
conspicuous ascending aorta on the right and
tortuous or serpentine descending aorta on
left
 It is seen in-
 Older individuals with atherosclerosis
 Systemic HTN
 Severe AR

17.  Trachea is shifted slightly to the left (instead
of to the right).
 Aortic knuckle is absent on the left side.
 soft tissue indentation on the right side of
the distal trachea
 right sided descending aorta
The right arch is often seen as high riding and
projecting as a mass in the right paratracheal
region

18.  usually associated with cyanotic congenital
heart disease which include
 tetralogy of Fallot
 truncus arteriosus
 tricuspid atresia
 transposition of the great arteries

19.  Figure 3 sign: formed by prestenotic
dilatation of the aortic arch and
left subclavian artery, indentation at the
coarctation site (also known as the "tuck"),
and post-stenotic dilatation of
the descending aorta.

21.  is seen on barium swallows in patients with
a coarctation of the aorta and is the medial
equivalent of the figure 3 sign seen on plain
chest radiograph.

22.  secondary to dilated intercostal collateral
vessels which form as a way to bypass the
coarctation and supply the descending aorta.
 the dilated and tortuous vessels erode the
inferior margins of the ribs, resulting in
notching
 seen only in long standing cases, and
therefore not seen in infancy (unusual in
patients <5 years of age)
 usually the 4th to 8th ribs are involved;
occasionally involves the 3rd to 9th ribs

23.  as the 1st and 2nd posterior intercostal
arteries arise from the costocervical trunk (a
branch of the subclavian artery) and do not
communicate with the aorta, these are not
involved in collateral formation, and the
1st and 2nd ribs do not become notched
 if bilateral rib notching: the coarctation must
be distal to the origin of both subclavian
arteries, to enable bilateral collaterals to
form

24.  coarctation lies distal to the brachiocephalic
trunk, but proximal to the origin of the
left subclavian artery.
 there may be a right sided aortic arch with
abberent left subclavian artery distal to
coarctation
collaterals cannot form on the left, as the
left subclavian is distal to the coarctation

25.  aberrant right subclavian artery arising after
the coarctation.
 Collaterals cannot form on the right, as the
aberrant right subclavian artery arises after
the coarctation

27.  coarctation of the aorta
 interrupted aortic arch
 subclavian artery obstruction
 Takayasu disease
 Blalock-Taussig shunt: involves only upper two rib
spaces
 arteriovenous malformation (AVM)
 superior vena cava obstruction with enlarged
venous collaterals
 pulmonary AVM
 tetralogy of Fallot 4
 neurogenic tumours
 schwannoma
 neurofibromatosis type 1

28. RV
PT
AA
LA
LV

29. Gastric air
bubble
Left upper
lobe
bronchus
IVC
Right
hemidiaphragm
LV
LA
RV
Pulmonary
outflow
tract
Aorta
Right upper
lobe bronchus
RPA
LPA
Confluence
of
pulmonary
veins
Brachiocephalic
vessels Trachea
Left
hemidiaphragm

31.  In LAO view anterior heart border is formed
by right atrium above and right ventricle
below.
 LAO view is superior projection for detection
of RVE, which is characterized by an increase
in the convexity of the anterior border of
cardiac silhoutte.

33.  LPA courses to the left and posteriorly and
hence its borders are just visible above the
middle of hilum
 RPA has a horizontal course within the
mediastinum so better visualised in CXR.
 RDPA is 10-15 mm in males and 9-14 mm in
females.
 RDPA is a useful parameter to judge the
pulmonary blood flow.

34.  Intrapulmonary arteries and segmental
bronchi subtend the same bronchopulmonary
segment and both are of approximately same
diameter with a ratio of
1.2:1(artery:bronchus)
 In outer third of the lungs, both pulmonary
arteries and veins are too small to be seen
clearly on chest X RAY.
 The normal ratio of the central(inner third)
and peripheral(outer third) arteries is 5:2

36.  In normal erect individuals, the upper zone
vessels are smaller than in the lower zones.
 In normal erect individual upper zone vessels
are smaller than the lower zones
 Normal ratio Lower: upper zone is 5:1

37. 1.RDPA<17MM
NORMAL PULMONARY CIRCULATION – 3 FEATURES

38. 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

40.  Main pulmonary
artery projects
more than the
tangent
 Causes:
1. Increased
pressure
2. Increased flow

41.  MPA > 15 mm from
the tangent.
 Causes:
1. TOF
2. TRUNCUS ARTERIOSUS

42.  RA enlargement
 LA enlargement
 RV enlargement
 LV enlargement

43.  Rt. Cardiac border becomes more convex > 50% of right
border
 Rt. Atrial border extends >3 intercostal spaces
 Measurement from mid vertical line to max. convexity in rt.
Border>5 cm in adult & >4cm in children
 Lateral view – fullness in space between sternum and front of
upper part of cardiac silhouette.

44. a b
Ab > 5cm

45.  Widening of carina( normal 45-75 degree)
 Elevation of left bronchus
 Straightening of left border
 Double atrial shadow( shadow within shadow)
 Grade 1 –double cardiac contour
 Grade2 - LA touches RA border
 Grade 3 – LA overshoots the Rt. Cardiac border
 Displaces the descending aorta to the left and
esophagus to right seen in barium swallow

46. HYPERTROPHIED
LA APPENDAGE

47. DOUBLE ATRIAL SHADOW
WIDENING OF CARINA
ELEVATION
OF LEFT
BRONCHUS
LAA
enlargement

49. LA pushing the
Esophagus posterior

50.  PA view
 (a)Left cardiac border gets enlarged and
becomes more convex resulting in cardiomegaly
 (b)Lt. cardiac border dips into lt. dome of
diaphragm
 (c) rounded apical segment
 (d) cardiophrenic angle is obtuse

51. Chest X ray shows left ventricular enlargement.
Left heart border is displaced leftward, inferior and
posteriorly.
Rounding of the cardiac apex.

52. Lateral view
 (a) Left ventricle enlarges inferiorly and
posteriorly
 (b)Rigler’s measurement A is >17 mm
 (c)Rigler,s measurement B is< 7.5 mm
 (d) Eyeler’s ratio becomes > 0.42

53.  Rigler’s A & B used to
diagnose left ventricular
enlargement
 Possible only when IVC
shadow is present
 Jn. Of IVC with Lt. Atrium
– J point
 Rigler’s A- from J point
along line of IVC draw a
line of 2 cm above and
mark the point X.

54.  Draw a horizontal line from pt. x to
posterior Cardiac border and mark
that pt. y
 Distance between points x & y is
Rigler’s measurement A
 NORMAL<17 mm
 Rigler’s B-from the pt. J drop a
perpendicular line to the dome and
this distance is Rigler’s
measurement B
 NORMAL<7.5 mm

55.  When LV enlarges,
 Posterior cardiac border gets
displaced posteriorly & IVC
shadow gets included in cardiac
shadow, without getting
displaced posteriorly
 Rigler’s measurement A >17 mm
and B<7.5 in lt. ventricular
enlargement.

56.  Valid when IVC shadow is
absent or cannot be visualised
 Mark the pt. of jn. where
postero inferior cardiac border
meets the dome as B
 From this pt. B draw a
horizontal line to the posterior
border of sternum-AB

57.  From pt.B - draw another
horizontal line posteriorly
to the inner border of the
rib-BC
 Ratio of AB/BC is
Eyeler’s ratio < 0.42
 Eyeler’s ratio > 0.42
seen in LV
enlargement.

58. LA Oblique view
 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

59. 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 space( RV occupies >1/3rd of body
of sternum
LEFT LATERAL VIEW
Rigler’s measurement will be17mm or less
Rigler’s measurement will be 7.5mm or more
Eyeler’s ratio is 0.42 or less

63.  LARRY ELLIOT’S CLASSIFICATION 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

64. GRADE 0 -PCWP< 12 MM HG
 Upper lobe pulmonary veins are less prominent than lower
lobe veins
GRADE 1- PCWP 13-17MMHG
Redistribution of blood flow with cephalization-’ANTLER
SIGN’
 1) increased resistance to flow due to interstitial odema
 2) alveolar hypoxia in lower lobes causes reflex
vasoconstriction

65.  GRADE 2- PCWP 18-25mm hg
 Interstitial edema
 Peribronchial cuffing
 Kerley A,B,C lines
 Interlobular effusion
 Pleural effusion
 Hilar haze
Peribronchial
cuffing

66.  Distended lymphatic
channels within edematous
septa coursing from
peripheral lymphatics to
central hilar nodes
 Towards the hilum.
KERLEY A LINES

67.  Horizontal lines
 1-3 mm thick
 Perpendicular to pleural
surface
 Towards the
costophrenic angle
 Accumulation of fluid in
interlobular septa.
 Highly specific for PVH
KERLEY B

68.  KERLEY C LINES
Crisscross lines seen between A &B
 GRADE 3 – pcwp > 25mm hg
Alveolar odema
B/l diffuse patchy
cotton wool opacities

70.  Pulmonary plethora – features
 Enlargement of central pulmonary artery , lobar and segmental
artery
 Upper & lower lobe vessels prominent
 RDPA > 17mm
 Right descending pulmonary artery> tracheal diameter
Ratio of RDPA to diameter of trachea > 1
 Plethora seen if shunt size >2:1

72.  Pulmonary oligaemia
 Decreased flow proximal to orgin of main pulmonary artery
 Small pulmonary artery
 Empty pulmonary bay
 Pulmonary vessels small
 Lung hypertranslucent

73. Empty
pulmonary bay

74.  Pruning
 High pressure left to right shunts are associated with
obliterative changes in the smaller pulmonary arteries &
arterioles
 Large main & large central pulmonary arteries taper down
rapidly to very small vessels( Central plethora with
peripheral pruning)
 Seen in Eisenmenger’s syndrome
 Precapillary PAH

76.  ASD
MPA DILATED
RV
APEX
RPA
DILATED
PULMONARY
PLETHORA

77.  VSD
MPA
DILATED
RPA
DILATED
LV APEX
PLETHORA

78.  PDA
 Linear or
railroad track
calcification at
site of ductus
may be seen in
adults with PDA
PROMINENT
MPA
LV APEX
PLETHORA
AORTIC KNOB

79.  COARCTATION OF AORTA
 “FIGURE OF 3” in CXR
 “REVERSE 3” or
“E sign” in
Barium meal
SUBCLAVIAN
ARTERY DILATION
COARCTATION
POSTSTENOTIC
AORTIC
DILATION
RIB
NOTCHING

80.  Cyanosis With Decreased
Vascularity
Tetralogy of Fallot
Tricuspid atresia
Transposition of great arteries
Ebstein’s anomaly
 Cyanosis With Increased
Vascularity
Truncus Arteriosus
TAPVC
Tricuspid atresia
TGA
Single ventricle

81. TOF
‘Cour en sabot’
Due to
1)Rv apex
2)Underfilled LV
3)Concave pulmonary
artery
4)Pulmonary oligaemia

82.  TGA
 ‘Egg on string’
 1)Narrow pedicle
 2)Rt. Border RA
 3)Lt. border LV
 4)Increased
vascularity
 5)Hypoplastic
thymus

83. TAPVC (supracardiac)
 ‘figure of 8’
“snowman”
 Rt border-SVC
 Upper border-left
innominate
 Left border-left vertical
vein
 Body of snowman-RA

84.  PAPVC(Scimitar sign)
 The scimitar sign is
produced by an
anomalous
pulmonary vein that
drains any or all of
the lobes of the
right lung.
 Scimitar vein
empties into the
inferior vena cava

86.  EBSTEIN
 ‘Box shaped’heart
 Enlarged RA
 Hypoplastic
pulmonary trunk
 Decreased
vascularity

87.  Radiographically, situs solitus is identified by
visualization of both aortic knuckle and
fundus of stomach on the left side
 The presence of longer and narrow left
bronchus on the left side is a more accurate
indicator of the presence of situs solitus,
while in situs inversus it lies on right side.