Chest X Ray Mediastinum Cohs Febr 2014
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Transcript of Chest X Ray Mediastinum Cohs Febr 2014
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Chest X ray
Mediastinum
COHS
February 2014
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Goals
• To understand the basic terminology and techniques
of chest x-rays
• To gain familiarity with "the normal chest x-ray“
• To learn and practice a standardized sequence of
chest x-ray interpretation
• To learn and be able to recognize several
common chest x-ray abnormalities
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Lung zones
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Pulmonary arteries
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ediastinum
• Many structures can be identified within
the mediastium;
• Heart, blood vessels, main airways,esophagus, lymph nodes, thymus ..…
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TWO SHADOWS/MAGNIFICATION
DISTANT STRUCTURES
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SHADOWS MERGE
ADJACENT STRUCTURES
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How many structures can you identify?
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LV
RV
SVCAortic pulmonary
recess
Left
Aortic
arch
RA
LA
Right
pulmonary
artery
Right
pulmonary
artery
(lower lobe)
Vascular
pedicle
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Postero-Anterior (PA) View
SVC
IVC
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Postero-Anterior (PA) View
RA
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Postero-Anterior (PA) View
RV
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Postero-Anterior (PA) View
PA
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Postero-Anterior (PA) View
LA
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Postero-Anterior (PA) View
LV
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Postero-Anterior (PA) View
Aorta
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Postero-Anterior (PA) View
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Postero-Anterior (PA) View
• Right border
– Superior vena cava
– Right atrium
– Inferior vena cava
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Postero-Anterior (PA) View
• Right border
– Superior vena cava
– Right atrium
– Inferior vena cava
• Left border
– Aortic knob
– Main pulmonary trunk
– Left ventricle
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Postero-Anterior (PA) View
• Pulmonary Arteries
– Right
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Postero-Anterior (PA) View
Pulmonary Arteries
Right
Left
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Postero-Anterior (PA) View
• Pulmonary Arteries
– Right
– Left
• Pulmonary VeinsLA
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How many structures
can you identify?
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Gastric air
bubble
Left upper
lobe
bronchus
IVC
Righthemidiaphragm
LV
LARV
Pulmonary
outflow
tract
Aorta
Right upper
lobe bronchusRPALPA
Confluence of
pulmonary
veins
Brachiocephalic
vessels Trachea
Left
hemidiaphragm
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Lateral View
RA
SVC
IVC
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Lateral View
RV
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Lateral View
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Lateral View
LA
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Lateral View
LV
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Lateral View
Aorta
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Lateral View
LV
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Lateral View
• Aorta
• Main Pulmonary Artery
• Inferior vena cava
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Lateral View
• Pulmonary Arteries
– Left
– Right
• Pulmonary Veins
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Which valve has been replaced?
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Which valve has been replaced?
Aortic valveNote the orientation of the
valve perpendicular to the
plane of the PA film.
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Which valve has been replaced?
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Which valve has been replaced?
PulmonicThe pulmonary outflow
tract is more superior
and lateral than many
people think.
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Last one, name the valves…
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The Vascular Pedicle
• Found in the superior mediastinum.
• Right and left margins are normally formed by the
superior vena cava and the descending portion of the
aortic arch, respectively.• A widened vascular pedicle can have several
etiologies including elevated intravascular volume,
aortic trauma, or pericardial effusion.
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Vascular
pedicle
Aortic
arch
Superior
vena cava
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Intravascular volume
depletion
Intravascular volume
elevationvs.
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Vascular
pedicleVascular
pedicle
Intravascular volume
depletion
Intravascular volume
elevation
Intravascular volume elevation resulting in an expanded SVC should not be mistaken
for hematoma, which would have a less distinct border and more opacified
appearance.
vs.
Superior
vena cava
AortaSuperior
vena cava Aorta
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Trauma patient with an aortic transection
Note the vascular pedicle’s “fuzzy”, opacified right border.
Wh i h i h ?
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What is happening here?
Wh i h i h ?
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What is happening here?
Can you follow the heart borders?
Wh t i h i h ?
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What is happening here?
The wide vascular
pedicle here results
from a pericardial
effusion
The pacemaker
wires roughly
outline the right
atrium border
If you look closely you can
make out the superior
pericardial border
The left heart border
can be seen within theeffusion
effusioneffusion
Comparing this with older films can also help make the diagnosis.
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Other ediastinal Structures
• Esophagus
• Thyroid
• Thymus
• Lymph nodes
•These are generally not seen unless there ispathology
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What could be the source of this anterior mediastinal mass?
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What could be the source of this anterior mediastinal mass?
Ddx: Lymphoma/leukemia, germ cell tumors (e.g., teratoma), thymic
mass (e.g., thymoma, cyst), enlarged thyroid, vascular (e.g.,
hematoma, aortic aneurysm).
This patient has a thymoma.
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How about this one?
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How about this one?
This patient has a an enlarged thyroid gland.
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A. Anteriorposterior chest radiograph obtained on
supine position shows mediastinal widening withenlarged and indistinct aortic knob and
aortopulmonary window opacification (a).
B. Contrast-enhanced axial
CT scan shows a rupture
of the aorta with apseudoaneurysm (star)
projecting anteromedially.
Also noted are mediastinal
hematoma and bilateral
hemothoraces.
C. 3-D volume rendering
image well demonstrates a
pseudoaneurysm (arrow)
of the aorta at isthmic
portion.
B
A
Traumatic Aortic RuptureCase 1. 68/M
C
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A. Chest radiograph appears normal.
B. Tc99m –MDP scan shows hot uptake at junction
between left 1st rib and manubrium.
C and D. Axial (C) and 3-D reconstruction (D) CT
scans reveal fracture of calcified left 1st costal
A C
D
B
Case 1. 49/M Fracture of the left 1st Costal Cartilage