Cxr revised 24 11-91
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Transcript of Cxr revised 24 11-91
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CXR Normal Anatomy
A. Almasi MDIran University of Medical Science
Department of Radiology
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PA CXR
• Quality Control• Trachea• Mediastinum& Heart• Diaphragms• Pleural space including fissures• Lungs• Hidden Areas of the Lungs• Hila• Below Diaphragm• Bones
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PA view
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Quality Control
• Inspiration:• Ant. end of 5th - 6th or post. end of 10th rib above the
diaphragm
• Centering: • Medial end of the clavicles equidistant from T4-5
spinous process
• Exposure:• Vertebral bodies and disc spaces behind the heart must
be barely visible and bronchovascular marking should be visible through the heart
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PA view
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Rotation Effect• Anterior structures (e.g. heart) shift to the side farther from the film• The lung farther from the film appears more lucent and the ipsilateral
hemithorax appears wider• In this rotated film skin folds can be mistaken for a tension
pneumothorax (blue arrows)
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Expiratory Film• Increased heart size• More prominent bronchovascular markings• Basal opacities• Tracheal deviation to the right
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Expiratory Film• Increased heart size• More prominent bronchovascular markings• Basal opacities• Tracheal deviation to the right
inspiration expiration
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Respiration and Rotation Effect
Inspiration Expiration& Leftwards Rotation
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Improper ExposureUnderexposed Overexposed
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Trachea
• Exact midline in the upper part& deviating to the right around the aortic knob
• Even diameter up to M:25mm F:21mm• Right paratracheal stripe <4-5mm• Azygos vein at the anlge between the RMB&
trachea (less than 10mm in diameter)• Carina at T6-7 angle: 60-75°
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Trachea in Superior Mediastinum• Left side of the trachea is not border forming on
CXR it is not surrounded by aerated lung
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Normal PA Viewright paratracheal stripe
SVC
right brachiocephalic artery
carina
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Right Paratracheal Stripe
Normal after Radiotherapy
Hodjkin’s Disease
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Wide Carinain Mitral Malady
left atrial appendage
cephalization
left atrium
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The Heart
• 1/3(1/5-1/2) to the right& 2/3 to the left of midline
• CT ratio 50% on PA and 60% on AP view• Diameter up to F:14.5cm M:15.5cm• 1-1.5cm increase on two consecutive films
is significant• Enlarges in expiration& when diaphragm is
high
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Cardiothoracic (CT) Ratio
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Normal PA View
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Mediastinal BordersRight Superior
Brachiocephalic A&VSVCTortuous or dilated
ascending aorta may contribute
InferiorRt atriumIVC (probable)
LeftSubclavian AAortic knobPulmonary ALt atrial appendageLt ventricle
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1.1MediastinalBorders
1.1.BraciocephalicA&V1.SVC2.RA3.SubclavianA4.Aortic Knob5.Descending Aorta6.Pulmonary Trunk7.LA Auricle8.LV
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Normal PA View
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ProminentPulmonaryTrunk
Is normal in young women& children
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Tortuous Aorta& Prominent LtCardiophrenicAngle Fat Pad
Ascending A
Fat Pad
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CardiophrenicAngle Fat Pad on LateralCXR
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Tortuous Aorta& Brachiocephalic Aneurysm
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PA CXR• Quality Control• Trachea• Mediastinum& Heart• Diaphragms• Pleural space including fissures• Lungs• Hidden Areas of the Lungs• Hila• Below Diaphragm• Bones
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Diaphragm
• Right hemidiaphragm is usually higher• More than 3cm difference between heights
of the hemidiaphragms may be abnormal• Dome of the hemidiaphragms is usually
posteriorly located but on the right it may be anterior 40% of the times
• Contour should be sharp except where heart lies on the diaphragm
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PA view
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Anterior right diaphragm dome
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High Hemidiaphragm DDx
• Normal esp. when there is much gas in the bowel, normal motion on fluoroscopy or sonography
• Diaphragmatic Paralysis esp. after thoracic surgery, paradoxical motion of the diaphragm
• Eventration usu.paradoxical motion on fluoroscopy
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High Hemidiaphragm
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DiaphragmaticScalloping
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DiaphragmaticSlipping in flatdiaphragms
• Athletes• Emphysema
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Hump of Diaphragm
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Hump
Sonography rules outsubdiaphragmatic mass
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Pleural Space
• Lateral Costophrenic Angles should be acute, blunting indicate effusion (250ml at least), flattening or thickening
• Posterior Costophrenic Angles can become blunted by as little as 75ml fluid on lateral view
• Fissures are double layered pleura separating lobes
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Fissures
• Oblique (major) visible only on lateral view
From T4-5 to just posterior to costophrenic angel on the right and 5cm posterior on the left
• Horizontal (minor) visible on both PA& lateral views
From right hilum to the 6th rib at axillary line
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Fissures
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Fluid-filled fissures• The patient below has a pleural effusion extending into the fissure. Which fissure is
which? • What is the bright loop near the center of the films?
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Segmental Lung Anatomy
•Lung lobes are separated by fissures which are composed of two adjacent layers of parietal pleura•A lung segment is the lung parenchyma surrounding a segmental bronchus
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Lobar& Segmental Anatomy of the Lungs
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Lobar& segmental anatomy
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Minor FissureFrom right hilum to the 6th rib at axillaryline
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MinorFissure
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Major FissuresFrom T4-5 crossing the hilum and terminating behind costophrenic angel on the right and 5cm more posteriorly on the left
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Fissuresminor
left major
right major
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The Lungs
• Opacity• Symmetry in marking& lucency• Vasculature
– Inferior vessels are more prominent– No vessel>3mm in diameter in the 1st anterior intercostal space– Concave lateral border of Rt descending pulmonary A
• Hidden Areas– Apex– Posterior Recess– Areas superimposed by mediastinum, hila& bones
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Normal PA View
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Lung Hila• Left hilum higher 97%• Symmetric in size and density• Concave lateral border• Contour made up of superior pulmonary vein&
descending branch of main pulmonary artery • Descending branch of main pulmonary artery on
the Rt has concave lateral contour and measures less than 16mm in diameter
• Normal LNs not visible
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Hilar Anatomy
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Hila on PA View
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Hila on Lateral View
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Hila on Lateral
View
* Lt Sup Bronchus
* Rt Sup Bronchus
Rt MainPul. A
Lt Main Pul. A
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Hilar Adenopathy
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HilarAdenopathy
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ProminentHila-Vascular(Pulmonary Venous HTN)
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ProminentHilaPulmonary ArterialHTN
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ProminentHilaPulmonary ArterialHTN
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Hilar Enlargement Vascular vs Adenopathy
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Below diaplragm, Soft tissue& Bones
• Gas shadows (stomach, bowel, surgical emphysema, etc.)
• Symmetric axillary lines, Mastectomy• Bone lesions
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Normal PA View
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Normal PA
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Prominent skin fold vs pneumothorax
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Calcified Costal Cartilage
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Hypertrophied 1st Costochondral Junction
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Hypertrophied 1st Costochondral Junction
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Lateral CXR
• Clear Spaces• Vretebral
Translucency• Diaphragm Outline• The fissures• The lung Hila• The Trachea& Upper
Lobe Bronchi• The Sternum
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Clear Spaces& Vertebral Translucency
• Ant. Clear Space– Ant. medistinal masses, LNs& aortic aneurysm
may fill this space– In emphysema it widens (>3cm)
• Post. Clear Space– Vertebral translucency increases progressively
downward in this space
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CXR Lateral View
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PE on lateral view(effect on vertebral translucency)
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PE
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Fissuresminor
left major
right major
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Hila on Lateral
View
* Rt Sup Bronchus
* Lt Sup Bronchus
Rt MainPul. A
Lt Main Pul. A
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HilarAdenopathy
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LLL Consolidation
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Lateral Decubitus Films
• To differentiate pleural effusion from thickening in case of a blunt costophrenic angle
• To assess the volume of pleural effusion• Demonstrates whether a pleural effusion is mobile or loculated• Detection of a pneumothorax in the nondependent hemithorax in a patient
who could not be examined erect• The dependant lung should increase in density due to atelectasis from the
weight of the mediastinum putting pressure on it. Failure to do so indicates air trapping
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PA versus AP CXR
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PA versus AP CXR
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Recommended order of reading a CXR
•It is recommended to start from the regions of least radiologic interest to decrease the likelihood of missing details. 1- Abdomen
2- Thorax (soft tissues and bones)
3- Mediastinum
4- Lung-unilateral
5- Lungs-bilateral
This order can be memorized by the breviation ATMLL
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Abdomen
• The recommended path is shown, beginning at the right lower corner.
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Thorax (soft tissues and bones)
• The path again starts from the right lower corner of the x-ray
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Mediastinum• Mediastinum can be assessed in two consecutive runs
one for the trachea And bronchi and the other for the soft-tissue structures and pulmonary hila
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Lung
• It is recommended to look at the lungs one by one at first and then a look that compares the two lungs
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Lateral Film• The same order that was mentioned (ATMLL) is
applicable to lateral films too
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Proposed reading order for a CXR
• Turn off stray lights, optimize room lighting, view images in order• Patient Data (name history #, age, sex, old films)• Routine Technique: AP/PA, exposure, rotation, supine or erect• Trachea: midline or deviated, caliber, mass• Lungs: abnormal shadowing or lucency• Pulmonary vessels: artery or vein enlargement• Hila: masses, lymphadenopathy• Heart: thorax: heart width > 2:1 ? Cardiac configuration?• Mediastinal contour: width? mass?• Pleura: effusion, thickening, calcification• Bones: lesions or fractures• Soft tissues: don’t miss a mastectomy• ICU Films: identify tubes first and look for pneumothorax
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Atelectasis vs Lobar Pneumonia
Atelectasis•
Volume Loss Associated Ipsilateral Shift
• Linear, Wedge-Shaped• Apex at Hilum
Pneumonia• Normal or Increased Volume
No Shift, or if Present Contralateral
• Consolidation, Air Space Process
• Not Centered at Hilum