Normal

Chest X-Ray, CT and MRI Benigno R Santi II, MD, FPCR

UST-FMS Department of Radiological Sciences) nd (Magboo C 2015, Transcribed from PPT and Lecture; few information lifted from Basic Radiology By Chen, 2 Ed.)

Radiographic Film in between two Fluorescent coatings (also called intensifying screens)

Radiography

Computed Tomography Magnetic Resonance

Spatial Resolution and Effective Radiation Dose of Thoracic Imaging Modalities Spatial Resolution Ability to define / differentiate 2 objects apart from each other at the least possible distance
(Think of pixels. If an image has better resolution, it would have more pixels, therefore would appear sharper and you can delineate even small objects)

These coatings are made of high atomic number materials. It can absorb x-rays more efficiently (compared to the film) and emit photons, which can now be efficiently absorbed by the x-ray film itself.

Modality CXR DR CT MRI Nuclear Medicine PET Angiography US Background Radiation Resolution (mm) 0.08 0.17 0.4 1.0 7.0 3.0 0.13 0.3 N/A Dose (mSv) 0.02 (PA), 0.04 (lateral) 0.02 (PA), 0.04 (lateral) 8 0 0.4 7 12 0 3 per year

Chest X-Ray has better spatial resolution than CT and MRI Because CXR is an actual picture of the Chest CT & MRI are digital images, which have been computed (Similar: a photograph taken using film vs. a digital camera) Indications for Chest Radiography
o Diagnostic n Cardiopulmonary symptoms p Cough, hemoptysis, shortness of breath, chest pain, etc. n Preoperative for thoracic surgery n Preoperative if known cardiopulmonary limitations n Staging of thoracic tumors and extrathoracic malignancies n Infection p Pleural, parenchymal, mediastinal Follow-up n Previously diagnosed cardiopulmonary disease p Pneumonia resolution to exclude endobronchial lesion p Pulmonary edema Monitoring of intensive care unit patients n Lung disease n Pleural disease n Lines and tubes positions Monitoring of postoperative patients

X-ray films are valuable. They can be used as a comparison to evaluate progression of pre-existing conditions or establish a if a finding have been present in previous examinations. Reading Chest Radiographs Density = White mass Lucency = Dark (represents air) Infiltrate = Abnormal density When looking at an X-Ray: Compare Right and Left sides Densities o Ribs (count the ribs and intercostal spaces) By description: on CXR, the Anterior and Posterior Ribs will be read separately because of the oblique orientation of the ribs, where the anterior would present to be at a relatively lower level o Heart and its Vascular Markings Equivalent Lucency (R to L) o Air Lungs (equivalent to other side) Difficult to compare when the shadow of the heart interferes (i.e. lower lung fields) o Divide the lungs into 3 divisions and note for the vascular markings.
Inner Lung Field (Great vessels coming from hila) Middle Lung Field (intermediate vessels) Outer Lung Field (very small vessels)

Trace the vascular markings to differentiate normal from an infiltrate.

O M I
Small Intermediate Large

Equivalent Side

2 Factors Affecting Radiographic Density

2.

3.

1. Tissue Depth Greater thickness = more dense Thick tissues will attenuate more X-ray beams More attenuation = More Density Less attenuation = More Lucency 2. Atomic Weight The Bone is the densest tissue you can find Because of the presence of Calcium Soft Tissues: Intermediate density (Water Density) Lungs very Lucent (Air in alveoli)

Chest X-Ray: the density of muscle, blood and liver are very close together (they are only translated as intermediate or water densities) Computed Tomography: can differentiate these minute differences fairly well Technique in doing Proper Chest X-ray 1. Upright position If the patient lies supine: There is pseudo-increase in the transverse diameter The level of the diaphragm may be deviated Note: the diaphragm upon CXR examination is usually described in halves. Right hemi-diaphragm th o Usually at the level of the 10 posterior rib o Can normally be higher than the left (due so the Liver being positioned on the Right side) Left hemi-diaphragm o Should not be higher than the Right

Inhale Deeply Take the X-ray at the end of a moderately deep inspiratory effort This is done to inflate the lungs o Demonstrate normal lucency Postero-Anterior The film is positioned in front of the patient The X-ray source is at the back of the patient o Lessens the Magnification of the Heart o Can be mistakenly interpreted as cardiomegaly Note: an x-ray is like casting a shadow, the greater the between the tube and the film, the lesser the magnification. The distance between the tube and the film determines magnification and clarity or sharpness. It is usually done at 6 feet.
(An AP film, taken from the same distance, which is 6 feet, enlarges the shadow of the heart - which is far anterior in the chest and makes the posterior ribs appear more horizontal)

Changes on the Chest X-ray corresponds to the air content of the lungs, specifically in the Acinus (which contain alveoli)

In CXR, The Lungs are referred to as: Upper Lobe and Lower lung Field (not lobe) They are separated by the minor fissure and the hila Because the middle lobe, lower lobes and lingual are superimposed on each other The Lower lung field will be divided by the oblique fissure and major fissure The lower lobes are more posteriorly located
The left image shows the right minor fissure (A) and the inferior borders (B) of the Major fissures bilaterally. The right image shows the superior border of the major fissures (B) bilaterally.

Companion Shadow Appearance of a smooth, homogenous, radiodensity with a well-defined margin that runs parallel with a bony landmark. They represent soft tissue that overlies the respective bony landmark in profile. They may or may not always be present. Rib companion shadow Scapular companion shadow Clavicular companion shadow

Azygous Fissure

Companion Shadow of the Clavicle. It is actually just soft tissue, and should not be mistaken for other abnormalities

Abnormal Density (Metallic Density); a slug of a bullet. Note: the density superior to the right clavicle (we can be able to determine if it is located outside of the thoracic cavity by tracing the outlines) this density is just actually the bandage of the patient (possibly from the bullets point of entry) Posteroanterior vs. anteroposterior radiograph. On the anteroposterior radiograph (A) of this normal patient, the detector is against the back of the patient. A combination of decreased distance between the source and the patient and increased distance between the detector and the anterior mediastinal structures compared with the posteroanterior radiograph (B) leads to magnification of the heart.

Apico-lordotic View Anteroposterior view of the chest Patient is in hyperextended position X-ray beam goes upward

Computed Tomography

Principles of computed tomography. The source of x-rays and The densities emanating from the ribs and clavicle will now be the detectors are on opposite sides of the gantry with the on the upper segments patient at the center of the gantry. Radiation that crosses the patient is detected, producing a projection of attenuation information. By rotating the gantry around the patient, multiple projections are obtained, which are then used to mathematically reconstruct tomographic attenuation images. Advantage: we can adjust the images and zero-in on specific structures Indications for Thoracic Computed Tomography o Pulmonary n Further characterize CXR abnormality (e.g., nodule, mediastinal mass) Lordotic view. In this patient with a left apical neurofibroma, n Detection and follow-up of neoplastic the abnormality is subtle on the posteroanterior radiograph disease (e.g., metastatic sarcoma, lymphoma) (A), but the lordotic view (B) improves visualization of the lung n Characterization of lung nodules apices, and the neurofibroma (asterisk) becomes more Benign vs. indeterminate apparent. n Parenchymal lung disease (e.g., emphysema, interstitial lung disease, infection) n Airway disease Central and peripheral airways n Pleural disease Empyema, metastasis, mesothelioma n Post-surgical complications n Percutaneous biopsy guidance n Localization for VATS o Cardiac n Cardiac abnormalities on CXR n Cardiac anatomy n Coronary arteries Calcification, patency with CTA Aberrant coronary arteries n Postcardiac bypass grafting complications Mediastinitis o Vascular n Aorta: aneurysm, trauma, dissection, coarctation n Pulmonary arteries: embolus, pulmonary hypertension n Venous: SVC/brachiocephalic vein thrombus or obstruction

 Computed tomography imaging. On a mediastinal window (A), the lungs are mostly black and the mediastinum and chest wall are emphasized. On a lung window (B), these structures are white and the fine structures of the lungs are emphasized. Lung nodule on computed tomography. The faint nodule projecting at the right lung base near the diaphragm (A) was further investigated by Computed Tomography, which revealed a calcified granuloma

Maximal intensity projection reconstructions. Information from a stack of images representing a volume can be combined into a single image representing for each pixel the maximum value of that pixel through the volume, shown here in the coronal (A) and sagittal (B) planes.

High resolution computed tomography allows exquisite visualization of the fine detail of the lung parenchyma in this patient with Langerhan's cell histiocytosis.

Three-dimensional reconstructions. Data can be further processed to produce three-dimensional images with shaded surface of any chest structure, such as the heart, mediastinum, lungs or ribs.

Coronal and sagittal reconstructions. Multiplanar reconstruction of the helical projection data in the coronal (A) and sagittal (B) planes can be performed. This improves visualization of some structures, such as the lung apices and the great vessels.

Magnetic Resonance Imaging (MRI)

Magnetic Resonance in the chest is only helpful as far as the mediastinum and the thoracic wall is concerned. The lung parenchyma is seen as low-signal areas because of the presence of air.

Magnetic properties of nucleus. A hydrogen nucleus has two important magnetic properties: a magnetic moment, represented by an arrow along its axis, and an angular momentum or spin. Indications for Thoracic Magnetic Resonance Imaging o Thoracic n Chest wall neoplasm (especially superior sulcus tumors) n Mediastinal tumors (e.g., bronchogenic cysts) n Lung parenchyma: limited, experimental n Thoracic outlet and brachial plexus o Cardiac n Congenital heart disease: shunts, complicated anatomy n Myocardium Cardiomyopathy Ischemic disease Hypertension Right ventricular dysplasia n Pericardium: thickening, effusion, tamponade, pericardial cyst n Masses: thrombus, tumors n Valves (limited): stenosis, regurgitation o Vascular n Aorta: aneurysm, trauma, dissection, coarctation n Pulmonary arteries: embolus, pulmonary hypertension n Venous: SVC thrombus or obstructionSVC, superior vena cava.

Magnetic resonance angiography. Magnetic resonance angiography of the aorta and its branches is useful to evaluate aortic dissection (A). Magnetic resonance angiography of the pulmonary arteries enables good visualization of the pulmonary arteries (B) and can be used to rule out pulmonary embolism.