THORAX

A normal chest x ray

Method for examining a CXR

start centrally and work out. the middle is the heart, which usually lies to the left and measures up to half of the total thoracic measurement in adults (more in children). Look carefully at the heart, and if the patient has had previous heart surgery you may see prosthetic valves or coronary stents. Next, look at the hilar region which is the region where the main vessels from the upper lobe and those from the lower lobe meet. The left should be higher than the right by about 2 cm, and they should be of equal size and density. The lungs should be fairly evenly dark, and areas of increased opacity may well reflect consolidation, but do not be fooled by breast shadows. The breasts are quite dense, especially in younger women Next, look at the ribs and soft tissues, making sure that both breasts are present. ( for women) Finally, look carefully at the areas above the clavicles and below the diaphragm, as free gas below the diaphragm--either postoperative or indicating bowel perforation--is best seen on an erect chest film. Do not forget to make sure that the film side marker is correct, as the commonest cause of diagnoses of dextrocardia is incorrect labelling.

42 y.o. male presents with acute SOB and has a CXR. What is the diagnosis? What would you do next?

40 year old female has onset of fever and shortness of breath. What are the findings and the most likely diagnosis? What other etiologies could give similar imaging appearances?

35 y.o female after a recent transatlantic flight presents with right sided pleuritic chest pain and severe shortness of breath. Does the CXR explain the shortness of breath? What are the various imaging investigations that can be performed for the clinical suspicion? Which concerns are there if the patient is pregnant

Signs in Thoracic Imaging

Different signs are used as clues to the characteristics and anatomy of the radiological findings

Silhouette sign
sign describes the observation that an intrathoracic lesion will obliterate borders of shadows of similar radiodense structures that it contacts example: right middle lobe pneumonia will obliterate apex of the right heart border

Silhouette sign

Normal

Pneumonia (+) silhouette sign (no heart silhouette)

Pulmonary edema + silhouette sign

Pneumonia - silhouette sign

Cervicothoracic sign
describes the finding that only structures seen in the posteriorly located apex of the lung are seen above the clavicles Also differentiates an intrathoracic soft tissue mass vs. soft tissue mass of the neck example: structures of the neck will appear cutoff in the lung anatomy above the clavicles

Air-bronchogram sign
Air-filled bronchi are normally not seen because they are surrounded by air-filled lung. If the lung is filled with a waterbased pathology (ie, pneumonia) the air filled bronchi will appear as radiolucent tubular densities transversing the lung.

Airbronchogram = Pneumonia

Air-space pattern of lung disease (notice the air-bronchogram of the right upper lobe)

Diseases of the airways

Atelectasis Bronchial Asthma Bronchiectasis Bronchopulmonary sequestration Congenital bronchogenic cysts Emphysema

Atelectasis

incomplete inflation of the lung involves lung, lobe, segment, or subsegment suggests presence of another disease radiographic findings: loss of pulmonary volume increased radiodensity distorted anatomical structures

Atelectasis of the right upper lobe caused by hilar mass high right hemidiaphragm elevated horizontal fissure reversed S configuration (s sign of Golden)

Emphysema (imaging findings)

bilaterally flat, depressed hemidiaphragm lung overinflation increased pulmonary radiolucency increased retrosternal space (>4.5cm) accentuated kyphosis increased intercostal spaces prominent hilar vasculature, decreased peripheral bullae

normal
emphysema

Bullous emphysema

Pneumonia (radiographic type)

*broncho (lobular) pneumonia (mc) alveolar and bronchial, central lobar pneumonia alveolar, peripheral interstitial pneumonia thickened interstitium aspiration pneumonia bilateral gravity dependent consolidation

pneumonia
where is the pneumonia located?

Tuberculosis (imaging findings)

primary infection often no radiographic findings lymphadenopathy with or without parenchymal consolidation; central lung typically resolve completely Ranke complex -hilar lymph node calcification with a parenchymal (Ghon) granuloma

Hilar LN Calcif and peripheral granuloma (ranke complex)

Pulmonary granulomas

Tuberculosis (imaging findings)

secondary infection = reactivation of previous primary infxn upper lobe distribution parenchymal involvement causes incomplete consolidation with strand-like radiodensities and cavitations Complication: superinfections by fungus

Tuberculosis (imaging findings)

secondary infection = reactivation of previous primary infxn upper lobe distribution parenchymal involvement causes incomplete consolidation with strand-like radiodensities and cavitations Complication: superinfections by fungus

Bronchitis 5 years before today

Patient Not Responding to Treatment

AIDS and Lung Disease

Tumors
n n

Kaposis Non-Hodgkins lymphoma

AIDS: Opportunistic Infections

Pneumocystis carinii (85%)

CMV-most frequent infection at autopsy

Mycobacterium (20%)
Avium-intracellulare (83%) Tuberculosis (9%)

CXR:Bilateral diffuse air-space opacities with cystic/cavitary lesions of varying size in a predominant perihilar distribution. The walls of these lesions appear thick.

ARDSyndrome

This CXR shows diffuse bilateral alveolar infiltrates similar to acute pulmonary edema of cardiac origin, except that the cardiac silhouette is usually normal. CXR changes often lag many hours behind functional changes and the hypoxemia may seem disproportionately severe compared to the edema observed by CXR.