Chest X ray

Mediastinum
COHS
February 2014
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

Lung zones
Pulmonary arteries
Many structures can be identified within
the mediastium;
Heart, blood vessels, main airways,
esophagus, lymph nodes, thymus ..
TWO SHADOWS/MAGNIFICATION
DISTANT STRUCTURES

SHADOWS MERGE
ADJACENT STRUCTURES
How many structures can you identify?
LV
RV
SVC
Aortic pulmonary
recess
Left
Aortic
arch
RA
LA
Right
pulmonary
artery
Right
pulmonary
artery
(lower lobe)
Vascular
pedicle
Postero-Anterior (PA) View
SVC
IVC
Postero-Anterior (PA) View
RA
Postero-Anterior (PA) View
RV
Postero-Anterior (PA) View
PA
Postero-Anterior (PA) View
LA
Postero-Anterior (PA) View
LV
Postero-Anterior (PA) View
Aorta
Postero-Anterior (PA) View
Postero-Anterior (PA) View
Right border
Superior vena cava
Right atrium
Inferior vena cava


Postero-Anterior (PA) View
Right border
Superior vena cava
Right atrium
Inferior vena cava

Left border
Aortic knob
Main pulmonary trunk
Left ventricle

Postero-Anterior (PA) View

Pulmonary Arteries
Right



Postero-Anterior (PA) View

Pulmonary Arteries
Right
Left




Postero-Anterior (PA) View

Pulmonary Arteries
Right
Left


Pulmonary Veins


LA
How many structures
can you identify?
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
Lateral View
RA
SVC
IVC
Lateral View
RV
Lateral View
Lateral View
LA
Lateral View
LV
Lateral View
Aorta
Lateral View
LV
Lateral View
Aorta


Main Pulmonary Artery


Inferior vena cava




Lateral View

Pulmonary Arteries
Left
Right

Pulmonary Veins



Which valve has been replaced?
Which valve has been replaced?
Aortic valve
Note the orientation of the
valve perpendicular to the
plane of the PA film.
Which valve has been replaced?
Which valve has been replaced?
Pulmonic
The pulmonary outflow
tract is more superior
and lateral than many
people think.
Last one, name the valves
Last one, name the valves
Aortic
Tricuspid
Mitral
Tricuspid
Mitral
Aortic
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.
Vascular
pedicle
Aortic
arch
Superior
vena cava
Intravascular volume
depletion
Intravascular volume
elevation
vs.
Vascular
pedicle
Vascular
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
Aorta
Superior
vena cava
Aorta
Trauma patient with an aortic transection
Note the vascular pedicles fuzzy, opacified right border.
What is happening here?
What is happening here?
Can you follow the heart borders?
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 the
effusion
effusion
effusion
Comparing this with older films can also help make the diagnosis.
Esophagus
Thyroid
Thymus
Lymph nodes

These are generally not seen unless there is
pathology
What could be the source of this anterior mediastinal mass?
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.
How about this one?
How about this one?
This patient has a an enlarged thyroid gland.
A. Anteriorposterior chest radiograph obtained on
supine position shows mediastinal widening with
enlarged and indistinct aortic knob and
aortopulmonary window opacification (a).
B. Contrast-enhanced axial
CT scan shows a rupture
of the aorta with a
pseudoaneurysm (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 Rupture Case 1. 68/M
C
A. Chest radiograph appears normal.
B. Tc
99m
MDP scan shows hot uptake at junction
between left 1
st
rib and manubrium.
C and D. Axial (C) and 3-D reconstruction (D) CT
scans reveal fracture of calcified left 1
st
costal
cartilage, just lateral to sternocostal joint.
A C
D
B
Case 1. 49/M
Fracture of the left 1
st
Costal Cartilage