RADIOLOGI

THORAX

Sumarsono
• Lateral decubitus position:
It is helpful to assess the volume of
pleural effusion and demonstrate
whether a pleural effusion is mobile or
loculated.

Lateral decubitus position film showing mobile pleural effusion (arrows)

•
Dasar
Sinar-X :
Citra/Gambar

Jaringan Densitas Jaringan Gambaran

Logam Metal Desity Hyper radiopak
Tulang Bone Density Radioopak
Cairan Water Density Intermediate
Lemak Fat Density Radiolusen
Udara/Gas Air Density Hyper Radiolusen
 Five Radiographic Opacities

Air Fat Soft tissue Bone Metal

least opaque to most opaque

most lucent to least lucent
Black to White
Radiographic Opacities & Contrasts

Air Air
Fat Mineral oil
Water Water
Bone Tums
Metal ???
 Tujuan pemeriksan foto toraks
• Menilai jantung, misalnya :
kelainan letak jantung, pembesaran
atrium atau ventrikel, pelebaran dan
penyempitan
aorta.

• Menilai kelainan paru, misalnya

edema paru, emfisema paru,
tuberkulosis paru.
• Menilai adanya perubahan pada
struktur ekstrakardiak.
• Gangguan pada dinding toraks •
Fraktur iga • Fraktur sternum
• Gangguan rongga pleura •
Pneumotoraks • Hematotoraks • Efusi
pleura
• Gangguan pada diafragma • Paralisis
saraf frenikus
• Menilai letak alat-alat yang dimasukkan
ke dalam organ di rongga toraks
misalnya: EET, CVP, NGT dll
 SYARAT FOTO THORAX YANG
BAIK
• 1. FULL INSPIRASI
• 2. TIDAK ADA TUMPANG TINDIH
• 3. SIMETRIS
• 4. KONDISI FOTO BAIK
• 5. REPRESENTATIF
Thorax Normal
Chest breast implants
Normal Anatomy
Anatomi Thorax, PA
Anatomi Thorax, Lateral kiri
Gambaran Thorax Normal
Posisi Posteroanterior &
Lateral
• Pada Foto thorax
normal, hal-hal yang
perlu diperhatikan
adalah :
1. Posisi
2. Simetrisasi
3. Inspirasi
4. Kondisi
The right upper lobe (RUL) occupies the upper 1/3
of the right lung.
Posteriorly, the RUL is adjacent to the first three to
five ribs.
Anteriorly, the RUL extends inferiorly as far as the
4th right anterior rib
 The right middle lobe is typically the
smallest of the three, and appears
triangular in shape, being narrowest near
the hilum
 RIGHT LOWER LOBE
 The right lower lobe is the largest of all three lobes,
separated from the others by the major fissure.
 Posteriorly, the RLL extend as far superiorly as the 6th
thoracic vertebral body, and extends inferiorly to the
diaphragm.
 Lung Anatomy on Chest X-ray

 These lobes can be

separated from one
another by two fissures.
 The minor fissure
separates the RUL from the
RML, and thus represents
the visceral pleural
surfaces of both of these
lobes.
 Oriented obliquely, the
major fissure extends
posteriorly and superiorly
approximately to the level
of the fourth vertebral
body.
No defined left minor fissure, there are only two lobes on the left;
the left upper lobe and left lower lobe.
 The 12-Step Program

• 1: Name
• 2: Date
• 3: Old films
} Pre-read

• 4: What type of view(s)

•
•
•
5: Penetration
6: Inspiration
7: Rotation
} Quality Control

•
•
•
•
8: Angulation

10: Mediastinum
11: Diaphragms
}
9: Soft tissues / bony structures Findings

• 12: Lung Fields

 The 12-Step Program

• 1: Name
• 2: Date
• 3: Old films
} Pre-read

• 4: What type of view(s)

•
•
•
5: Penetration
6: Inspiration
7: Rotation
} Quality Control

•
•
•
•
8: Angulation

10: Mediastinum
11: Diaphragms
}
9: Soft tissues / bony structures Findings

• 12: Lung Fields

 Pre-Reading

• 1. Check the name

• 2. Check the date
• 3. Obtain old films if available

• 4. Which view(s) do you have?

• PA / AP, lateral, decubitus, AP lordotic
 Quality Control

• 5. Penetration

• Should see ribs

through the heart

• Barely see the

spine through the
heart

• Should see
pulmonary vessels
Overpenetrated Film
• Lung fields darker than
normal—may obscure
subtle pathologies
• See spine well beyond the
diaphragms
• Inadequate lung detail
 Underpenetrated Film
•Hemidiaphragms are obscured
•Pulmonary markings more prominent than they actually are
 Quality Control
1
• 6. Inspiration 2

4
• Should be able to
count 9-10 5

posterior ribs 6

• Heart shadow 8

should not be
9
hidden by the 10
diaphragm
 Poor inspiration
can crowd lung
markings
producing pseudo-
8
airspace disease

About 8 posterior ribs are showing

With better inspiration, the

“disease process” at the
lung bases has cleared
9

9-10 posterior ribs are showing

 Quality Control

• 7. Rotation

• Medial ends of
bilateral clavicles
are equidistant
from the midline or
vertebral bodies
 If spinous process appears closer to the right clavicle (red
arrow), the patient is rotated toward their own left side

If spinous process appears closer to the left clavicle (red arrow),

the patient is rotated toward their own right side
 Quality Control

• 8. Angulation 1
2

• Clavicle should
lay over 3rd rib
 AP versus PA
The Effect of Magnification

AP portable film makes the On this PA film done on the

heart look larger than it does… same patient an hour later
 kondisi

You should be able to

just see the thoracic
spine through the
heart.
 Penetration
With correct exposure you should
barely see the intervertebral disc
through the heart

• If you see them very

clearly the film is
overpenetrated

• If you do not see them

it is underpenetrated
Penetration
 TERPOTONG ATAU TIDAK

DASAR PENILAIAN:
• SUPERIOR:
TAMPAK APEKS PARU DAN VERTEBRA
CERVIKALIS VI/VII
• INFERIOR:
SINUS COSTOPHRENICUS DAN DIAFRAGMA
• SAMPING KANAN DAN KIRI:
AXILLA TAMPAK
 IDENTITAS

• IDENTITAS SISI
MARKER (L ATAU R)

• IDENTITAS REGISTRASI
NAMA, UMUR, NO. REGISTER,TANGGAL FOTO

LAYAK / TIDAK ?
 BAGAIMANA
membedakan sisi kiri dan kanan
How to read the film correctly
 Now for the Cases…

Remember… be systematic!
 Hal-hal yang harus diperhatikan
dalam Pembacaan Foto Polos
Thorax
a. Jaringan lunak, tulang
b. Corakan bronkhovaskuler
c. Parenkim paru Keadaan hilus
d. Sinus costofrenikus
e. Diafragma
f. Cor : CTR
 Viewing PA radiograph of the chest

Hilar region:
• Both hila should be
concave.
• Both hila should be of
similar density.
• The left hilum is usually
superior to the right by up
to 1 cm.
 Viewing PA radiograph of the chest

Bones and soft tissue:

• Ribs (anterior and
posterior)
• Clavicles
• Vertebrae
• Shoulder joints
• Look carefully at the soft
tissues for asymmetry (i.e.
mastectomy)

Ribs
Viewing PA radiograph of the chest

Don’t Forget to look at hidden areas

Normal PA View of the chest
 COMMON SIGNS IN CHEST
RADIOLOGY
• Silhouette sign
• Air bronchogram sign (ABS)
• Solitary pulmonary nodule
SILHOUETTE SIGN
Lung Fields: Using Structures /
Silhouettes
Silhouette / Structure Contact with Lung
Upper right heart Anterior segment of RUL
border/ascending aorta (right upper Lobes)
Right heart border RML (right medial lobes)
Upper left heart border Anterior segment of LUL
Left heart border Lingula (anterior)
Apical portion of LUL
Aortic knob
(posterior)
Anterior hemidiaphragms Lower lobes (anterior)
 Lung Fields: Using Structures /
Silhouettes
Upper right heart
border / Aortic knob
ascending aorta (Apical portion
(anterior RUL) of LUL )

Upper left
Right heart border heart border
(medial RML) (anterior
LUL)

Left heart
border
Anterior (lingula;
hemidiaphragms anterior)
(anterior
lower lobes)
 Lung Fields: Fissures

• The fissures can also help you to

determine the boundaries of pathology

Major Oblique Fissure Separates the LUL from the LLL

Separates the RUL/RML from
Right Major Fissure
the RLL
Separates the RUL from the
Right Minor Fissure
RML
 Silhouette Sign

• Hilangnya the lung/soft tissue interface

disebabkan adanya cairan dalam paru
yang normalnya adalah udara
• If an intrathoracic opacity is in
anatomic contact with a border, then
the opacity will obscure that border
• Sering terlihat dengan perbatasan
jantung , aorta , dinding dada , dan
diafragma
SILHOUETTE SIGN
 Air Bronchogram Sign (ABS)

Sebuah garis tubular dari saluran napas dibuat

terlihat karena pengisian alveoli sekitarnya
dengan eksudat cairan atau inflamasi

Terlihat pada :
• Lung consolidation
• Pulmonary edema
• Non-obstructive pulmonary atelectasis
• Interstitial disease
• Neoplasm
• Normal expiration
AIR BRONCHOGRAM
AIR BRONCHOGRAM
AIR BRONCHOGRAM
SOLITARY PULMONARY
NODULE
 KEDUA APEKS PARU

PENILAIAN :
• TENTUKAN LOKASI APEKS PARU
• GAMBARAN APEKS

INTERPRETASI
• APEKS TENANG/ BERSIH
• APEKS TERDAPAT INFILTRAT ( UKURAN DAN
BENTUK, DENSITAS)
 KEDUA APEKS PARU

APEKS TENANG TERDAPAT PENINGKATAN DENSITAS

DI APEKS KANAN
 CORAKAN
BRONKHOVASKULER
• CARA PENILAIAN
BAGI PARU DARI TEPI MENJADI 3, LIHAT BAGIAN 1/3
LATERAL

• NORMAL :
CORAKAN BRONKHOVASKULER TIDAK MELEBIHI 2/3 MEDIAL
(1/3 LATERAL TAMPAK BERSIH)

• INTERPRETASI:
NORMAL /MENINGKAT
 CORAKAN
BRONKHOVASKULER

NORMAL MENINGKAT
 PARENKIM PARU
GAMBARAN PARENKIM PARU

APABILA TERDAPAT INFILTRAT:

TENTUKAN :
LOKASI, UKURAN, JUMLAH, BENTUK
PARENKIM PARU
 SINUS COSTOPHRENICUS

INTERPRETASI
• LANCIP ATAU TUMPUL
• NORMAL : LANCIP
• BILA TUMPUL PASTIKAN ADA
KELAINAN ATAU TERPOTONG
 SINUS COSTOPHRENICUS

TERPOTONG EFUSI PLEURA

 Normal R costophrenic angle Blunted L costophrenic angle

When 200-300cc of fluid accumulate in pleural space, the usually acute

costophrenic angle (sulcus), as seen on the right in this person,
becomes blunted (as seen on the left in this person)
 DIAFRAGMA

NORMAL :
• Kanan lebih tinggi dari kiri (jantung
menekan)
• Selisih <3 cm)/ atau sebagai patokan tidak
lebih dari 2 vertebra
• Licin
 Viewing PA radiograph of the chest

Pleura and Diaphragm:

• The highest point of the right diaphragm is usually
1–1.5 cm higher than that of the left.
• Each costophrenic angle should be sharply outlined.
 Viewing PA radiograph of the chest

Pleura and Diaphragm:

• Assessment of diaphragmatic flattening
• The highest point of a hemidiaphragm should be at
least 1.5 cm above a line drawn from the
cardiophrenic to the costophrenic angle.
 JANTUNG

• Size
• Shape
• Silhouette-margins should be sharp
• Diameter (>1/2 thoracic diameter is
enlarged heart)

Remember: AP views make heart appear larger than it

actually is.
 Cardio-thoracic ratio
• seen on postero-anterior
CTR = B/A x 100% (PA) view only
• >50% is considered
abnormal in an adult; more
than 66% in a neonate.
• Possible causes of a ratio
greater than 50% include:
• cardiac failure
• pericardial effusion
• left or right ventricular
hypertrophy

*AP views make heart appear larger than it actually is.*

Sometimes, CTR is more than 50%
But Heart is Normal

 Extra-cardiac causes of
cardiac enlargement
 Portable AP films
 Obesity Flat / elevated
diaphragm
 Pregnancy
 Ascites
 Straight back syndrome
 Pectus excavatum
Sometimes, CTR is less than 50%
But Heart is Abnormal

 Obstruction to outflow of the ventricles

 Ventricular hypertrophy

 Must look at cardiac contours

Sometimes, CTR is more than 50%
But Heart is Normal

 Extra-cardiac causes of
cardiac enlargement
 Portable AP films
 Obesity Flat / elevated
diaphragm
 Pregnancy
 Ascites
 Straight back syndrome
 Pectus excavatum
 >50%

Here is a heart that is larger than 50% of the cardiothoracic ratio, but it is still a normal heart.
This is because there is an extracardiac cause for the apparent cardiomegaly. On the lateral
film, the arrows point to the inward displacement of the lower sternum in a pectus excavatum
deformity.
Enlarged or not?

Yes
Enlarged or not?

Yes
Enlarged or not?

No
 Contoh Pembacaan
Foto Thorax Normal
• Foto Thorax PA,errect,simetris, inspirasi
dan kondisi cukup
• Tidak ada soft tissue swelling
• Sistema tulang intak
• tampak kedua apex paru tenang
• tampak corakan bronkhovaskuler di kedua
lapangan paru normal
• sinus costophrenicus kanan-kiri lancip
• Diafragma kanan dan kiri licin
• Cor : CTR kurang dari 0,56
CONTOH GAMBARAN
THORAX ABNORMAL
 Abnormal Chest X-ray

• Radiopacity (whiteness) = increased density

• Radiotranslucency (blackness) = decreased
density
 Radiopacity
Alveolar Pattern Interstitial Pattern Vascular pattern
• Halus, lembut , •konsolidasi • If there is an
batas-batas tidak jaringan interstitial increase in size
jelas opacifications of the pulmonary
< 1cm diameter • Kelihatan seperti arteries as they
ranting-ranting yang extend out into lung
• Possible causes: menyebar ke perifer – pulmonary
1. Pulmonary Paru hypertension
edema
2. Viral pneumonia • Possible causes: • Jika
3. Pneumocystis 1. Interstitial ada penurunan
4. Alveolar cell pneumonitis ukuran, pemotongan
carcinoma 2. Pulmonary , atau penghapusan
fibrosis (obliterasi) dari arteri
pulmonalis :
embolus

• Lack of vascular
marking in the
periphery
– pneumothorax
The PATTERNS

Too dense
Too lucent
 Lung: Too DENSE

• Alveolar pattern
• Interstitial pattern
• Masses
 Lung: Alveolar Pattern

• Something of unit/soft tissue/water

density replaces the air in the alveolar
ducts, alveolar sacs and the alveoli
 Alveolar Lung Pattern: causes

• PUS
• WATER
• BLOOD
• Lymphoma
• BAC
• Alveolar proteinosis
 Alveolar Lung Pattern: findings

• Increased density
• Confluence
• Ill defined margins
• Air bronchograms
Lung: Interstitial Pattern

SUATU PENEBALAN
interstitium of the lung
parenchyma
 What?

• Edema
• Inflammatory cells
• RBC’s
• Malignant cells
• Fibrosis
 How?

All of them ADD tissue to the

peripheral and axial interstitium
of the secondary pulmonary
lobule
Secondary Pulmonary Lobules
 Who?

• Many, many diseases present with the

same interstitial patterns
• You need history, lab, and frequently
biopsy to make a specific diagnosis
 The Interstitial Patterns

• Lines: fine, medium, or coarse

• Nodules: tiny to 3 cm
• Reticular: network of crossing lines
• Reticular-nodular: lines and nodules
Lines
Nodules
Reticular pattern
Lines and nodules
 What do they mean?

• Garis kasar berarti fibrosis , juga

disebut " pola sarang lebah “
• The other patterns usually mean more
active disease, but aren’t specific
 Kerley lines, A and B

• Thickened secondary lobule septae

• Often, but not always due to CHF
• Basically, they are just a slightly
specialized intertstitial linear pattern
• A and B differ only by location
PARU-PARU
 Consolidation

Paru dikatakan konsolidasi ketika alveoli

dan saluran udara kecil diisi dengan bahan
padat

Bahan padat ini dapat terdiri dari :

• Pus (pneumonia)
• Fluid (pulmonary edema)
• Blood (pulmonary hemorrhage)
• Cells (cancer)
Consolidation
• Lobar consolidation:
– Alveolar space filled with
inflammatory exudate
– Interstitium and
architecture remain intact
– The airway is patent
– Radiologically:
• A density corresponding
to a segment or lobe
• Air bronchogram, and
• No significant loss of lung
volume
Consolidation
 Atelectasis
• Terdapat bayangan lobus yang kolaps
• Ditemukan tanda “silhouette”
• Pergeseran struktur untuk mengisi
ruangan yang normalnya ditempati
lobus yang kolaps
• Pada kolaps keseluruhan paru :
keseluruhan hemithorax tampak
opaque dan ada pergeseran hebat pada
mediastinum dan trachea
 Pneumonia

Typical findings on the chest radiograph

include:

• Airspace opacity

• Lobar consolidation

• Interstitial opacities
 Lung pathologies

White Lung field Black lung Field

Well defined ill defined( TIDAK

(JELAS) JELAS)
 Collapse  Consolidation
 Pleural Effusion  Fifrosis
 Pulmonary Edema
 Infiltration
Well-Defined

Calcification

ill-Defined Mass
Pulmonary Fibrosis
Cavitating lesion
Miliary shadowing
 BRONCHITIS AKUT

• corakan
bronkovaskular
meningkat di kedua
lapang paru
Untuk kronik
• diafragma letak
rendah
• jantung terdrop
 Chronic Obstructive Pulmonary
Disease (COPD)
• Kedua lapangan paru terlihat
lebih hitam dan lebih besar
secara volume
• Diafragma letak rendah
sehingga jantung seolah
tergantung
• Hemidiafragma terlihat rata
• Lebih sedikit pembuluh
darah yang terlihat secara
peripheral terutama di
bagian atas dan tengah
• arteri pulmonari terlihat
besar di pertengahan
 Pneumoni
air bronchogram sign

1. Berawan/Perselubungan, lokasi bisa diatas,

ditengah, maupun di lapangan bawah paru,.
2. ABS (+).
3. Volume paru tidak berubah
 Pneumotorax
Pneumothorax adalah suatu keadaan dimana udara terkumpul di dalam
cavum pleura sehingga memisahkan pleura visceral dari pleura parietal.

• gambarannya
Hiperadiolussen
avascular,
• diafragma normal
Expiration reduces lung volume,
making a small pneumo easier to
see
Efusi Pleura
PLEURAL DISEASE
PLEURAL DISEASE
Hemothoraces
 Hemothorax

Supine Upright
 TBC
• 1. TBC Aktif : Bercak, berawan/nodular
cavitas (area rongga terisi gas berbatas
putih).
2. TBC Lama Tenang : Bintik kalsifikasi,
fibrosis.
3. TBC Lama Aktif : bila terdapat minimal 1
tanda kategori 1 dan minimal 1 tanda
kategori 2 dengan lokasi di apex paru.
• : Lokasi utama di apex paru, dengan kata lain
bila perselubungannya tidak terdapat di apex
paru, maka suspek TBC bisa dihilangkan
TBC
 EDEMA PARU
• jantung membesar
• hilus yang melebar
• pedikel vaskuler dan vena azygos yang
melebar
• ABS
• “silhouette sign” yaitu hilangnya visualisasi
bentuk diafragma atau mediastinum
berdekatan
• adanya garis kerley A, B dan C akibat edema
interstisial atau alveolar
• Garis kerley A : garis linear panjang yang
membentang dari perifer menuju hilus yang
disebabkan oleh distensi saluran anastomose antara
limfatik perifer dengan sentral.
• Garis kerley B terlihat sebagai garis pendek dengan
arah horizontal 1-2 cm yang terletak dekat sudut
kostofrenikus yang menggambarkan adanya edema
septum interlobular.
• Garis kerley C berupa garis pendek, bercabang
pada lobus inferior
EDEMA INTESRTITIAL
• Infiltrat di daerah
basal (edema basal
paru)
• Edema “ butterfly”
atau Bat’s Wing
(edema sentral
NO. Gambaran Edema Kardiogenik Edema Non
Radiologi Kardiogenik
1 Ukuran Jantung Normal atau Biasanya Normal
membesar
2 Lebar pedikel Normal atau melebar Biasanya normal
Vaskuler
3 Distribusi Vaskuler Seimbang Normal/seimbang

4 Distribusi Edema rata / Sentral Patchy atau

perifer
5 Efusi pleura Ada Biasanya tidak
ada
6 Penebalan Ada Biasanya tidak
Peribronkial ada
7 Garis septal Ada Biasanya tidak
ada
8 Air bronchogram Tidak selalu ada Selalu ada
Metastatic Lung Cancer: multiple nodules seen
Lateral Decubitus view
JANTUNG
 Jantung : Cardiomegali

• Apex cordis tergeser kebawah kiri pada

pembesaran Ventrikel kiri
• Apex cordis terangkat lepas dari
diafragma pada pembesaran ventrikel
kanan
• SVC: superior vena cava; PA: pulmonary
arteries, RA: right atrium; RV: right
ventricle; IVC: inferior vena cava
Ao: Aorta, , Lau: auricle of the left atrium, which itself sits posteriorly at
the base of the heart. PV: Vena pulmonary converging on the left atrium.
Mitral Stenosis

shows a prominent
left atrial
appendage caused
by pressure
overload of the left
atrium.
 0 mm 15 mm
Ao
Ao

Main
Pulmonary
Artery
Main
Pulmonary
Artery

LV

LV
Main pulmonary
artery ranges from
0 mm–15mm
from tangent line
Heart failure

showing
pulmonary edema
with Kerley lines
and perihilar
engorgement.
 Congestive Heart Failure
• Increased heart size:
cardiothoracic ratio >0.5
 Large hila with
indistinct markings
 Cephalization
 Fluid in interlobar
fissures
 Pleural effusions,
alveolar edema
Congestive Heart Failure

 Alveolar edema
(Bat’s wings)
 Kerley B lines
(Interstitial edema)
 Cardiomegaly
 Dilated prominent
upper lobe vessels
 Pleural effusion
Venous Hypertension
RDPA usually
> 17 mm

Upper lobe
vessels equal
to or larger
than size of
lower lobe
vessels =
Cephalization
 PERICARDIAL EFFUSION

• jantung
membesar
berbentuk
globuler (water
bottle SIGN)
• baru tampak jika
cairan lebih dari
250ml
DEXTRA CARDIA
 Pericardial pathology
pericardial effusion

after pericardiocentesis dan

thoracentesis
Congenital cardiovascular
anomalies
dextrocardia with complete situs inversus