Download Lecture - Radiology

M-1
CHEST
RADIOLOGY
Francis H. Neuffer, MD
USC-SOM
2009
Click for speaker notes
1
OBJECTIVES
 Understand chest X-ray anatomy
 Relate catheters and medical devices
to anatomy
 Identify landmarks at standard CT section levels
 Correlate common pathology to anatomy
2
NORMAL CHEST
X-RAY
PA
LATERAL
Two (2) projections are needed for most x-rays to locate structures in 3 planes
(1)Right or Left , (2) Anterior or Posterior) or (3) Superior or Inferior.
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NORMAL PEDIATRIC CHEST
WITH THYMUS
6 MONTHS OLD
Normal pediatric chests will often have thymic tissue which looks
masslike on a chest x-ray. This tissue involutes in the adult and is not
seen.
Adult chest
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NORMAL HEART
BORDERS
Note cardiac chambers that account for margins on the chest X-ray
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LEFT 4TH RIB
POSTERIOR AND ANTERIOR PORTIONS
POSTERIOR
4
ANTERIOR
P
A
6
LT.
Rib fracture on the left are associated with a small pleural effusion blunting the costophrenic
angle. Compare with normal RT. side.
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BRONCHOGRAM—CONTRAST OUTLINING AIRWAY
TRACHEA
LT. MAIN BRONCHUS
RT. MAIN BRONCHUS
CARINA
OBLIQUE FISSURE
major
OBLIQUE FISSURE
(major)
This exam shows barium contrast outlining the bronchial tree. This is an old exam not done now with CT
imaging replacing it. It does demonstrate the anatomy of the hila which is superimposed over the pulmonary
arteries and veins. This is why anatomy here on the chest X-ray is difficult in this region.
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ENDOTRACHEAL TUBE IN
POST OPERATIVE PATIENT
NOTE THE ENDO TRACHEAL TUBE!
Distal endotracheal tube in right main stem bronchus does not allows for ventilation of the left lung. The air in the left lung
is absorbed into the blood stream and the lung collapsed into an airless state without effective aeration. Prompt retraction
of the endotracheal tube will rectify this.
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NORMAL CHEST ANATOMY
LATERAL CHEST XRAY
Diaphragm-AP view
AORTIC ARCH
LT.
TRACHEA
HORIZONTAL
FISSURE
Diaphragm- Lateral view
OBLIQUE FISSURE
LT.
RT. HEMI
DIAPHRAGM
RT.
LT. HEMI DIAPHRAGM
LT.
COLON GAS
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FRONTAL
LATERAL
Air stripe
WHAT AND WHERE IS IT?
Coin in esophagus shows a wider diameter than possible in the trachea and is
posterior to the tracheal air stripe on the lateral chest x-ray.
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FISSURES DIVIDE
LUNGS INTO LOBES
RIGHT lung has:
UPPER
HORIZONTAL
FISSURE
MIDDLE
lobes
LOWER
LEFT lung has:
UPPER
lobes
LOWER
With heart failure edema builds up in lungs and edema along fissures allows them to be seen more easily
on chest x-ray
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Lt
NUCLEAR MEDICINE
LUNG SCANS
Nuclear medicine images are obtained using breathing of radioactive particles to assess ventilation and by
injection of radioactive particles to assess perfusion. Pneumonias would show a defect in ventilation and emboli
would show a defect in perfusion.
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MR
ARTERIOGRAM
FLOW
STUDY
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PULMONARY ARTERIOGRAM
CATHETER
LT. BRACHIOCEPHALIC
VEIN
LT. PULMONARY ARTERY
LT. UPPER LOBE
VESSELS
RT. UPPER LOBE
VESSELS
RT. MIDDLE LOBE
VESSELS
RT.
PULMONARY
ARTERY
MAIN
PULMONARY
ARTERY
RT. LOWER LOBE
VESSELS
LT. LOWER LOBE
VESSELS
Intravenous contrast has been injected from a catheter placed from a Lt. subclavian site with the tip of the catheter in the main
pulmonary artery. Rapid imaging while the opacified blood flows though the pulmonary arterial tree gives this image. It is used
to assess for pulmonary emboli due from blood clots migrating to the lungs. Typically these are from lower extremity venous
thrombi.
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INT. JUG. VEIN
PULMONARY ARTERY
CATHETER
SVC
PA
RT. PUL .ART.
RA
SWAN CATHETER
RV
Note that catheter extends distally into Rt. Ventricle into the Main pulmonary artery to the Rt. pulmonary artery. The catheter
crosses the tricuspid and pulmonary valves to reach the distal site.
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INT. JUG. VEIN
SUBCLAVIAN
VEIN
BRACHIOCEPHALIC VEIN
UPPER
EXTREMITY
VENOUS DRAINAGE
SVC
ELECTRODES
(NOTE CATHETERS)
The catheters are outlining the path of blood flow into the chest.
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RT. COMMON CAROTID
LT. COMMON CAROTID
LT. SUBCLAVIAN
ARTERY
RT. PUL
ARTERY
LT. PUL
ARTERY
AORTA
LT ATRIUM
SUBTRACTION IMAGE
AORTA
MR CONTRAST ARTERIOGRAM
Here a MR angiogram can show the aortic arterial flow and branches. Subtraction image is a catheter exam
showing flow . The bony structures are removed to better show vascular detail.
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OBLIQUE
ESOPHAGUS
TRACHEA
OBLIQUE
SPINE
BARIUM FILLED
ESOPHAGUS
The esophagus extends through the
chest. It is a muscular tube and
collapsed in the resting state. Here the
patient has ingested barium and is
rotated to the left to show the extent of
the esophagus without overlap of the
spine.
LEFT HEMIDIAPHRAGM
FUNDUS OF STOMACH
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X-RAY MAMMOGRAPHY
PATIENT
POSITIONING FOR
MAMMOGRAPHY
Marker is always put on the axillary side of the breast
This exam is done to screen for breast malignancy and assess palpable breast masses. In this exam
the darker tissue is fat and the lighter tissue is glandular and fibrous tissue. Masses show as focal
regions of lighter denser tissue.
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SCREENING MAMMOGRAPHY
VIEWS
MLO
FATTY TISSUE
CC
MUSCLE
CC VIEW
CRANIO - CAUDAL
GLANDULAR AND
FIBROUS TISSUE
MLO VIEW
Two images are obtained to assess tissue. A ”CC “or cranio-caudal image is a
top/down projection and a “MLO” medio-lateral oblique is a side/side image.
MEDIO-LATERAL OBLIQUE
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NORMAL CC
MAMMOGRAPHY
1.5 CM MASS
US = SIMPLE CYST
There is a rounded soft tissue mass medially in the breast. The mammogram cannot
separate solid and cystic lesions. The ultrasound demonstrates a benign breast cyst that
does not need biopsy.
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AORTA
Aorta
Pulmonary
artery
PA
RA
RV
LV
Left
Ventricle
Your hands function as a cardiac model. The fingers are the atria and the dorsum of the hand is the ventricle. The thumbs are
the pulmonary artery and the aorta. The arteries run along the knuckles and between the palms.
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NORMAL HEART
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PACEMAKER
WITH
RT. ATRIAL AND RT. VENTRICULAR LEADS
RA
RV
The pacemaker supplies an impulse to drive the heart rhythm if there is a conduction abnormality
in the normal course from the SA node to the AV node to the Bundle branches of the ventricles.
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TRICUSPID AND MITRAL VALVE
REPLACEMENT
ARROWS SHOW DIRECTION OF BLOOD FLOW THROUGH
VALVES FROM ATRIA TO VENTRICLES
T
T
M
M
Right to left
Posterior to anterior
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POST OP VALVE
REPAIR
M- MITRAL
A- AORTIC
A
M
Post surgical aortic and mitral valve repair are shown. Note the pulmonary
catheter does not go through either valve to get into the pulmonary artery.
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Pacemaker
Electrode
on skin
AORTIC AND PULMONARY
VALVE REPLACEMENT
P
A
Pacer in Rt.
Ventricle
Note position of valves relative to diagram and chest x-ray.
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CORONARY
ARTERY
ANATOMY
Note coronary arteries are in AV(atrioventricular) grooves and interventricular grooves.
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CORONARY
ARTERIES
RT.
LT.
LAD
CIRCUMFLEX
The right coronary artery is located in the groove of the RT. atria and Rt. ventricle extending to the base of heart. The left coronary artery
bifurcates into the left anterior descending which lies in the interventricular groove and the left circumflex which is in the Lt. atria/Lt.
ventricular groove. Coronary blood flows to the posterior descending coronary artery and is typically by the Rt. circulation. This is called
Rt. dominance. If the Lt circumflex artery feeds the vessel it is termed Lt. dominance.
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LAD
CORONARY
ARTERIOGRAM
CIRCUMFLEX
LEFT MAIN
ARTERIAL INJECTION
Coronary arteriogram -- left main coronary
artery injection
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CT THORACIC ANATOMY
LOOK AT AN XRAY AS IF THE
PATIENT IS LOOKING AT YOU.
LOOK AT A CT SCAN AS IF THE
PATIENT IS LYING ON THEIR BACK
AND YOU ARE LOOKING FROM
THEIR FEET TO THEIR HEAD.
CT images are viewed from the feet. Note RT/LT markers on images if
question remains.
Anterior projection
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RT
SCAN LEVELS
GREAT VESSELS
AORTIC ARCH
PULMONARY/CARINA
ATRIA
VENTRICULES
CT CHEST ANATOMY
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RT
RT
CT CHEST ANATOMY
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CHEST-- CT
RT
BRACHIOCEPHALIC ARTERY
SVC
TRACHEA
LT. COMMON CAROTID ART.
LT. SUBCLAVIAN ART.
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CT CHEST ANATOMY
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CHEST -- CT
INTERNAL MAMMARY (THORACIC)
ARTERY AND VEIN
SVC
AORTIC ARCH
ESOPHAGUS
SCAPULA
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CT CHEST ANATOMY
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CHEST -- CT
STERNUM
ASCENDING
AORTA
LT. PULMONARY
ARTERY
CARINA
DESCENDING
AORTA
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CHEST - CT
LT. ATRIUM
ASCENDING AORTA
RT ATRIUM
LT ATRIUM
DESCENDING
AORTA
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CT CHEST ANATOMY
43
CHEST -- CT
RT. VENTRICLE
SEPTUM
DOME OF DIAPHRAGM
LT. VENTRICLE
DESCENDING AORTA
44
INTERESTING CASES
INFECTION
NEOPLASTIC
CARDIOVASCULAR
TRAUMA
45
Right middle lobe pneumonia has changed the normal air density of the lung to soft tissue density of pneumonia. The borders
of the fissures are now clearly seen and the right heart border is no longer visualized since no air is there to outline it.
47
WHICH
LOBE?
Note how the Rt. upper
lobe(RUL) pneumonia shows
feature similar to the Rt. Middle
lobe(RML) disease.
48
Pneumonia compared with
normal thymus
NUCLEAR MEDICINE
FDG-PET SCAN
CXR
PET
The mass in the RT. upper chest shows increased signal on the nuclear medicine scan. This scan shows radioactive
glucose metabolism and indicates a lesion that is very active more so that normal tissue and supportive of malignancy.
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PULMONARY METASTATIC NODULES
Multiple lesions in the chest are typical for metastatic disease since the pulmonary capillary bed is often the first site
metastatic lesions appear as they spread and embolize the pulmonary capillaries and grow in the new location.
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NORMAL HEART
CARDIOMEGLY
CARDIOMEGLY
CONGESTIVE
HEART FAILURE
Evolution of congestive heart failure and pulmonary edema. With Progressive Lt. Ventricular failure blood backs into the left
atrium—then to the pulmonary veins (PULMONARY VENOUS HYPERTENSION) then to the pulmonary interstitium (INTERSTITIAL
EDEMA) then to the alveoli (ALVEOLAR EDEMA)
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CORONARY
ARTERIOGRAMS
NORMAL
ABNORMAL
Irregular atherosclerotic plaque in left anterior descending artery
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CORONARY
ARTERY STENTS
A catheter tipped balloon is used to dilate the vessel and
expand a wire stent to maintain the vessel lumen
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CHEST- POST – OP
CABG
ENDO TRACHEAL TUBE
CORNARY ARTERY BYPASS GRAFT
CATHETER ENTERS SKIN AT
LT SUBCLAVIAN VEIN
x
LT. BCV
RT SUBCLAVIAN VEIN
STERNAL WIRES
SVC
RT. PUL .ART.
PA
RA
CARDIAC
ELECTRODES
RV
LV
CATHETER PATH
SUBCLAVIAN VEIN
LT. BRACHIOCEPHALIC VEIN
SUPERIOR VENA CAVA
RIGHT ATRIUM
THROUGH TRICUSPID VALVE
RT VENTRICLE
PULMONARY ARTERY
RT PULMONARY ARTERY
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SAPHENOUS VEIN
GRAFT TO RIGHT
CORONARY ARTERY
3D CT MODEL OF
CORONARY ARTERIES
Median sternotomy is the surgical means to reach the coronary arteries. The narrowed vessels are bypassed with a
vein graft from the ascending aorta or by using the Internal Mammary (Thoracic) artery.
57
LEFT INTERNAL
THORACIC (MAMMARY)
ARTERY GRAFT
APPLIED
SURGICAL
CLIPS
The metallic clips identify the internal mammary artery and are branches that
have been ligated to direct blood flow into the distal diseased coronary vessel.
RADIOLOGY
7/2008
58
PNEUMOTHORAX
Air in the pleural space separates the visceral and parietal pleura. This limits effective ventilation of the lung
59
TENSION PNEUMOTHORAX
PRESSURE INCREASE
RESTRICTS VENOUS
RETURN CAUSING
CARDIOVASCULAR
COLLAPSE
Here air has built up under pressure in the pleural space and collapsed the lung severely compromising ventilation. The
pressure builds due to a ball valve type leak of air into the pleural space with air going into the space on each inspiration.
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PNEUMOTHORAX
PLEURAL
EFFUSION
PLEURAL
EFFUSION
NORMAL
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LARGE LEFT
EFFUSION
CT SCAN
63
CHEST TUBES IN
PLEURAL SPACE TO
EVACUATE AIR / FLUID
AND RE-EXPAND LUNG
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WHO DREW THIS PICTURE ?
65
THERE IS ONE MEDICAL STUDENT IN THIS PICTURE.
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