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Transcript of Posteroanterior Projection1 Lateral Projection2 Right Anterior Oblique Projection 3 Left Anterior...
CHEST RADIOLOGY
Dr. Hari Soekersi, Sp.Rad.
Posteroanterior Projection1
Lateral Projection2
Right Anterior Oblique Projection3
Left Anterior Oblique Projection4
NORMAL FOUR VIEWS OF THE HEART
1. Right innominate vein2. Superior vena cava3. Right main branch of the pulmonary artery4. Upper and lower lobe veins5. Right atrium6. Tricuspid valve7. Inferior vena cava8. Arch of the aorta
9. Left main branch of the pulmonary artery10. Main pulmonary artery11. Left upper lobe vein12. Appendage of the left atrium13. Mitral valve14. Left ventricle15. Right ventricle
POSTEROANTERIOR PROJECTION
POSTEROANTERIOR PROJECTION
POSTEROANTERIOR PROJECTION
POSTEROANTERIOR PROJECTION
Right Atrium
Superior vena cava
Left Ventricle
Appendage of the left atrium
Pulmonary artery
Aorta
1. Superior vena cava2. Ascending aorta3. Main pulmonary artery4. Right atrium5. Tricuspid valve6. Right ventricle7. Aortic arch8. Left main branch of the pulmonary artery
9. Left atrium10. Mitral valve11. Left ventricle12. Descending aorta13. Inferior vena cava
LATERAL PROJECTION
LATERAL PROJECTION
LATERAL PROJECTION
LATERAL PROJECTION
Right Ventricle
Root of the main pulmonary artery
Left Ventricle
Left Atrium
Because these structures are in contact with mediastinal fat, their margin may be indistinct
1. Anterior wall of the trachea2. Innominate vein3. Anterior border of the superior vena cava4. Superior vena cava5. Right main branch of the pulmonary artery6. Thoracic aorta7. Left atrium8. Right atrium9. Inferior vena cava
10. Left innominate vein11. Arch of the aorta12. Left main branch of the pulmonary artery13. Main stem of the pulmonary artery14. Left main bronchus15. Tricuspid valve16. Mitral valve17. Right ventricle18. Left ventricle
RIGHT ANTERIOR OBLIQUE PROJECTION
RIGHT ANTERIOR OBLIQUE PROJECTION
1. Superior vena cava2. Right main branch of the pulmonary artery3. Ascending aorta4. Main pulmonary artery5. Right atrial appendage6. Tricuspid valve7. Right ventricle8. Left subclavian artery
9. Posterior border of the trachea10. Left main branch of the pulmonary artery11. Left main bronchus12. Left atrium13. Mitral valve14. Left ventricle15. Inferior vena cava
LEFT ANTERIOR OBLIQUE PROJECTION
LEFT ANTERIOR OBLIQUE PROJECTION
ANATOMY OF THE HEART
HISTOLOGY OF THE HEART
2. Myocardium of atrium
1. Endocardium of atrium
3. Annulus fibrosus
4. Mitral valve :a. Endocardiumb. Connective tissue
core
5. Chorda tendina
6. Endocardium of ventricle
7. Myocardium of ventricle
8. Purkinje fibers (conduction fibers)
10. Coronary artery
9. Plate A
11. Coronary sinus
12. Coronary vein with valve
13. Epicardium of atrium
14. Subepicardial connective tissue and fat
15. Perimysial septa with blood vessels
16. Epicardium and subepicardium of ventricle
17. Columnae carneae
18. Apex of papillary muscle
Analyze each case with six steps:
PLAIN FILMS DIAGNOSIS OF CARDIAC DISEASE
12
34 5
6
Analyze each case with six steps:
PLAIN FILMS DIAGNOSIS OF CARDIAC DISEASE
EVALUATION OF THE THORACIC CAGE FOR SIGN OF PREVIOUS SURGERY OR OTHER
ABNORMALITIES
IDENTIFICATION OF THE POSITION OF THE STOMACH BUBBLE AND HEPATIC SHADOW TO
DETERMINE BODY SITE
EVALUATION OF GREAT VESSELS FOR SIZE AND POSITION
EVALUATION OF SPECIFIC CHAMBER ENLARGEMENT
EVALUATION OF CARDIAC SIZE AND CONTOUR
EVALUATION OF PULMONARY VASCULARITY
Signs of previous surgery
- periosteal elevation- asymmetry thoracic cage- smaller and slightly deformed rib- resected rib in previous thoracotomy
EVALUATION OF THE THORACIC CAGE FOR SIGN OF PREVIOUS
SURGERY OR OTHER ABNORMALITIES
1
Congenital heart disease:
- premature fusion of sternum→ cyanotic form- hypersegmentation of sternum → Down’s syndrome
- bulging of sternum → enlarged right ventricle
EVALUATION OF THE THORACIC CAGE FOR SIGN OF PREVIOUS
SURGERY OR OTHER ABNORMALITIES
1
COMPLETE FUSION OF STERNAL SEGMENTS
HYPERSEGMENTATION OF THE STERNUM
ATRIAL SEPTAL DEFECT WITH ENLARGED RIGHT VENTRICLE AND
ANTERIOR BULGING OF THE STERNUM
Abnormal hepatic and stomach position show
abnormalities in position of the viscera congenital
cardiac disease
IDENTIFICATION OF THE POSITION OF THE STOMACH
BUBBLE AND HEPATIC SHADOW TO DETERMINE BODY SITE
2
SITUS SOLITUS WITH DEXTROCARDIA
Stomach bubble is under the left diaphragmLiver is on the rightHeart is on the right with cardiac axis directed to the right
SITUS INVERSUS WITH DEXTROCARDIA
Stomach bubble is under the right diaphragmLiver is on the leftHeart is on the right with cardiac axis directed to the right
ISOLATED LEVOCARDIA OR SITUS AMBIGUS
Stomach bubble is under the right diaphragmLiver is on the leftNormal heart position
DEXTROCARDIA
Dextrocardia :Location of the heart in the right side of the thorax, the apex pointing to the right
Dextroversion :Location of the heart in the right chest, the left ventricle remaining in the normal position on the left with the apex pointing the the left
DEXTROVERSION
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Enlargement of the pulmonary artery segmentProminent pulmonary arterial segment along the left upper cardiac borderIn TGV and truncus arteriosusabnormal position (concave)
Enlargement of the aortaThree portions of the aorta can be evaluated: ascending aorta, aortic arch dan descending aorta.
EVALUATION OF GREAT VESSELS FOR SIZE AND POSITION3
ENLARGEMENT OF PULMONARY ARTERY SEGMENT
TRANSPOSITION OF GREAT VESSELS
TRANSPOSITION OF GREAT VESSELS
TRUNCUS ARTERIOSUS
TRUNCUS ARTERIOSUS
ENLARGEMENT OF THE AORTA
Usually, the ascending aorta does not extend
beyond the right upper mediastinal shadow.Here, there is enlargement of the aorta.
Signs of left atrial enlargementSigns of left ventricular enlargementSigns of right atrial enlargementSigns of right ventricular enlargement
EVALUATION OF SPECIFIC CHAMBER ENLARGEMENT4
Posteroanterior projection1. Displace the barium-filled esophagus below the
carina to the right2. Prominent bulge along the mid-left cardiac border3. A double density along the right cardiac border4. Widening of the angle of the carina >900
Lateral projection1. Posterior displacement of both walls of the
barium-filled esophagus
SIGNS OF LEFT ATRIAL ENLARGEMENT
Left anterior oblique projectionElevate the left mainstem bronchus and obliterates the spaces between the posterior cardicac margin and the left mainstem bronchus
SIGNS OF LEFT ATRIAL ENLARGEMENT
LEFT ATRIAL ENLARGEMENT
Posteroanterior projection1. Left ventricular dilatation produces downward
displacement of the apex toward diaphragm.2. Left ventricular hypertrophy produces a round left
cardiac borderLeft anterior oblique projection
Posterior cardiac margin to overlap the vertebral column
SIGNS OF LEFT VENTRICULAR ENLARGEMENT
LEFT VENTRICULAR DILATATION
LEFT VENTRICULAR HYPERTROPHY
Posteroanterior projectionDifficult increased convexity of the lower right heart
border on PA projection
SIGNS OF RIGHT ATRIAL ENLARGEMENT
RIGHT ATRIAL ENLARGEMENT
SIGNS OF RIGHT VENTRICULAR ENLARGEMENT
Posteroanterior projectionRounding and elevation of the cardiac apexLateral projection
Retrosternal space is obliteratedLeft anterior oblique projection
Increased convexity of the anterior cardiac border
RIGHT VENTRICULAR ENLARGEMENT
Index of cardiac enlargement is the cardiothoracic ratio.In infants: 0.55In adults : 0.45The lateral and oblique views must be considered
EVALUATION OF CARDIAC SIZE AND CONTOUR5
CARDIOTHORACIC RATIO
(Cardiac width / Thoracic cage width) x 100%
In normal the pulmonary vascular marking taper gradually toward the periphery of the lung fields, and more prominent in the lower lung fields.The vessels in the right hillum is larger than in the left
EVALUATION OF PULMONARY VASCULARITY6
1. Normal pulmonary vascularity2. Increased pulmonary vascularity due to increased
pulmonary blood flow.- the peripheral arteries are sharply outlined and dilated and distributed equally to both the upper and lower lobes.- ex. VSD, PDA, truncus arteriosus, transposition of the great vessels.
SIX DIFFERENT VASCULAR PATTERNS ARE RECOGNIZED
3. Decreased pulmonary vascularity due to right-to-left shunts.- small pulmonary arterial segment- reduced diameter of the hilar pulmonary arteries- ex. Tetralogy of Fallot, tricuspid atresia,
pulmonary stenosis
4. Pulmonary venous congestion- occurs in condition that causes increased resistance distal to pulmonary capillaries- fluid accumulates in the interstitial tissues and Kerley B lines- ex. Mitral stenosis, acute left ventricular failure are common causes.
5. Bronchial collateral
6. A bizarre pattern of pulmonary vascularity- different vascular pattern in each lung
• Five factors influence the distribution of pulmonary blood flow.
• Interstitial osmotic and alveolar pressures remain constant throughout the lung
• Hydrostatic, pulmonary arterial and pulmonary venous pressures, diminish from base to apex because of gravitational effects.
• In left-sided cardiac failure, the increased pulmonary venous pressure resulting from the elevated left ventricular end-diastolic pressure
PULMONARY VASCULARITY IN LEFT-SIDED FAILURE
• The transudation of fluid into the pulmonary interstitium causes an increase in the interstitial pressure
• The earliest radiographic manifestation on left-sided cardiac failure is:1. An indistinctness of the vascular markings caused
by the increased interstitial fluids.2. The hilar vessels become enlarged and indistinct.3. The increased interstitial fluid can be seen as
‘peribronchial cuffing’.
• Later, ‘cephalization’ occurs. The vascular markings are prominent in the upper lobes owing to the constriction of the lower lobe vessels and redistribution of flow to the upper lobes.
• Pleural effusion occurs late• Transudation of fluid into the alveoli leads to pulmonar
edema. This appears in a perihilar location (‘butterfly wings’ or ‘bat wings’).
• Kerley B lines, due to fluid in the lobular septum.
Several non-cardiac causes as differential diagnosis of pulmonary edema:1. Uremia. Increased capillary permeability.2. Fluid overload. Decreased plasma osmotic pressure.3. Neurogenic. Altered capillary permeability or capillary pressure.4. Hypoproteinemia. Decreased plasma osmotic pressure.5. Transfusion and allergic reactions. Altered capillary
permeability.6. Inhalation of toxic gases. Altered capillary permeability
CEPHALIZATION
KERLEY B
KERLEY A, B, & C
• Kerley A : white arrow• Kerley B : white arrow head• Kerley C : black arrow head
EDEMA PARU INTERSTITIAL
EDEMA PARU ALVEOLAR
PULMONARY VASCULARITY IN PULMONARY HYPERTENSION
• Pulmonal artery segment dilatation• Right ventricular enlargement• Reduced bronchovascular marking
Mild PAH Severe PAH
1. Decrease bronchovascular marking
a) Acyanotic1. Pulmonary Stenosis (PS)
b) Cyanotica) Tetralogy Fallotb) Trilogy Fallotc) Atresia Pulmonald) Atresia Tricuspide) Ebstein Anomaly
CONGENITAL HEART DISEASE
2. Increase bronchovascular marking
a) Acyanotic1. Atrial septal defect (ASD)2. Ventricle septal defect (VSD)3. Right atrioventricular anomaly4. Patent ductus arteriosus (PDA)5. Partial Anomalous Pulmonary
Venous Return (PAPVR)
b) Cyanotic1. Total Anomalous Pulmonary
Venous Return (TAPVR)2. Truncus Arteriosus3. Transposition of the Great Vessels
(TGV)
PULMONARY STENOSIS
PULMONARY STENOSIS
Pulmonary stenosis make right ventricular resistancy increased, causing radiographic feature:• Right ventricular enlargement• Rounding and elevation of the cardiac apex• Bulging of pulmonary trunc• Bronkhovascular marking decreased
TETRALOGY FALLOT
TETRALOGY FALLOT
The malformation has four components:Right ventricular hypertrophy, Overriding aorta, Pulmonary stenosis, and Ventricular septal defectRadiographic features:• Right ventricular enlargement• Boot shape contour• Pulmonary artery segment concave• Right sided aortic arch• Pulmonary vascularity decreased
EBSTEIN ANOMALY
EBSTEIN ANOMALY
• Atrial septal defect• Displace tricuspid valveRadiographic feature:• Vary • Widening of right heart border• Rounded heart (cardiomegali all chamber)• Bronchovascular marking decreased
ATRESIA PULMONAL
ATRESIA PULMONAL
Radiographic feature:• Cardiomegali with oval heart contour• Bronchovascular marking decreased
ATRESIA TRICUSPID
ATRESIA TRICUSPID
• ~ Atresia pulmonal• Cardiomegali with oval heart contour• Pulmonary vascularity decreased
ATRIAL SEPTAL DEFECT
ATRIAL SEPTAL DEFECT
The feature related to how large the defect and the complication on the pulmonary vascularityRadiographic feature:• Right atrial enlargement, widening right heart border• Right ventricular enlargement, rounded and
elevation of the cardiac apex• Prominent conus pulmonalis, with widening of hillum• Bronchovascular marking increased• Signs of pulmonary hypertension
VENTRICULAR SEPTAL DEFECT
VENTRICULAR SEPTAL DEFECT
Radiographic feature:
• Small defect (Maladie de Roger)• Heart is not enlarged• Normal pulmonary vascularization
• Mild • Heart is enlarged to the left (left ventricle hypertrophy)• Apex downward to the diaphragm.• Right ventricle has not enlarged.• Left atrium dilated• Increase pulmonary vascularization.
VENTRICULAR SEPTAL DEFECT
Radiographic feature:• Moderate – Severe
• Right ventricle dilatation and hypertrophy.• Left atrium dilatation.• Widening of the pulmonary artery and its branches• Normal right atrium.• Left ventricle hypertrophy.• Small aorta.
• Pulmonary hypertension• Right ventricle is enlarged.• Pulmonary artery is widening with prominent of conus pulmonalis.• Normal left atrium.• Small aorta.• Decrease peripheral pulmonary vasculature.• Pulmonary emphysematous
PATENT DUCTUS ARTERIOSUS
PATENT DUCTUS ARTERIOSUS
• Small defect– Normal
• Moderate– Normal or mild enlargement of descendent aorta and
aortic arch.– Prominent of conus pulmonary.– Widening of the pulmonary artery and its branches.– Left atrial enlargement.– Right and left ventricle enlargement.
PATENT DUCTUS ARTERIOSUS
• Severe (pulmonary hypertension)– Enlarge central pulmonary vasculature.– Decrease peripheral pulmonary vasculature.– Prominent conus pulmonalis.– Widening of the ascendent aorta with prominent
aortic knob.– Normal left atrium.
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