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Mukbil Hourani M.D.
AUBMCDiagnostic Radiology
Introduction to CXRand
Chest CT
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Objectives
Technique Learn the difference
between PA vs. AP CXR Learn the utility of a
lateral decubitus CXR
Anatomy Learn the basic anatomy of
the fissures of the lungs,heart borders, bronchi, andvasculature that can beseen on a chest x-ray and
CT Interpretation Develop a consistent
technique Learn the silhouette sign
Pathology Learn the concept of
atelectasis and the abilityto recognize it on a chestx-ray
Appreciate the appearanceof pulmonary edema Appreciate the difference
findings of atelectasis andpneumonia
Recognize pleural effusions
and pneumothorax Recognize the signs of
COPD Pulmonary nodules & masses Others.
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PA View
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Lateral View
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Ribs and Diaphragm
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Postero-anterior or Antero-posterior
PA AP
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Inspiration
-The patient should be examined in full inspiration.
-The diaphragm should be found at about the level
of the 8th - 10th posterior rib or 5th - 6th anterior rib
on good inspiration.
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Right and Left Upper Lobes
Right Middle Lobe
Right and Left Lower Lobes
Left Upper Lobe
Major Fissure
Left Lower Lobe
Right Upper Lobe
Minor or Horizontal
Fissure
Right Middle Lobe
Major Fissure
Right Lower Lobe
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Right Lung containing:
RUL: Apical Segment
RUL: Posterior Segment
RUL: Anterior Segment
RML: Lateral Segment RML: Medial Segment
RLL: Anterior Basal Segment
Left Lung containing:
LUL: Apical Posterior Segment
LUL: Anterior Segment LUL: Lingula Superior Segment
LUL: Lingula Inferior Segment
LLL: Anteromedial Segment
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CT Anatomy
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CT Anatomy
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CT Anatomy
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CT Anatomy
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CT Anatomy
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Pulmonary Vasculature
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Fissures
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Lobes and Fissures
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Lobes and Fissures
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How to Read a Chest X-Ray
Patient Data (name history #, age, sex, old films) Routine Technique: AP/PA, supine or erect Trachea: midline or deviated, caliber, mass Lungs: abnormal shadowing or lucency Pulmonary vessels: vascular enlargement Hila: masses, lymphadenopathy Heart: thorax: heart width > 2:1 ? Cardiac configuration? Mediastinal contour: width? mass? Course of aorta Pleura: effusion, thickening, calcification Bones: lesions or fractures
Soft tissues: dont miss a mastectomy ICU Films: identify tubes first and look for pneumothorax
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Looking for Abnormalities
Do a directed search of the chest film
rather than simply gazing at the film
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Silhouette Sign
One of the most usefulsigns in chest radiology
Described by Dr. BenFelson
The silhouette sign is inessence elimination ofthe silhouette or loss oflung (air)/soft tissueinterface caused by amass or fluid in the
normally air filled lung.
If an intrathoracic opacityis in anatomic contact withthe heart border, then theopacity will obscure thatborder.
The sign is commonlyapplied to the heart, aorta,chest wall, and diaphragm.
The location of thisabnormality can help to
determine the locationanatomically.
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Which lobe is it?
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Silhouette Sign
For the heart, the silhouettesign can be caused by an opacityin the RML, lingula, anteriorsegment of the upper lobe, and
anterior portion of the pleuralcavity.
This contrasts with an opacity inthe posterior pleural cavity,posterior mediastinum, or lower
lobes which cause an overlap andnot an obliteration of the heartborder.
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Silhouette Sign
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Silhouette Sign
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Air Bronchogram
Is a tubular outline of anairway made visible byfilling of the surroundingalveoli by fluid orinflammatory exudates
Six causes of airbronchograms are; lung consolidation, pulmonary edema, nonobstructive pulmonary
atelectasis, severe interstitial disease, neoplasm, and normal expiration.
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Atelectasis
Collapse or incompleteexpansion of the lung orpart of the lung
Often caused by anendobronchial lesion,
such as mucus plug ortumor
Extrinsic compressioncentrally by a mass suchas lymph nodes or
peripheral compressionby pleural effusion
Atelectasis is almostalways associated with alinear increased densityon chest x-ray
Indirect signs of volume
loss include vascularcrowding or fissural,tracheal, or mediastinalshift, towards thecollapse.
Segmental andsubsegmental collapsemay show linear,curvilinear, wedgeshaped opacities. This ismost often associatedwith post-op patients
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LLL Collapse
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RUL Collapse
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RML Collapse
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Pulmonary Edema
Two basic types ofpulmonary edema. cardogenic edema caused
by increased hydrostaticpulmonary capillary
pressure. noncardogenic pulmonary
edema, and is caused byeither altered capillarymembrane permeability
or decreased plasmaoncotic pressure.
NOT CARDIAC Near-drowning, Oxygen therapy, Transfusion or trauma,
CNS disorder, ARDS, aspiration, oraltitude sickness,
Renal disorder orresuscitation,
Drugs, Inhaled toxins, Allergic alveolitis, Contrast or contusion.
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Pulmonary Edema
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Pulmonary Edema
June 2, 2009 June 4, 2009
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Congestive Heart Failure
Congestive heart failure (CHF) is one of themost common abnormalities evaluated byCXR.
The earliest CXR finding of CHF iscardiomegaly, detected as an increasedcardiothoracic ratio (>50%).
In the pulmonary vasculature of the normalchest, the lower zone pulmonary veins arelarger than the upper zone veins due togravity.
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CHF
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Kerley B lines
Horizontal lines less than 2cm long, commonly found in the lower zone periphery. These
lines are the thickened, edematous interlobular septa.
Causes include; pulmonary edema, lymphangitis carcinomatosa and malignant lymphoma,
viral and mycoplasmal pneumonia, interstital pulmonary fibrosis, pneumoconiosis,
sarcoidosis, chronic CHF
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Atelactasis vs. Pneumonia
Atelectasis Pneumonia
Volume LossAssociated Ipsilateral Shift
Linear, Wedge-Shaped
Apex at Hilum
Normal or Increased VolumeNo Shift, or if Present Then
Contralateral
Consolidation, Air Space
Process
Not Centered at Hilum
Air bronchograms can occur in both.
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indistinct borders, air bronchograms, and silhouetting of the
right heart border.
LLL P i
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LLL Pneumonia
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? P i
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? Pneumonia
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Lung abscess
A
F
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Pleural Effusion
Upright film, will cause blunting on
the lateral and iflarge enough, theposterior costophrenic
sulci. A large effusion canlead to a mediastinalshift away from theeffusion and opacifythe hemithorax.
Approximately 200 mlof fluid are needed todetect an effusion.
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Pl l Eff i
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Pleural Effusion
P i di l Eff i
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Pericardial Effusion
An enlarged heart shadow thatis often globular shaped(transverse diameter isdisproportionately increased).
Serial films can be helpful in
the diagnosis especially if rapidchanges in the size of the heartshadow are observed.
Approximately 400-500 ml offluid must be in the pericardiumto lead to a detectable change
in the size of the heart shadowon PA CXR. Pericardial effusion can be
definitively diagnosed witheither echocardiography or CT
P i di l Eff i
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Pericardial Effusion
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COPD
COPD / E h
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COPD / Emphysema
C l ifi d G l
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Calcified Granuloma
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T b Li & C th t
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Tubes, Lines & Catheters
P th
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Pneumothorax
A tension PTX; air enters
the pleural cavity and istrapped during expirationusually by some type ofball valve mechanism. Thisleads to increasing intra-thoracic pressure.Eventually the pressurebuildup is large enough tocollapse the lung and shiftthe mediastinum.
Defined as air inside thethoracic cavity butoutside the lung.
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Mass vs Infiltrate
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Mass vs. Infiltrate
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Mass Location Intraparench mal s ple ral s e traple ral
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Mass Location; Intraparenchymal vs. pleural vs. extrapleural
Sub centemetric Nodules
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Sub-centemetric Nodules
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Solitary Pulmonary Nodule
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Solitary Pulmonary Nodule
A common finding on achest x-ray. Most nodules are benign Nodules are diagnosed
as benign if they Show little or no growth
for 2 years Calcification
Central, laminated ordiffuse pattern indicatesa granuloma
Eccentric calcification canbe seen in a carcinoma orin a cancer that hasengulfed a granuloma.
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Hiatal Hernia
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Hiatal Hernia
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CT Calcium Score & CT Coronary Angiography
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CT Calcium Score & CT Coronary Angiography
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Aortic Aneurysm
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Aortic Aneurysm
CAD
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CAD
New Developments
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New Developments
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- This is a chest x-ray of anadult female patient.
- The silhouette of the rightupper Mediastinum is lost
and the consolidation isconfined inferiorly by thehorizontal fissure.
- Within the consolidation airbronchograms are evident.
- There is consolidation of theright upper lobe
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- In a patient of age 56, the presence of anupper lobe collapse should alert one to thepossibility of an endobronchial neoplasm.
- An endobronchial malignancy may be theunderlying cause for an upper lobe collapse oran upper lobe pneumonia which fails to resolvewith treatment.
- referral for bronchoscopy is advised
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Air Bronchogram
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Air Bronchogram
Air bronchograms are dueto the air within bronchisurrounded byconsolidated lung. Thesesmaller bronchi are not
normally delineated fromthe lung, but due toconsolidation a contrastdifference occurs. Theyare not always present,but when they are they
suggest consolidation(usually infection) in thelung.
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A = Right Main Stem BronchusB = Right Upper Lobe BronchusB1 = Apical Segmental BronchusB2 = Anterior Segmental BronchusB3 = Posterior Segmental Bronchus
C = Bronchus IntermediusD = Right Middle Lobe Bronchus
D4 = Lateral Segmental BronchusD5 = Medial Segmental Bronchus
E = Right Lower Lobe BronchusE6 = Superior Segmental Bronchus
E7 = Medial Basal Segmental BronchusE8 = Anterior Basal Segmental BronchusE9 = Lateral Basal Segmental BronchusE10 = Posterior Basal Segmental Bronchus
F = Left Main Stem BronchusG = Left Upper Lobe Bronchus
G1, G2 = Apicoposterior Segmental BronchusG3 = Anterior Segmental Bronchus
H = Lingular BronchusH4 = Superior Lingular Segmental BronchusH5 = Inferior Lingular Segmental Bronchus
I = Left Lower Lobe BronchusI6 = Superior Segmental BronchusI7 = Medial Basal Segmental BronchusI8 = Anterior Basal Segmental BronchusI9 = Lateral Basal Segmental BronchusI10 = Posterior Basal Segmental Bronchus
Lobes and Fissures
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Lobes and Fissures
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