Normal'Chest'X!

Ray,%CT%and%MRI"
Benigno'R'Santi'II,"MD,#FPCR!
UST!FMS$!Department)of)Radiological)Sciences)!!
nd
(Magboo'C'2015,"Transcribed"from"PPT"and"Lecture;"few!information)lifted)from)Basic)Radiology)By)Chen,)2 !Ed.)!

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Radiographic+Film!in#between#two#
Fluorescent+coatings!(also&called&
intensifying)screens)!

!!!!!!!Radiography!

These$coatings)are$made$of$high$
atomic'number'materials."It!can$
absorb&x#rays%more!efficiently)
(compared*to*the*film)*and$emit$
photons,!which%can%now$be#efficiently#
absorbed(by(the(x#ray$film$itself.!

Computed)Tomography! Magnetic)Resonance!

!
Spatial'Resolution'and'Effective'Radiation'Dose'of'Thoracic'
Imaging'Modalities"
Spatial'Resolution'!Ability'to'define'/'differentiate'2'objects'
apart%from%each%other%at%the%least%possible%distance!
(Think'of#pixels."If"an"image"has"better!resolution,+it+would+have+
more% pixels,% therefore% would% appear% sharper' and' you' can'
delineate(even(small(objects)!

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Modality!

Resolution*(mm)!

Dose%(mSv)!

CXR!

0.08!

DR!

0.17!

CT!
MRI!
Nuclear(Medicine!
PET!
Angiography!
US!

0.4!
1.0!
7.0!
3.0!
0.13!
0.3!

0.02$(PA),$!
0.04$(lateral)!
0.02$(PA),!
0.04$(lateral)!
8!
0!
0.4!
7!
12!
0!

Background+
Radiation!

N/A!

3"per"year!

Chest&X#Ray$has$better$spatial$resolution$than$CT$and$MRI!
!
Because'CXR'is'an'actual'picture'of'the'Chest!
CT#&#MRI#are#digital#images,(which(have(been(computed!
!
(Similar:)a)photograph(taken(using(film(vs.(a(digital'camera)!
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Indications*for*Chest*Radiography"
Diagnostic!
! Cardiopulmonary-symptoms!
" Cough,'hemoptysis,'shortness'of'breath,'
chest&pain,&etc.!
! Preoperative*for*thoracic*surgery!
! Preoperative*if*known*cardiopulmonary*limitations!
! Staging'of'thoracic'tumors'and'extrathoracic'
malignancies!
! Infection!
" Pleural,(parenchymal,(mediastinal!
Follow#up!
! Previously+diagnosed+cardiopulmonary+disease!
" Pneumonia)resolution)to)exclude)
endobronchial%lesion!
" Pulmonary*edema!
Monitoring(of(intensive(care(unit(patients!
! Lung%disease!
! Pleural'disease!
! Lines&and&tubes&positions!
Monitoring(of(postoperative(patients!

!X#ray$films$are$valuable.$They$can$be$used$as$a$comparison$to$
evaluate'progression'of'pre#existing(conditions%or%establish%a%if%
a"finding"have"been"present"in"previous"examinations.!
!
Reading(Chest(Radiographs"
Density(=(White(mass!
Lucency'='Dark'(represents'air)!
Infiltrate*=*Abnormal(density!
!
When%looking%at%an!X#Ray:%Compare%Right%and%Left%sides!
Densities'!
o Ribs!(count'the'ribs!and$intercostal$spaces)!
By#description:#on#CXR,#the#Anterior#and#
Posterior(Ribs(will(be(read(separately(because(of(
the$oblique$orientation$of$the$ribs,$where$the$
anterior(would(present(to!be#at#a#relatively#
lower&level!
o Heart&and&its&Vascular(Markings!
Equivalent+Lucency!(R#to#L)!
o Air!!Lungs&(equivalent&to&other&side)!
Difficult(to(compare(when(the(shadow(of(the(
heart&interferes&(i.e.&lower&lung&fields)!
o Divide&the&lungs&into&3&divisions&and&note$for$
the$vascular$markings.!
Inner%Lung%Field%(Great%vessels%coming%from%hila)!
Middle&Lung&Field&(intermediate&vessels)!
Outer&Lung&Field&(very&small&vessels)!

Trace&the&vascular&markings&to&differentiate&
normal'from'an'infiltrate.!

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!!!!!!!!!!!!!!!!!!!!!!!!Small!!!!!!!Intermediate!!!!!!!!Large!

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Equivalent+Side!

2"Factors"Affecting"Radiographic"Density"

2.

3.

1.#Tissue&Depth!
!
Greater&thickness&=!more%dense!
!
Thick&tissues&will&attenuate&more&X#ray$beams$!
!
More%attenuation%=%More%Density!
!
Less$attenuation$=$More$Lucency!
2.#Atomic#Weight!
!
The$Bone!is#the#densest#tissue#you#can#find!
!
!
Because'of'the'presence'of'Calcium!
!
Soft%Tissues:"Intermediate"density"!
(Water&Density)!
!
Lungs!very%Lucent%(Air!in#alveoli)!
!

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Chest&X!Ray:"the"density"of"muscle,"blood"and"liver"are"
very%close%together%(they%are%only%translated%as%
intermediate)or)water&densities)!!
Computed)Tomography:"can"differentiate"these"minute"
differences)fairly%well!
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Technique)in)doing)Proper)Chest)X!ray"
1. Upright(position!
If#the#patient'lies'supine:!
There$is$pseudo#increase(in(the(transverse(diameter!
The$level$of$the$diaphragm$may$be$deviated!
Note:&the&diaphragm&upon&CXR&examination&is&
usually&described&in&halves.!
Right&hemi"diaphragm!
th
o Usually'at'the'level'of'the'10 !
posterior(rib!
o Can$normally$be$higher$than$the$
left%(due%so%the%Liver%being%
positioned)on#the#Right#side)!
Left%hemi"diaphragm)!
o Should'not"be"higher"than"the"Right!
!
!

Inhale'Deeply!
Take%the%X#ray$at#the#end#of#a#moderately#
deep$inspiratory$effort!
This%is%done%to%inflate%the%lungs!
o Demonstrate*normal*lucency!
Postero#Anterior!
The$film$is$positioned$in$front$of$the$patient!
The$X#ray$source$is$at$the$back$of$the$patient!
o Lessens%the%Magnification%of%the%Heart!
o Can$be$mistakenly$interpreted$as$
cardiomegaly,!
Note:!an#x"ray$is$like$casting$a$shadow,$
the$greater$the$between$the$tube$and$
the"film,"the"lesser%the%magnification.!
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The$distance$between$the$tube$and$the$film!
determines)magnification)and)clarity)or)
sharpness.!It#is#usually#done#at!6"feet.!
(An#AP#film,#taken#from#the#same#distance,#which#is#6#
feet,%enlarges%the%shadow%of%the%heart%"!which%is%far%
anterior(in(the(chest(and(makes(the(posterior(ribs(
appear%more%horizontal)!

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Changes(on(the(Chest(X#ray$corresponds$to$the$
air$content$of$the$lungs,$specifically$in$the$
Acinus'(which'contain'alveoli)!
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In#CXR,#The$Lungs$are$referred$to$as:!
Upper%Lobe!and!
Lower&lung&Field&(not%lobe)!
They%are%separated%by%the$minor$fissure$and$
the$hila!
Because'the'middle'lobe,'lower'lobes'and'
lingual'are'superimposed'on'each'other!
The$Lower$lung$field$will$be$divided$by$the$
oblique(fissure(and(major(fissure!
The$lower$lobes$are$more$posteriorly$located!
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Companion(Shadow"
Appearance(of(a(smooth,(homogenous,(radiodensity(with(
a"well#defined&margin!that$runs!parallel&with&a&bony&
landmark.$They$represent$soft$tissue$that$overlies$the$
respective)bony)landmark)in)profile.)They)may)or)may)
not$always$be$present.!
!
Rib$companion$shadow!
!
Scapular(companion(shadow!
!
Clavicular)companion)shadow!
!
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The$left$image%shows%the%right%minor&fissure&(A)&and&the&inferior&
borders'(B)'of'the'Major'fissures'bilaterally.!The$right$image$
shows%the%superior%border%of%the%major%fissures%(B)%bilaterally.!
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!Azygous(Fissure!
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Companion(Shadow(of(the(Clavicle."It#is#actually'just'soft'
tissue,'and'should'not'be'mistaken'for'other'abnormalities!

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!
Abnormal)Density)(Metallic)Density);)a)slug)of)a)bullet.!
Note:&the&density&superior&to&the&right&clavicle&(we$can$be$
able%to%determine%if%it%is%located%outside%of%the%thoracic%
cavity'by'tracing'the'outlines)'this%density%is%just%actually%
the$bandage'of'the'patient'(possibly!from%the%bullets%
point&of&entry)!
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Posteroanterior*vs.*anteroposterior*radiograph.!On#the#
anteroposterior*radiograph*(A)*of*this*normal*patient,*the*
detector'is'against'the'back'of'the'patient.'A'combination'of'
decreased'distance'between'the'source'and'the'patient'and'
increased)distance&between&the&detector&and&the&anterior&
mediastinal*structures*compared*with*the*posteroanterior*
radiograph)(B))leads)to)magnification)of)the)heart.)"
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Apico!lordotic(View!
Anteroposterior*view*of*the*chest!
Patient'is'in'hyperextended'position!
X#ray!beam%goes%upward!

Computed)Tomography"

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Principles*of*computed*tomography.*The$source$of$x#rays%and%
The$densities$emanating$from$the$ribs$and$clavicle$will$now$be$ the$detectors$are$on$opposite$sides$of$the$gantry$with$the$
on#the#upper#segments!
patient'at'the'center'of'the'gantry.'Radiation'that'crosses'the'
!
patient'is'detected,'producing'a'projection'of'attenuation'
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information.*By*rotating*the*gantry*around*the*patient,&
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multiple(projections(are(obtained,(which(are(then(used(to(
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mathematically*reconstruct*tomographic*attenuation*images.*!
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Advantage:*we*can*adjust*the*images*and*zero#in#on#specific#
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structures!
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Indications*for*Thoracic*Computed*Tomography"
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Pulmonary"
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! Further'characterize'CXR'abnormality'(e.g.,'
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nodule,(mediastinal(mass)!
Lordotic'view.'In#this#patient#with#a#left#apical#neurofibroma,#
! !Detection(and(follow#up#of#neoplastic#
the$abnormality$is$subtle$on$the$posteroanterior$radiograph$
disease&(e.g.,&metastatic&sarcoma,&lymphoma)!
(A),%but%the%lordotic(view((B)(improves(visualization(of(the(lung(
! Characterization,of,lung,nodules!
apices,(and(the(neurofibroma((asterisk)(becomes(more(
!!!!!!Benign&vs.&indeterminate!
apparent."
! Parenchymal+lung+disease+(e.g.,+emphysema,%
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interstitial)lung)disease,)infection)!
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! !Airway'disease!
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!!!!!!Central(and(peripheral(airways!
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! Pleural'disease!
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!!!!!!Empyema,(metastasis,(mesothelioma!
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! Post#surgical)complications!
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! Percutaneous+biopsy+guidance!
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! Localization*for*VATS!
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Cardiac"
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! !Cardiac'abnormalities%on%CXR!
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! Cardiac'anatomy!
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! !!!Coronary'arteries!
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!!!!!!Calcification,+patency+with+CTA!
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!!!!!!Aberrant(coronary(arteries!
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! !!!Postcardiac*bypass*grafting*complications!
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!!!!!!Mediastinitis!
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Vascular"
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! Aorta:'aneurysm,'trauma,'dissection,'
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coarctation!
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! Pulmonary*arteries:(embolus,(pulmonary(
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hypertension!
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! Venous:(SVC/brachiocephalic(vein(thrombus(
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or#obstruction!
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Computed)tomography)imaging."On"a"mediastinal"
window&(A),&the&lungs&are&mostly&black&and&the&
mediastinum*and*chest*wall*are*emphasized.*On*a*
lung#window#(B),#these#structures#are#white#and#the#
fine%structures%of%the%lungs%are%emphasized.!"
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Maximal'intensity'projection'reconstructions.&Information*
from%a%stack%of%images%representing%a%volume%can%be%combined%
into%a%single%image%representing%for%each%pixel%the%maximum%
value&of&that&pixel&through&the&volume,&shown&here&in&the&
coronal'(A)'and'sagittal'(B)'planes.'!
!

Lung%nodule%on%computed%tomography.%The$faint$nodule$
projecting+at+the+right+lung+base+near+the+diaphragm+(A)+
was$further$investigated$by$Computed$Tomography,+
which%revealed%a%calcified%granuloma"
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High%resolution%computed%tomography%allows&exquisite&
visualization+of+the+fine+detail+of+the+lung+parenchyma+in+this+
patient'with'Langerhan's'cell'histiocytosis.'!
!

Coronal'and'sagittal'reconstructions.'Multiplanar)
reconstruction*of*the*helical*projection*data*in*the*coronal*(A)*
and$sagittal$(B)$planes$can$be$performed.$This$improves$
visualization+of+some+structures,+such+as+the+lung+apices+and+
the$great$vessels.$!

Three!dimensional*reconstructions.*Data$can$be$further$
processed(to(produce(three#dimensional*images*with*shaded*
surface(of(any(chest(structure,(such(as(the(heart,(mediastinum,(
lungs&or&ribs.&!
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Magnetic)Resonance)Imaging)(MRI)!

!
Magnetic)properties)of)nucleus.)A)hydrogen)nucleus)has)two)
important)magnetic)properties:)a)magnetic)moment,)
represented(by(an(arrow(along(its(axis,(and(an(angular(
momentum'or'spin.'!
Indications*for*Thoracic*Magnetic*Resonance*Imaging"
Thoracic"
! Chest&wall&neoplasm((especially(superior(
sulcus%tumors)!
! Mediastinal*tumors*(e.g.,*bronchogenic*cysts)!
! Lung%parenchyma:%limited,%experimental!
! Thoracic(outlet(and(brachial(plexus!
Cardiac"
! !Congenital*heart*disease:*shunts,*
complicated+anatomy!
! !Myocardium!
!!!!!!Cardiomyopathy!
!!!!!!Ischemic(disease!
!!!!!!Hypertension!
!!!!!!Right&ventricular&dysplasia!
! Pericardium:+thickening,+effusion,+
tamponade,*pericardial*cyst!
! !Masses:&thrombus,&tumors!
! Valves'(limited):'stenosis,'regurgitation!
Vascular"
! "Aorta:'aneurysm,'trauma,'dissection,#
coarctation!
! !Pulmonary*arteries:*embolus,*pulmonary*
hypertension!
! !Venous:(SVC(thrombus(or(obstructionSVC,(
superior(vena(cava.!
!
!

Magnetic)Resonance)in)the)chest)is)only)helpful)as)far)as)the)
mediastinum*and*the*thoracic*wall*is*concerned.!
The$lung$parenchyma%is%seen%as%low#signal'areas'because'of'the'
presence'of'air.!
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Magnetic)resonance)angiography.)Magnetic)resonance)
angiography*of*the*aorta*and*its*branches*is*useful*to*evaluate*
aortic'dissection'(A).'Magnetic'resonance'angiography'of'the'
pulmonary*arteries*enables*good*visualization*of*the*
pulmonary*arteries*(B)*and*can*be*used*to*rule*out*pulmonary"
embolism.)!
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