Radiology Basics CXR Yr 3

Felix Chingoli, MBBS (Mw) Radiology Registrar.

OUTLINE
Objectives General information Technical Aspects of CXR Systemic Approach reading a CXR Basic Anatomy of a CXR Pattern of Diseases on CXR
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Objectives
At the end of this presentation, you should be able to:
Be conversant with some general term of CXR

Analyse the technical quality of CXR using simple parameters

Identify basic normal CXR anatomy on both PA & lateral views Recognize radiographic patterns of diseases & describe using appropriate terms
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General Information
Attenuation:
Reduction of the intensity of an x-ray beam as it traverses matter.

Density:
The ability of a structure to attenuate (absorb) the xray beam(air < fat < water < soft tissue < bone/metal/calcium)

CXR - Density

General Contd
Absorption is inversely proportional to penetration

Structures further away from film are enlarged due to scattering of rays
Contrast: difference between densities Standard views:
Erect PA and left lateral

Differentiate AP Vs PA, & Supine Vs Erect

Supplemental films may include:
oblique and decubitus (left or right) views
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Differential X-Ray: Absorption

Silhouette Sign
In CXR, can see diaphragm and mediastinum
Abrupt change of radiodensities between lung and these structures. Silhouette sign refers to loss of normally appearing profiles or interfaces implying solid change in adjacent lung R heart border = RML consolidation L heart border = lingula R hemidiaphragm = right lower lobe (RLL) or pleura L hemidiaphragm = left lower lobe (LLL) or pleura Aortic arch = anterior segment left upper lobe (LUL) superior vena cava = right upper lobe (RUL)

Other processes may also produce silhouette sign (atelectasis, masses)

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Silhouette Sign: RLL Pneumonia

Assess CXR Technical Quality

Adequacy
The whole chest fitting on the film

Inspiratory effort
9-10 Posterior ribs 6 -7 Anterior ribs

Penetration
Thoracic intervertebral disc space just visible

Positioning/ Rotation
Medial clavicle heads equidistance from spinous process

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Inspiratory Effort- Low Lung Volumes

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Inspiration Effort- Full Inspiration

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Exposure- Over Exposure

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Exposure- Proper Exposure

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Overexposure

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Proper Exposure

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Rotated (Oblique)

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Approach to Reading CXR

Mnemonic: IMPQRSABCHLA It

M ay
P rove Q uite R ight but S top A nd Be C ertain H ow L ungs

A ppear
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Extrinsic
I dentification: Pt name, sex, age, date M arkers: R and L P osition: medial ends of clavicles should be equidistant from spinous process at midline Q uality: degree of penetration (e.g. disc spaces just visible through the heart but not able to see detailed bony anatomy)
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Exntrinsic Contd
R espiration: right hemidiaphragm at 6th anterior interspace or 10th rib posteriorly.
Poor inspiration results in poor aeration, vascular crowding, compression and widening of central shadow.

S oft tissues: neck, axillae, pectoral muscles, breasts/nipples, chest wall

Nipple markers can help identify nipples Look for masses and amount of soft tissue present Soft tissues may cast shadows into the lung fields

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Intrinsic
A bdomen: liver, stomach and gastric bubble, spleen, gas-filled bowel loops, vertebrae, free air. B ones: C-spine, T-spine, shoulder girdle, ribs
Turn film on its side to help focus on ribs Sternum (best on lateral film)

C entral shadow: trachea, heart borders, great vessels, mediastinum, spine H ila: pulmonary vessels, mainstem and segmental bronchi, nodes L ungs: pleura, diaphragm, lung parenchyma A bsent structures: review the above, noting ribs, breasts, lung lobes
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Worth a Second Look

Apices Retrocardio areas (right and left) Hilar regions

Below Diaphragm

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Apical TB

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Apical TB (2)

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Left Retrocardiac Opacity

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Nodule Behind Diaphragm

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Basic CXR Anatomy

Frontal and Lateral View Heart

Aorta
Pulmonary Arteries

Airways

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Basic Anatomy (2)

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Basic CXR Anatomy (3)

Basic CXR Anatomy Aortic arch Right Pulmonary artery Left Pulmonary artery

Trachea and bronchi

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Basic Radiology

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Common CXR Abnormalities

Abnormal findings are not pathognomonic of a particular diagnosis and only suggest certain types of disease Always consider the clinical history ALWAYS HAVE PREVIOUS FILM FOR COMPARISON (if available)

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Chest Radiographic Patterns of Disease

Consolidation/air space opacity Interstatial Opacity Nodules and masses Lymphadenopathy Cysts and cavities Pleural abnormalities

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Consolidation/ Air Space Opacity

Caused by filling of the alveoli with fluid, pus, blood, cells (tumor) etc. May be diffused, or isolated to segments or lobes of the lungs May be associated with air bronchograms (air-filled bronchus surrounded by opacified lung

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Pneumonia

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Interstitial Opacity
Diseases localized to the pulmonary interstitium i.e alveolar septae and the connective tissues that support the alveoli Hallmarks
Lines and/or reticulations Small well defined nodules
Milliary pattern.

DDX:
Pulmonary edema, ILD e.g. idiopathic pulmonary fibriosis) sarcodiosis, infection, tumor ( lymphangitic spread)
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Interstitial Opacity- Lines

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Interstitial Opacity- Lines and Reticulation

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Nodules and Masses

Nodules: Discrete pulmonary lesions, sharply defined, nearly circular opacity 0.2-3 cm Mass: Larger than 3cm Describe qualifier
Single or multiple Size Border characteristics Presence or absence of calcification Location

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Nodules and Masses

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Lymphadenopathy (LAN)
Non Specific terms
Mediastial widening Hilar prominence

Specific Patterns
Particular station enlargement

Important to know what Normal should look like in order to recognize the abnormal

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Normal Frontal Chest Radiograph

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Bones and Soft Tissues

Obliteration of clavicular companion shadow may represent excess fat or supraclavicular adenopathy.

Lytic or sclerotic lesions may be primary or mets Fractures in ribs Features of osteoporosis (osteopenia, compression #, wedged vertebral bodies) may be seen in the T-spine (see Musculoskeletal System section)
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Pleural, Diaphragm and Viscera

pleural and extrapleural masses: form obtuse angles at their edges pulmonary/parenchymal masses: form acute angles with the pleura Pleural thickening and effusions

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Pleural, Diaphragm and Viscera

High diaphragm: abdominal distention, lung collapse, diaphragmatic paralysis, pneumonectomy, pregnancy, pleural effusion low diaphragm: asthma, emphysema, large pleural effusion, tumour Free air underneath diaphragm
Pneumoperitoneum

Calcifications in diaphragm:
Asbestosis

Gastric air bubble located under the left hemidiaphragm

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Blunting of Costophrenic Angles

Indicates pleural effusion or thickening Features of effusion
Fluid is higher laterally than medially Fluid forms meniscus with pleura, best seen on lateral Where effusion runs into a fissure, both sides of the fissure are visible Trachea and mediastinum central or pushed to opposite side

lateral decubitus film with effusion in dependent position will show layering

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Blunting of Costophrenic Angles

Need at least 200 cc of fluid in subpulmonic pleural space for blunting to occur Never see horizontal fluid level unless associated with pneumothorax (always a meniscus), i.e. a hydropneumothorax Effusions more likely to be malignant when massive. Blunting may also represent scarring of parietal pleura from old infections, trauma, surgery U/S superior over plain film for detection of small effusions (can also aid in thoracocentesis)
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Pneumothorax
Thin, veil-like pleural margin over the lung edge with no lung markings extending beyond Air collects superiorly More obvious on expiratory or lateral decubitus film Atelectasis (partial, complete) may be seen Mediastinal shift if air under tension

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Enlargement/Distortion of Cardiovascular Shadow Cardiothoracic ratio aka CTR In adults, the ratio of the greatest transverse dimension of the central shadow to the greatest transverse dimension of the thoracic cavity
only valid on good quality erect PA chest film > 0.5 abnormal Cardiomegaly, poor inspiration, supine position, obesity, pectus excavatum DDx of ratio > 0.5: cardiomegaly suggests either myocardial hypertrophy, Myocardial dilatation or pericardial effusion (pure hypertrophy very hard to see) May be < 0.5 and still be enlarged if multiple problems (e.g. cardiomegaly + emphysema)
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Enlargement/Distortion of Cardiovascular Shadow

pericardial effusion
Globular heart Loss of indentations on left mediastinal border Peri- and epicardial fat pad separation on lateral film

Transverse diameter of heart changes by 1 cm between systole and diastole

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Atrial Enlargement
RA
Increase in curvature of right heart border Enlargement of superior vena cava (SVC)

LA
Straightening of left heart border Increased radio-opacity of lower right side of cardiovascular shadow (double heart border) Elevation of left main bronchus (specifically, the upper lobe bronchus on the lateral film), Distance between left main bronchus and heart border > 7 cm, splayed carina (late) Compression of esophagus on GI barium studies
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Cardiac Enlargement Patterns

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Ventricular Enlargement
RV
Elevation of cardiac apex off diaphragm Interior enlargement on lateral leading to loss of retrosternal air space Increased contact of RV against sternum

LV
Displacement of cardiac apex inferiorly and posteriorly Increased outward lower bulging On lateral film, from junction of inferior vena cava (IVC) and heart at level of diaphragm, Measure 1.8 cm posteriorly then 1.8 cm superiorly > if cardiac shadow extends beyond this, Then LV enlargement (Riglers Sign
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Cardiac Enlargement Patterns

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Lateral Chest Showing Valves Valve calcification

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Hyperinflation
Increased radiolucency (increased aeration) vasculature spread further apart (attenuation) low, flattened diaphragms, often serrated (fibrosis), seen best on lateral look for spontaneous pneumothorax secondary to rupture of air bullae increased AP chest diameter and retrosternal airspace on latera

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Air Space Disease vs Interstitial Disease

Air space disease: pathological process primarily in alveoli
Acinar shadows (small, fluffy, ill-defined densities which tend to coalesce) Air bronchogram The silhouette sign

DDx:
Fluid (pulmonary edema), Pus (pneumonia), Blood (hemorrhage), Cells (lung cancer/lymphoma), Protein (alveolar proteinosis)
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Consolidation
Process whereby air in lung acini is replaced by fluid (or tissue) (i.e. air space disease) Areas vary from 5 mm to entire lung fields Initially may have multiple foci, ill-defined and irregularly-shaped Foci may later coalesce into areas of homogeneous radiopacity (i.e. lobar consolidation)
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Features Consolidation
Shape conforms to that of lobes or segments No homogeneous shadow outside the lung edge.

Air bronchogram may be present

Trachea and mediastinum are pulled toward side of shadow (secondary to volume loss) Silhouette sign
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Consolidation RUL (AP & Lat)

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Consolidation RML (AP & Lat)

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Consolidation RLL (AP & Lat)

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Consolidation LLL (AP & Lat)

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Consolidation LUL (AP & Lat)

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Consolidation Lingula (AP & Lat)

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Pulmonary Edema
Either: Cardiogenic (CHF), renal failure, fluid
overload OR: Non-cardiogenic
ARDS, aspiration, noxious gas inhalation), neurogenic

Oedema fluid initially collects in interstitium > reticulonodular pattern first > Kerley B lines Seen first in hilum, then spread outwards to periphery. In severe pulmonary edema, fluid begins to collect in alveoli ("bat wing's appearance" is seen with alveolar edema)

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Septal (Kerley) Lines

Thickened connective tissue planes Occur most commonly in pulmonary edema and lymphangitis carcinomatosis. Kerley A lines: radiate towards hila in mid- and upper-lung zones, lines 3-4 cm long,
smaller than vascular markings

Kerley B lines: horizontal, < 2 cm long and 1 mm thick, at periphery of lung, reach lung edge. Differential diagnosis of Kerley B Lines: pulmonary edema, lymphangitic carcinomatosis, sarcoid, lymphoma
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Atelectasis
Loss of volume pattern (subsegmental pulmonary collapse) May be secondary to bronchial obstruction, fibrosis, pleural disease, pulmonary embolus (PE), bronchiectasis
Bronchogenic cancer & post-op mucus plugging

Causes:
Resorption: Collapse of alveoli develops within a few hours of airway obstruction because air distal to lesion is resorbed Passive: Decreased lung volume 2nd to a space-occupying lesion Cicatrization: Increased recoil secondary to fibrosis
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Signs of collapse
Shift of a fissure (most important) Mediastinal shift to the side of collapse (except in a tension pneumothorax) and the shift of hilum. Diaphragm elevation (less volume in the hemithorax) Increased density (shadow of collapsed lobe) Compensatory hyperinflation (ventilated areas are blacker) Silhouette sign may be seen Bronchogenic cancer until proven otherwise
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