IMAGENOLOGIA DEL

CORAZON Y GRANDES VASOS

RADIOLOGIA-UNMSM
Hallazgos de aparente cardiomegalia y congestión vascular pulmonar son posibles
cuando se toma con pobre esfuerzo inspiratorio. Esto se determina por el nivel del
diafragma relativo a las costillas posteriores. Con los diafragmas elevados
característico de espiración forzada, es natural que la trama vascular pulmonar este
mas aglomerada y de la apariencia de congestión pero no se encontraran líneas
Kerley B o acentuación bronquial.
Cuando el diámetro horizontal de la silueta cardiaca basal excede la mitad del
diámetro interno del tórax se califica como cardiomegalia. Verificar siempre que
la placa este bien inspirada, el diafragma debe estar por debajo del nivel del arco
costal posterior 9 o 10.
SPECT- Sestamibi en
actividad miocárdica
Superficie de corte
vertical, ha la izquierda
corte coronal y sección
sagital. el corte coronal
ilustra la posición de
las válvulas mitral y
tricúspide comparada
con el septum
interventricular, el que
en su región superior
esta adelgazado
corresponde al septum
membranoso . Esto es
evidente en el corte
sagital donde el
septum se adelgaza
justo debajo de la
válvula aortica.
La figura ilustra corte a nivel del miocardio del ventrículo izquierdo. Mayor parte del
curso de las arterias coronarias mayores yace en el epicardio en la superficie del
corazón, con los vasos con frecuencia envueltos en grasa. Aquí se ilustra un vaso
penetrante a través de la pared miocárdica para irrigar segmentos como el septum.
La ilustración compara el tejido del corazón y grandes vasos con una
representación esquemática mostrando la posición de las válvulas y la
sobre posición de las estructuras derechas con el ventrículo izquierdo, la
aorta ascendente y la aurícula izquierda.
Oblicua anterior izquierda: la proyección anterior del grueso miocardio ventricular
izquierdo (normalmente <11 mm de grosor) comparado con la delgada pared libre
ventricular derecha (generalmente menos de 3mm de grosor). Debajo de la arteria
pulmonar izquierda principal esta la orejuela auricular izquierda, y adyacente a la
porcion mas baja de la VCS esta la orejuela de la aurícula derecha.
Vista lateral izquierda: las estructuras fibrosas anclando la válvula mitral con la aurícula
izquierda posteriormente. El flujo del ventrículo derecho se dirige anterior y
superiormente muestra la delgada pared ventricular derecha anterior, y la mas alta
posición de la válvula pulmonar en relación de la aortica la que se ve sutilmente a la
sombra del septum ventricular membranoso.
This illustrates a cut section view through the short axis of the left ventricular cavity in a
plane through the body of the papillary muscles. Note the greater trabecular pattern of
the right ventricle and the thinner right ventricular free wall myocardium (3 mms.)
compared to the left ventricular myocardium (up to 11 mm thick in normal septum or
lateral walls). The simplified schematic shows the crescentic shape of the right ventricle
in this view compared to the circular left ventricular cavity and the path of the coronary
arteries anteriorly in the interventricular groove (left anterior descending artery) and
posterior interventricular groove (where lies the posterior descending artery).
This illustrates a cut section view through the short axis of the left ventricular cavity in a plane
through the body of the papillary muscles. Note the greater trabecular pattern of the right ventricle
and the thinner right ventricular free wall myocardium (3 mms.) compared to the left ventricular
myocardium (up to 11 mm thick in normal septum or lateral walls).
• Ionizing versus non-ionizing radiation
Medical imaging techniques can be broadly grouped into those which use ionizing
radiation versus those that do not. The ionizing radiation group consists of those
images created by the use of x-rays or gamma rays. Both x-rays and gamma rays are
high energy, short wavelength (less than an angstrom) electromagnetic radiation that
is capable of penetrating and passing through most tissues. Gamma rays arise from
the nuclear decays of radioactive tracers introduced into the body, while x-rays arise
from an x-ray tube where high speed electrons bombard a small spot on a tungsten
anode target. Ionizing radiation, as it passes through the body is differentially
absorbed by tissues of greater thickness or higher atomic mass (e.g. calcium has a
higher atomic weight than hydrogen which is a major component of tissue water).
Different portions of the body tissues attenuate differing amounts of the incident
radiation. One mechanism of that attenuation is ionization of the tissue atoms which
make them chemically reactive and potentially capable of cell damage. Ionizing
radiation is therefore not used casually but only when medically indicated. X-rays are
nonetheless highly useful diagnostically and are a backbone of medical imaging by
both computed tomography and film.
• It is the locally differential pattern of x-ray radiation escaping the body that creates the
"shadowgram" on an x-ray film. That escaping radiation strikes a fluorescent screen
inside a film cassette, and fluorescent light from those screens in turn expose the film
emulsion (n.b.: if x-ray film was actually only sensitive to exposure by x-rays, we
wouldn't need darkrooms for handling those films).
• Non-ionizing radiation techniques mainly use either acoustic pulses (ultrasound) for
echo-ranging imaging (somewhat like radar) or radio-waves combined with high-field
magnets, in the case of magnetic resonance imaging.
• Medical images can be understood to
belong to one of two main groups:
tomographic or projection techniques.
Projection techniques, such as x-ray films
are "shadowgram-like" transilluminations
of the body. Because of the nature of
trans-illumination, various tissues are
imaged as overlapping each other and
often need multiple views (thus the PA
and Lateral) for visual under-standing
• Ionizing radiation is a portion of the high energy
electromagnetic radiation spectrum which can
penetrate and be transmitted through tissues
(unlike light, which is mostly absorbed at the skin
surface, failing to adequately penetrate thick
body parts such as the skull). One of the chief
modes by which Ionizing radiation interacts with
tissues is by knocking out atomic shell electrons
losing energy in the process. The resulting
differential absorption can be detected by a film
cassette at the opposite side of the body from
the radiation entrance
Tomography is a "slicing" of the body into various sections and in various view planes.
The tomographic sections when viewed in sequence or integrated by a computer allow
the display and understanding of 3-dimensional anatomy.
X-ray imaging is a method of illuminating the body with a penetrating high energy ionizing radiation.
The differential absorption of this radiation by the various tissues of the body creates on film an
inverse shadow of the body. Less dense, lower atomic weight structures, such as the lung, allow
transmission of more radiation flux producing greater fluorescence on an absorbing screen which
exposes an adjacent film more densely, making those areas black. Higher atomic weight structures
(bone) absorb and block the radiation, thus do not result in the exposure of the silver halide grains
in the film emulsion, and so bony structures such as the ribs appear white (transparent).
As Ionizing radiation passes through the body, it is differentially absorbed by tissues of
greater thickness or high atomic mass (e.g. calcium). Different portions of the body
tissues attenuate differing amounts of the incident radiation. The radiographic density is
mainly the result of x-ray radiation scattering or loss of the incident radiant energy by
ionization.
The range of densities that an X ray can display is the key to its usefulness as a
diagnostic imaging tool. The X ray tube emits a large burst of X rays, generated by
bombarding a tungsten target in a vacuum tube with high energy electrons (40-150 keV).
Many of these X rays when directed toward a person will pass through the body and
strike a fluorescent screen in a cassette, exposing a light-sensitive film adjacent to it.
Coronary angiography requires multiple separate views
to completely examine coronary anatomy and resolve
potential vessel overlap. Several separate sequential
injections of left (LCA) and right coronary arteries (RCA)
are shown. Here, "postero - anterior" (PA), "left anterior
oblique" (LAO), and "right anterior oblique" (RAO) views
of a normal coronary tree are provided. The "Left
Ventriculogram" is an RAO view with direct contrast
injection into the cavity to examine myocardial function.
Computed tomography is a digitally based x-ray
technique. Like x-ray, the resulting images arise from
differential x-ray absorption of tissue, a feature that
rests primarily on atomic weight (and thus the electron
density) of the various tissues. The technique uses a
narrowly collimated x-ray beam to irradiate a slice of
the body. The amount of radiation transmitted along
each projection line is collected by photo-multiplier
tubes and counted digitally. By rapidly acquiring views
from numerous different projections, achieved by
quickly rotating the tube and detectors around the
body, the transmissivity of the body from different
angles can be established externally.
Nuclear medicine images arise from injected radioactive tracers which subsequently emit
radiation from within body organs. The radioactive compounds tend to be designed to
accumulate selectively in specific tissues. For example, lung scans used in the diagnosis
of pulmonary embolus arise from technetium-labeled macroaggregated albumin, which
when injected into a vein, spreads and is deposited relatively evenly throughout normally
perfused lung micro-vasculature. Creates image solely of the lungs
Planar nuclear projection images of myocardial perfusion using technetium-99m
sestamibi as the perfusion agent demonstrates the anterior, left anterior oblique, and left
lateral nuclear images compared to comparable anatomic illustrations. The majority of
the nuclear myocardial image is provided by the full thickness of the left ventricular
myocardium. The right ventricular free wall and atrial walls are much thinner structures
but define the outline of their cavities.
The SPECT camera is a
large scintillation crystal
connected to multiple
photo-multiplier tubes
which detect radiation
emanating from the body.
The technology of
SPECTarises from
positioning the camera
head at multiple angles
around the body
accumulating as many as
180° of views at specific
angular intervals. A
certain number of counts
are obtained from each
view. In some cases
multi-headed cameras
are used to increase the
speed of acquisition.
Software integrates all
individual projection
views into a composite
data set which can be re-
Nuclear myocardial perfusion tomograms using
the radioactive compound technetium-99m
sestamibi are shown compared to illustrations of
the heart from similar views. Note that most of the
myocardial wall activity arises from the left
ventricular myocardium since it is considerably
thicker (11 mm) than the right ventricular free wall
(3 mm). The short axis tomogram shows the left
ventricular myocardium as a donut shape while
the vertical long axis and horizontal long axis
tomograms display the myocardial wall as U-
shaped structures.
 Technetium radioactive
labeling of red blood
cells which are stable
enough to permit
equilibrium imaging of
the major vessels and
cardiac blood pool
primarily of the cardiac
chambers, when gated
with the electrocardium
into 15 to 20 time
segments between
systole and diastole,
create a radionuclide
angiogram from which
calculation of ventricular
ejection fraction,
regional wall motion, and
general chamber sizes
These blood pool images are known variously as MUGA can be assessed.
(multi-gated acquisition) or more conventionally, ERNA
(equilibrium radionuclide angiogram). This technique is
considered one of the most accurate for estimating left
ventricular systolic function.
The medical imaging portion of the sound spectrum begins in the megahertz range, well
above the maximum audible frequency of 15 kilohertz. In the 2 to 7 megahertz range
used by ultrasound imaging, the wavelength of the acoustic pulses are less than a
millimeter and are therefore capable of resolving fine anatomic structures.
Transesophageal echocardiography is performed by using a miniature high-frequency (5
MHz) ultrasound transducer mounted on the tip of a directable gastroscope about 12mm
diameter. Using topical anesthesia and a little sedative, most individuals can swallow
the probe without difficulty. Because the transducer lies in the lower esophagus in close
direct fluid contact with the posterior of the heart, the images are superb since there is
no interference by lung tissue.
Magnetic resonance imaging depends on immersing the body in a steady, strong
magnetic field, commonly up to 1.5 Tesla (i.e. 15,000 Gauss - for reference, the earth's
magnetic field is about 0.5 Gauss). Some modern "whole-body" (i.e. apertures wide
enough to accept a person's thorax) machines now operate at 4 or more Tesla.
Hydrogen atoms, pervasive in the water which makes up about 70% of the body's mass,
have a dipole property by virtue of their characteristic spins.
The cardiac silhouette
is the most prominent
central feature of the
chest x-ray and it
produces a familiar
gourd shape with the
apex of the left ventricle
located just behind the
left chest nipple. The
inferior left ventricle wall
lies on the left
diaphragm and the
superior base of the
heart shows the aortic
knob lying just to the left
of the spine. A linear
line descending from it,
lying to the left of the
spine, represents the
lateral edge of the
descending aorta.
Findings of apparent
cardiomegaly and
pulmonary vascular
congestion must be
viewed in the light of
possibility of a poor
inspiratory effort.
This is determined
by noting the level
of the diaphragm
relative to the
posterior ribs. With
the high diaphragms
characteristic of a
forced expiration, it
is natural that
pulmonary vascular
markings will be
more crowded and
may give the
appearance of
congestion but the
lungs will lack
Kerley B lines or
When the horizontal diameter of the lower cardiac silhouette well exceeds one half of the
internal diameter of the thorax, cardiomegaly is diagnosed. It is wise to assess the depth
of the inspiration by noting whether the diaphragm lies lower than the ninth or tenth rib
posteriorly as it should if there is an adequate inspiratory effort.
The PA (postero-
anterior) radiograph
at first appears to
provide reassuring
evidence that the tip
of the pacemaker
lies in the right
ventricular apex.
The slightly
thickened metal tip
of the pacemaker is
seen just lateral to
the border of the
descending aorta.
The value of a
lateral radiograph is
best exemplified
when the course of
the pacemaker wire
is followed inferior
and is found to lie
well posterior to the
expected position of
the right ventricular
Pneumonic
infiltration of the
lingula increases
the density lung
immediately
adjacent to the left
cardiac border.
The presence of
two areas of
similar soft tissue
density results in a
loss of the
conventional sharp
boundary to the
heart. The
radiographic
appearance of a
sharp boundary at
the left cardiac
border would still
be present if the
lung density were
located posterior to
the heart, say in
This case exemplifies an acute occlusion of the right coronary artery - click the "Pre
angiogram" button. After thrombolysis of the clot, the proximal obstruction was dilated by
balloon angioplasty - click on "Post angiogram". Though flow was restored to the
coronary, a discrete moderate stenosis is still present in mid-coronary. It was
subsequently successfully dilated by balloon angioplasty.
Sequential right coronary artery (RCA) angiograms ("1", "2" and "3") showing diagnosis
and treatment of a patient whose acute coronary syndrome was caused by a clot at the
site of a high - grade stenosis in the proximal right coronary. Angio "1" shows the clot as
a void in the contrast. Angio "2" shows balloon angioplasty of the stenosis. Angio "3"
shows placement of an intra-coronary stent with complete restoration of lumen patency
Findings to be observed
in normal lungs include
vascular markings
composed primarily of
the vertically oriented
pulmonary artery
segments and the
horizontally directed
pulmonary veins toward
the left atrium. The
gradual decrease in
size of the vessels as
they branch peripherally
should be noted. Close
to the hilar structures
the smaller bronchials
seen as thin walled
darker circles.
Edematous thickening
of these bronchial walls
are one of the earliest
findings of congestive
failure.
 Erect posterior-anterior
chest radiograph PA
images commonly show
significant differences
from AP (antero-
posterior) films
particularly in relation to
the proportional size of
the mediastinum. The
PA position places the
heart and upper
mediastinum closer to
the film with greater
distance to the exposing
Xray tube (generally 72
inches) making the
Xrays more parallel as
they enter the body and
avoiding disproportional
enlargement of anterior
Effects of gravity have visible effects on the pulmonary vs. posterior structures.
vasculature since the pulmonary artery pressures are low (~25
mm Hg. in systole and ~12 mm Hg. in diastole) and the vessel
walls are soft and compliant.
On a supine frontal Xray of the chest there are significant differences in the appearance
of normal pulmonary vasculature and mediastinum. The closer distance of the exposing
Xray tube (often only 40 inches from the film cassette) makes the Xrays more diverging
and disproportionally enlarges the appearance of structures that are farther from the film
(the anterior body structures such as the ascending aorta). Although the pulmonary
artery pressures are low (~25 mm Hg. in systole and ~12 mm Hg. in diastole) and the
vessel walls are soft and compliant, the upper lung arterial vessels and the lower lobe
vessels are now at the same level as the cardiac chambers.
Angiograms are created by
injecting an iodine solution
into the bloodstream.
Iodine was chosen
because it is a high atomic
weight material which
differentially attenuates x-
rays but is nonetheless well
tolerated by the body (it is
mostly excreted in the
urine). When a catheter is
threaded into the
pulmonary artery and an
iodinated solution ejected
from its tip, the pulmonary
arteries are quickly first
opacified showing a
relatively vertically oriented
branching pattern,
originating at the hilum.
Normal arteries
progressively reduce in
diameter after multiple
branches.
Observation of discrete
abnormal densities within the
lung fields are described as
nodules. When the density is
similar to that of the ribs, they
can be presumed to be
calcified. Confirmation of the
presence of calcium can be
obtained quantitatively from
computed tomography which
may, with its greater
quantitative soft tissue
sensitivity, reveal other
inapparent parenchymal
densities.
This 28 year old male with a
history of non-seminomatous
testicular ca was being
followed by routine chest X-
rays. The x-ray in this ex
shows very little evidence of
abnormality but the computed
tomography scan done
simultaneously show multiple
nodules and demonstrate the
increased sensitivity of that
cross-sectional technique for
small tissue density nodules in
the lungs. Some of the greater
visibility of these nodules on
CT are due to that technique's
greater range of intensity
differentiation of soft-tissue
densities, but some of the
result is also due to the cross-
sectional imaging plane it
produces which avoids
confusing overlapping
structures.
This PA radiograph demonstrates a
large wedge-shaped density in the
right middle lobe. Also note a coin
lesion at the right costophrenic
angle. The right middle lobe large
density on biopsy was determined
to be a metastasis from cervical
carcinoma. Note that the sharp
upper boundary of the right middle
lobe triangular mass is the right
middle lobe fissure. In addition,
there is enlargement of the right
hilar structures due to metastases
within the hilar lymph nodes.
The Westermark is an eponym
indicating the abrupt cutoff of
pulmonary vascularity distal to a
large central pulmonary embolus.
The presumed mechanism behind
the image arises from the nearly
complete obstruction of bloodflow to
the pulmonary artery distal to the
embolic clot. Presumably the lack
of flow to these more distal vessels
results in their radiographic
transparency and an appearance of
an abrupt truncation as is shown in
this exemplary case.
</TD< TR>
Enlargement of one or both hila
must distinguish between
lymphadenopathy vs. vascular
enlargement. With few
exceptions, vascular
enlargement produces a
branching pattern at its borders
and generally is bilateral,
whereas lymphadenopathy is
more spherical or elipsoidal.
Bilateral lymphadenopathy
occurs with a variety of
immunological disorders as well
as sarcoid, but unilateral
adenopathy results from either
unilateral pulmonary infection or,
more ominously, malignant
tumors.
Hilar adenopathy (due to sarcoid).
Hilar adenopathy must be
distinguished from enlargement of
the hilar vasculature (such as by
pulmonary hypertension). Hilar
lymph nodes appear more nodular
and "lumpy" than hilar vessels
which usually retain their branching
pattern when enlarged. Bilateral
hilar adenopathy implies diseases
that are generalized and include
sarcoid and lymphoma.
Normal blood flow in the
pulmonary capillaries are
subject to a variety of
influences. The mean
hydrostatic intravascular
pressure in the pulmonary
artery is approximately 14
mmHg. The transmural
vascular pressure is the
intravascular pressure minus
the intrapleural pressure in
the larger vessels. Pressure
in the pulmonary circulation
is significantly influenced by
gravity.
Patients with congestive heart
failure commonly will have
increased density of the
interstitial markings of the lung
fields. Very specific patterns have
been described as Kerley "B" or
"A" lines. The "B" lines are most
commonly cited and when
identified imply the presence of
interstitial edema in the
pulmonary septa. The Kerley "B"
lines are short, horizontal lines
perpendicular to the lateral
aspects of the lung.
Se pueden diferenciar las ramas ascendente y descendente de la Aorta .
Pacientes ancianos con historia de HTA con frecuencia tienen una
configuracion estasica de la Aorta, con un patron tortuoso de la aorta
descendente. Dilatacion de la aorta ascendente puede encontrarse en el
sindrome de Marfan, asi como insuficiencia aortica,dilatacion post-
estenotica, y aneurismas aorticos.
The PA (postero-anterior) radiograph
is only very subtly abnormal in the
mediastinum. Looking through the
central mediastinal density there is a
suggestion of air and possibly an air
fluid level in the region medial to the
descending aorta. (Incidentally noted
is a central venous line entering under
the right clavicle and terminating in
the superior vena cava). The CT scan
is definitive and shows clearly the air-
filled dilated esophagus posterior to
the trachea. Radiodense fluid such as
barium defines the esophageal space
and its dilatation.
Forty-eight year-old male
with longstanding
moderately severe aortic
insufficiency due to past
endocarditis. When the
volume of the regurgitant
fraction is significant,
there is enlargement of
the left ventricle and,
therefore, a globular
widening of the cardiac
silhouette.
These images arise from a
forty-two year-old male with
progressive dyspnea on
exercise over a two-year period.
The patient had a strong family
history of cardiomyopathy with
two of three siblings who died in
their 30's of idiopathic
cardiomyopathic disorders. The
cardiomegaly visible on this
frontal chest film was not
present on a film taken two
years before but became
progressive as shown by the
film of just two months previous.
Chest radiographs of patients with
hypertension generally are
nonspecific. In this 44 y.o. male with
malignant hypertension the only
suggestive finding is the prominence
of the ascending aorta appearing as
a bulge in the upper mediastinum on
the patient's right. This is caused by
an ectatic unwinding of the
ascending aorta in response to the
high arterial pressures. Note that the
cardiac silhouette does not appear to
be significantly enlarged since the
major abnormality is increase in
thickness in the myocardial wall
rather than dilation of the ventricle.
Mitral stenosis generally creates
a characteristic configuration
dominated by enlargement of the
left atrium. Note that the left
mainstem bronchus is elevated
and lies more horizontal than
normal. The tissue boundary
angulated away from the spinal
column below the left mainstem
bronchus represents the lateral
boundary of the enlarged left
atrium.
This radiograph was obtained from a
sixty-two year-old male with sudden
onset of substernal chest pain
radiating to the left arm and jaw. The
chest x-ray often may show a normal
cardiac size and normal vasculature if
the area of cardiac ischemia is
limited. Large areas of myocardial
ischemia or accumulations of
ischemic events involving many
myocardial segments or multiple
coronary arteries can lead to
congestive failure and a pulmonary
edema pattern.
Radiography of patients with
pericardial effusion will show
apparent cardiomegaly when
the effusion is large enough.
Since the pericardial fluid is
roughly the same radiographic
density as blood in myocardium,
it may be impossible to confirm
whether the cardiomegaly is due
to enlargement of the ventricular
chambers or whether the fluid is
located in the pericardial space
Ventricular septal defect.
a) The heart is moderately enlarged and there is shunt
vascularity. The distinct vessel margins indicate no
interstitial edema. Cardiac catheterization showed a large
shunt (2.5: 1) at the ventricular level.
b) There is posterior displacement of the esophagus
(arrows) by left atrial enlargement.