Matthias Hofer (Editor) N.Abanador L Kan1per H Rattunde C Zentai + Abbreviations AAI AAL AC ACB AO AP ARDS AV AVM AZ BC CCA CHD COA COPD CT CVP CTR eve CXR DO ODD DIC DISH EEG FAST HRCT IABP lCD ICS ILO IRDS ITA IVC kPa LA Pacemaker code, see page 167 Anterior axillary line Acrom1oclav1cular Aortocoronary bypass Aorta Anteroposterior Adult respiratory d1stress syndrome Arterioventricular Artenovenous malformations Apical zone Bronch1al carcinoma Common carotid artery Coronary heart disease Coarctation of the aorta Chron1c obstructive pulmonary disease Computed tomography Central venous pressure Cardiothoracic ratio Central venous catheter Chest x-ray Differential d1agnosis Pacemaker code, see page 167 Disseminated intravascular coagulation (, consumption coagulopathy) Diffuse idiopathic skeletal hyperostosis Electrocardiogram Focussed assessment with sonography for trauma High-resolution computed tomography Intra-aortiC balloon pump Implantable cardioverter-defibrillators Intercostal space International Labor Office Infant respiratory distress syndrome Internal thoracic artery Inferior vena cava Kilopascal (unit of pressure) Left atrium lL LLD LV ll MCL ML mmHg mSv MZ NHL PA PAL PeP PCWP PDA PEEP PNET PrO OT RA RCS RLD RSS RV so svc TAA TB TEE TGA TIPSS UICC UL uz VDD VSD VVI Lower lobe Left lateral decubitus Left ventricle Lower zone Midclavicular line Middle lobe Millimeters mercury column Millisievert Middle zone Non-Hodgkin lymphoma Pulmonary artery, Posterior-anterior View Posterior axillary lme Pneumocystis carinii Pneumonia Pulmonary capillary wedge pressure Patent ductus arteriosus Pos1t1ve end-expiratory pressure Primitive neuroectodermal tumor Presumptive diagnosis OT-time interval! (ECGI Right atrium Retrocardiac space Right lateral decubitus Retrosternal space R1ght ventricle Standard dev1at1on Superior vena cava Thoracic aort1c aneurysm Tuberculosis Trans esophageal echocardiography Transposition of the great arteries Transjugular intrahepatic portosystem1c shunt Union internationale contre le cancer Upper lobe Upper zone Pacemaker code, see page 167 Ventricular septal defect Pacemaker code, se page 167 Acknowledgments We would like to thank Inger Jurgens from Cologne, who contributed greatly to the success of this project with her gra phic design work, drawings, and production support We are grateful to my teacher, Prof Dr U Madder, and to my colleag ues Prof Dr Furst and Dr Jorg Schaper for providing several of the illustrative images and offering advice on issues in pediatric and critical-care medicme We thank Prof Dr Peter Vock of the lnselspital in Bern, Switzerland for his kind permission to reprint several images from his institution We thank Medtronic Hall, St Jude Medical, and Biotronik for providing photographs of their pacemakers and prosthetic heart valves, and we thank Braun Melsulgen and Bionic Medizintechmk for providing photographs of the1r catheters We particularly thank Mr Ralf Sickmg of Biotronik for supplying additional techn1cal background information We thank the companies C R Bard and Datascope for providing illustrative images of their port systems and the intra-aortic balloon pump We also thank our colleagues at the anesthesiology department (Prof Dr Tarnow, Director), Dr Andreas Schwalen (pulmonology), and Dr Georg Gross (St Josef Hospital, Haan) for providing the intervent1onal images and for critically reviewing the manuscript We are grateful to our copyeditors Stefanie Hofer, Dr Uwe Hoffmann, Michelle Abanador, and Svenja Kamper for their meticulous proofreading Mr Alexander Rosen was kind enough to a headstand to illustrate the basal-to-apical redistribution of pulmonary blood flow Finally, we will be grateful for any comments or suggestions which our readers may send to the publisher on how this workbook might be improved (see p 2) The Authors October, 2006 ~~r The~~Hest X-Ray A Systematic Teaching Atlas fj ng ) ~ rh!eme Getting the Most out of this Book I This workbook has several features that will help you learn the systematic viewing and interpretation of chest radiographs in the most efficient way: To save time, the figure numbers are based on page numbers While many textbooks require readers to leaf through numerous pages to find, say, "Figure 2.23" (i.e , the 23rd figure in Chapter 2), the figures in this workbook are easy to locate because they are based on page numbers For example, if you are looking for Figure 121.2a, you can find it quickly and easily by turning to page 121 Additional time is saved by presenting topics on facing pages The running text that describes abnormalities and their imaging features is generally placed close to the corresponding images- usually on the same page or on two facing pages This makes it easy to compare posteroanterior (PA) and lateral radiographs or ultrasound images and computed tomography (CT) scans without having to hunt through the book Numerical labels and colors Many structures in the illustrative images are labeled with numbers rather than abbreviations These black numerical labels appear in boldface type and parentheses when they are cited in the text This allows you to view every image with a detective's eye and identify structures on your own, without being prompted by a label that gives you the answer This active problem-solving approach is an excellent way to learn, even though it may seem "inconvenient" at first The [numbers in brackets refer to the list of references on the back flap of the book Direction of the blue arrows Many critical findings in images are indicated by green arrows Notice which direction the arrows are pointing when you want to find the arrow reference quickly in the text The direction in which a particular arrow is pointing in an image corresponds precisely to the direction the arrow in the accompanying text on that page is pointing This makes it easy to locate the text passage that describes the finding of interest Repetition In some cases the same finding may appear at different places in the book Firstly, this repetition is based on discoveries from research on learning and memory, which confirm the value of repeating information at intervals (this principle is reinforced by the quiz sections) Also, some findings may have a patchy, focal, or reticular appearance on images and are therefore listed as a possible differential diagnosis in more than one chapter 'I Matthias Hofer, MD, MPH, MME Diagnostic Radiologist University Hospital Duesseldorf Heinrich-Heine University Duesseldorf, Germany Nadtne Abanador, MD Department of Cardiology Hellos Cltn1c Wuppertal Wuppertal, Germany Lars Kamper, MD Clinic for Internal Medicine and Cardiology Alfried-Krupp Hospital Essen, Germany Henning Rattunde, MD Institute for Diagnostic, lnterventional, and Pediatric Radiology lnselspital, University Hospital Bern Bern, Switzerland Christian Zentai University Hospital Aachen Clinic for Anesthesiology Aachen, Germany Library of Congress Cataloging-in-Publication Data is available from the publisher © 2007 (english edition), Georg Thieme Verlag, RudigerstraBe 14, 70649 Stuttgart, Germany Thieme New York, 333 Seventh Avenue, New York, N.Y 10001, U.S.A Design and Typesetting by: Dipl Des Inger Jurgens, Cologne: www.mgerj.de Important Note: Medicine is an ever-changing science undergoing continual development Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are 1n accordance with the state of knowledge at the time of production of the book Nevertheless this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect of any dosage instructions and forms of application stated in the book Every user is requested to examme carefully the manufacturers' leaflets accompanying each drug and to check, 1f necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book Such examination is particularly important with drugs that are either rarely used or have been newly released on the market Every dosage schedule or every form of application used is entirely at the user's own risk and responsibility The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text Therefore, the appearance of a name without designation as proprietary 1s not to be construed as a representation by the publisher that it is ·n the public domain Printed in Germany by: WAZ-Druck, DUtsburg ISBN 978-3-13-144211-6 (GTV) ISBN 978-1-58890-554-3 (TNY) ISBN 978-3-13-144971-9 (Asia) This book, including all parts thereof, is legally protected by copyright Any use, exploitation or commercialization outside the narrow limits set by copyright legislation, without the publisher's consent, is illegal and liable to prosecution This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kmd, translating, preparation of microfilms, and electromc data processing and storage Contents Overview Chapter Thoracic Anatomy Chapter Image Interpretation p.23 Chapter Chest Wall: Soft Tissues and Bone p.35 Pleura p.51 Mediastinum p.63 , Chapter Chapter hapter 10 Chapter 11 p Patchy Lung Changes p.1 05 Focal Opacities p.123 Linear and Reticular Opacities p.139 Foreign Bodies p.157 Thoracic Trauma p.183 Intensive Care Unit p.197 I I I I I I I I II a I Appendix Detailed information on chapter contents can be found at the beginning of each chapter and in the Table of Contents on pages and Table of Contents Chapter Thoracic Anatomy Chapter Goals Thoracic Skeleton, lucencies, Opacities Principal Divisions of the lung, lobar Anatomy Segmental Anatomy Tracheobronchial Tree Segmental Anatomy on CT Scans Fine Structural Divisions of the lung Pulmonary Vessels Mediastinal Borders Interstitium and lymphatic Drainage Bronc hial Vessels and Innervation Chapter 10 12 13 14 16 18 20 21 22 Image Interpretation Chapter Goals AP versus PA Radiographs Calibers of Pulmonary Vessels, Depth of Inspiration Scatter-Reduction Grids Determining the CTR, Effect of Age Silhouette Sign Perfusion and Ventilation Sequence of Image Interpretation "Crying lung" (Pediatrics) Quiz - Test Yourself ! 23 24 25 26 27 28 29 30 31 32 Chapter Chest Wall: Soft Tissues and Bone Chapter Goals Density Variations Other Soft-Tissue Effects Soft-Tissue Emphysema, Pneumomediastinum Variants in the Thoracic Skeleton Clavicle, Acromioclavicular Joint Tessy and Rockwood Classification, Humerus Ribs, Rib Notching Skeletal Metastases Spinal Degenerative Changes Scheuermann Disease Intra-abdominal Findings Quiz - Test Yourself ! Chapter Chapter Goals, Normal Findings Pleural Thickening Pleural Fibrosis Pleural Calcifications Pleura l Tumors Thoracentesis Quiz - Test Yourself ! 35 36 37 38 39 40 41 42 43 45 46 47 48 Pleura 51 53 54 56 58 60 62 Chapter Mediastinum Chapter Goals Normal Mediastinal Contours Mediastinal Widening Retrosternal Go1ter lymphomas Thymus Germ Cell Tumors, Lymphangioma Lymph Node Enlargement Hilar Widening Central Bronchial Carcinomas Vascular Hilar Changes Neurogenic Tumors Mediastinal Abscess Heart Cardiomegaly Congenital Valvular Disease Aortic Configuration Mitral Configuration Congenital Heart Disease Tetralogy of Fallot Coarctation of the Aorta Transposition of the Great Arteries (TGA) Pericardium Pericardia! Effusion, Pericardia! Tamponade Pericarditis, Pneumopericardium Pericardia! Cysts Aorta Aortic Aneurysm Aortic Dissection Aortic Sclerosis, Right Descending Aorta Esophageal Diverticula Esophageal Carcinoma Diaphragmatic Hernias Mediastinal Emphysema, Mediastinal Shift Quiz - Test Yourself ! Chapter 63 64 65 68 69 70 71 72 73 76 77 78 79 81 82 83 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 101 Patchy Lung Changes Chapter Goals Opacities Pleural Effusions Crescent Sign Differential Diagnosis of Pleural Effusion Differential Diagnosis of "White lung" Upper lobe Atelectasis Middle Lobe Atelectasis Lower Lobe Atelectasis Segmental Atelectasis Differentia l Diagnosis of Segmenta l Atelectasis Pneumonia Misdirected Intubation, Tumors Hyperlucent Areas General Differential Diagnosis of Hyperlucencies Emphysema, Bullae (Tension) Pneumothorax Quiz - Test Yourself ! 105 106 107 108 110 111 112 113 114 115 116 117 118 119 120 121 - - ~ Table of Contents Chapter Focal Opacities Chapter Goals Differential Diagnosis of Solitary Focal Opacities General Differential Diagnosis, Criteria for Benignancy Differential Diagnosis of Solitary Focal Opacities Pulmonary Metastases Azygos Lobe Bronchial Carcinoma TNM Classification Clinical Manifestations Intrapulmonary Hemorrhage Sarcoidosis (Boeck Disease) Tuberculosis (Tb) Differential Diagnosis of Multiple Focal Opacities Wegener Granulomatosis, Multiple Metastases Differential Diagnosis of Ring Shadows and Cavities Aspergillosis, Tumor Necrosis Quiz - Test Yourself ! Chapter 124 125 126 127 128 129 130 131 132 133 134 135 136 137 Linear and Reticular Opacities Chapter Goals Variants: Azygos Lobe, etc Pulmonary Congestion and Pulmonary Edema ':ongestion in Pulmonary Emphysema Alveolar Pulmonary Edema Forms of Pneumonia Pneumocystis carinii Pneumonia (PeP) Differential Diagnosis of Pneumonia Pneumoconiosis, Classification Silicosis, Asbestosis Pulmonary Fibrosis Bronchiectasis Carcinomatous lymphangitis Quiz- Test Yourself! Chapter 123 139 140 141 142 143 144 146 147 148 149 150 151 152 154 Foreign Bodies Chapter Goals Central Venous Catheters (CVCs) Catheter Types and Applications Catheter Insertion EGG-Guided Catheter Insertion Complications Port Systems Dialysis Catheters: Shaldon, Demers Pulmonary Artery Catheters Pacemakers Designations, Pacing Modes, Typical ECG VVI/DDD Pacemakers AAINDD Pacemakers Biventricular Pacemakers Intra-Aortic Balloon Pump (IABP) 157 158 159 162 163 164 165 166 167 168 169 170 171 Prosthetic Heart Valves Mechanical and Biological Valves lilting-Disk and Bileaflet Valves Caged Ball Valves and Bioprosthetic Valves Annuloplasty Echocardiography, CT, MRI Endotracheal Tubes Foreign Material in the Gastrointestinal Tract Aspirated Foreign Bodies Foreign Materials Checklist Quiz - Test Yourself ! Chapter 10 172 173 174 175 176 177 178 179 181 182 Thoracic Traum a Chapter Goals 183 Rib Fractures 184 Hemothorax 186 Multiple Rib Fractures, Volume Estimation 187 Sternal and Vertebral Body Fractures 188 Parenchymal Lung Injuries 189 Pneumothorax 190 Pneumomediastinum 193 Focused assessment with sonography tor trauma (FAST) 194 Quiz - Test Yourself ! 196 Chapter 11 Intensive Care Unit Chapter Goals Foreign Material (Endotracheal Tubes, Catheters, Pacemakers) Pulmonary Congestion and Edema ARDS, IRDS Pneumothorax on Supine Radiographs Insertion of a Chest Tube Hemothorax, Pulmonary Embolism Quiz - Test Yourself ! 197 198 200 201 202 204 207 208 Appendix Answer Key Radiation Safety and Technology Subject Index List of References Number Key for Diagrams 209 222 223 Inside back cover Inside back cover flap Foreword Radiography of the heart and lung is still the most widely practiced 1magmg procedure Chest radiographs are an indispensable part of the basic diagnostic workup in major medical disciplines such as mternal med1cine, the surgical specialties, anesthesiology, and occupational medicine For that reason, students, residents and beginning practitioners have need for a practical reference guide that can lead them on the path from radiographic features to diagnostic interpretation in a systematic way The analytical format of this book should enable you to recognize the most important and most common findings while giving you greater confidence in reading and interpreting radiographs This book contains numerous illustrative radiographs, all vividly instructive and many accompanied by examples from other imaging modalities Text and illustrations are presented side-by-side to facilitate learning, and structures of key interest are clearly indicated by arrows and numerical labels A fold-out number key underscores the pract1ce-onented and user-friendly format in which the matenal1s presented The numerous qu1z sections allow you to check your progress and see how well you have mastered the essentials The book is characterized by a h1gh density of information within a small space- even includmg step-by-step 1nstruct1ons on thoracentesis, chest tube insertion, and the msert10n of central venous catheters (CVCs) The superb image quality, conc1se text, and extremely favorable cost-to-value ratio make it easy to recommend "Chest X-Ray"Atlas for all students and residents who are embarking on their professional career Prof U Madder, M.D Director, Department of D1agnostic Radiology Dusseldorf University Medical Center Dusseldorf, Germany Preface by the Authors What makes th is book different from comparable titles? Most radiology textbooks are orgamzed according to disease groups or pathophys1olog1cal categories But in the everyday practice of chest radiography, we not address the question of, say, wh1ch "pneumoconiosis" should be considered in the differential diagnosis Instead, the mterpreting physician is confronted w1th patchy, streaky, reticular, or nodular opacities in the pulmonary interstitiUm or parenchyma that he or she must fit into a differential diagnostiC framework Accordingly, this workbook is orgamzed according to the morphological patterns that are actually seen on chest radiographs There are also chapters that teach readers how to interpret the widening of the mediastinum and how to address specific clinical problems in ventilated intens1ve care unit (ICU) patients and trauma patients In using this book, you will come upon quiz sections that present Illustrative cases and ask questions about them These questions are designed to help you learn through the repetition and practical application of key points - points that might be missed or quickly forgotten by just skimming through the material As a result, you may find this workbook somewhat "unpleasant" at first, but on closer scrutiny you will see how effective it is in reinforcing long-term learning We hope you will enjoy using this book and we wish you much success in applying what you have learned On behalf of the authors: October 2006 Matthias Hofer, M.D • MPH, MME (ed.) Matthias Hofer Thoracic Anatomy Chapter Goals : Thoracic Skeleton We begin this workbook by familiarizing you with thoracic anatomy as it normally appears on chest radiographs The positive identification of anatomical structures is essential for accurate image analysis and will prevent many potential errors of interpretation Principal Divisions of the Lung A major goal of this chapter is to acquaint you with the appearance of pu lmonary vessels, bronchi, thoracic skeletal structures, and the mediastina l contours On completing this chapter, you should e able to: p.8 p.1 Lobar Anatomy p.1 Segmental Anatomy p.12 Tracheobronchial Tree p.13 Segmental Anatomy on CT Scans p.14 Fine Structural Divisions of the Lung p.16 • correctly identify (step 1) and draw (step 2) the structures of thoracic topographical anatomy as they appear on chest radiographs; Pulmonary Vessels p.18 Mediastinal Borders p.20 • localize focal abnormalities to specific pu lmonary lobes and segments; Interstitium and Lymphatic Drainage p.21 Bronchial Vessels and Innervation p.22 • draw and correctly label from memory the mediastinal borders as they appear on posteroanterior (PA) and lateral radiographs; • detect any abnormalities in the mediastinal Silhouette and relate them to the most likely causes; • correctly describe the basic anatomical struc ture of the lung, its tracheobronchial tree, and the pulmonary vessels; • describe the basic physiological principles of respiration, gas exchange, and lung perfusion Please take the self-quiz at the end of Chapter (p 32-34) to see how well you have achieved these goals To avoid the false sense of security that short-term memory gives, we suggest that you wait several hours before taking the quiz Working through these first two introductory chapters can be a valuable exercise for physicians as well as medical students, because we know from experience that many details of topographical anatomy can fade over time, often to an unexpected degree We wish you much success! • I Anatomy Thoracic Skeleton The bony structures of the chest absorb and scatter roentgen rays, thus causing greater attenuation (weakening) of the roentgen ray beam than the lung tissue and other thoracic soft tissues Because of this, less radiation reaches the roentgen ray mtensifying screen behind vertebral bodies (26), ribs (2), clavicles (23), and scapulae (27), and less film blackening occurs in those areas This is why bony structures appear lighte r on radiographs than the darker lung parenchyma, for example These areas of increased attenuation are call ed "opacities" in radiology, despite their greate r brightness (Fig 8.1) Conversely, areas that are more easily penetrated by the roentgen ray beam are called "lucenc1es" because of their hyperlucent (= darker than normal) appearance Examples are hyperinflated lung areas and emphysematous bullae The posterior rib segments (22a) are directed more or less horizontally, while the antenor segments (22b) pass obliquely forward and downward Occasionally, beginners will misinterpret the apical lung region enclosed by the first rib (*)as an emphysematous bulla (seep 119) or apical pneumothorax (see p 120) because of its hyperlucent appearance Actually this is an optica l illusion created by the strong contrast between the low radiogra phic density of the apical lung and the high radiographic density of the first rib 28 27 26 Fig 8.1b Fig 8.1a Thus, the radiographic appearance of thoracic structures depends mainly on their density While areas with a high density per unit volume (e.g., cortical bone) appear light or white, areas with a lower density that are more transparent to roentgen rays (e.g., air in the alveoli) appear dark (Fig 8.2) Bone Lead Brightness on radiograph Fig 8.2 D D D Muscle, blood Liver LiJ LiJ ~ ~ D D Fat II Air II I !II liil Solution to p.122: A rounded, nonhomogeneous area of confluent linear and focal opacities is visible on the right side and obscures the right cardiac border ("silhouette sign") The right costophrenic angle is clear (important differentiating sign from pleural effusion) This radiograph is overexposed (pu lmonary vessels are seen on ly in the retrocardiac area) DD: Pneumonia, left pneumothorax, emphysema (despite absence of flattened diaphragm leaflets on deep inspiration), atelectasis (although the opacity looks too nonhomogeneous for atelectasis) Diagnosis: Pneumonia of the right ML The lateral radiograph (Fig 214.1) demonstrates the exact location !1.1 Solution to p.137: A cursory look at this film may l:iil suggest an intrapulmonary mass in the left UZ But the lobu lated opacities on the right scapula are consistent with chondromatosis (chondroma formation in bones and joints), which also affects the left sternoclavicular joint The lesion, then, is extrapulmonary You are correct in thinking that we have not prepared you for a case of this kind But please approach this cha ll enge with an open mind We just want to remind you: Always scrutinize the soft tissues of the chest wall so that you can avoid errors of interpretation Incidental finding: The right subclavian eve is correctly positioned in the sve There is no evidence of pneumothorax m Solution to p.137: The object of this problem was not 1:11 to have you make an accurate diagnosis but to remind you of the options that should be considered in the differential diagnosis of multiple pulmonary nodules If the patient were a newborn, you would also have to consider meconium aspiration (see Fig 133.4) Miliary tuberculosis should also be considered, given the patient's history and possible weakened immune status Diagnosis: Mu ltiple metastases from thyroid carcinoma, which has one peak age incidence in children and another in older adu lts The patient is too young for stage II sarcoidosis, however 1!!1 l:iil Fig 214.1 EliJ Solution to p.122: Homogeneous opacity in the right ,Ia Nodular masses on the right hilum Opaque area with streaky, nodular, and confluent features in the right MZ Peripheral opacity along the right chest wa ll with blunting of the costophrenic angle (also on the left side) Increased lucency on the left side No signs of pulmonary congestion DD: Loculated subpulmonic effusion with cepha lad extension Pleural fibrosis Prior radiotherapy Enlargement of right hilar lymph nodes Diagnosis: Be of the right lung with hilar lymph node metastases and a concomitant malignant effusion There is compensatory hyperinflation of the left lung Solution to p.137: This radiograph shows predominantly centra l dilatation of the pulmonary vascular calibers (" ~) and moderate cardiomega ly ( ), although the radiograph was taken at only a moderate depth of inspiration (seep 25 and Fig 215.1) If you look closely, you will see sternal cerc lage wires (52) at the right mediastina l border, indicating previous heart surgery The horizontal fissure (31) is accentuated, and a biconvex opacity ( •) is projected over the fissure on the right lateral chest wall Does the "lemon" shape sound familiar? Diagnosis: Mild pulmonary venous congestion with predominantly left-sided cardiomegaly and bilateral pleural effusions, including a loculated effusion in the horizontal fissure of the left lung If you would like to exclude a tumor, one way to so is to reexamine the patient after cardiac recompensation (a little furosemide was adequate in this case) Answer Key 215 ' ,.-52 31 Fig 215.1 m Fig 215.2a Solution to p.137: Figure 215.2a is a lateral radiograph of the same patient In what segment is the large, globular density located? If you are not sure, refer back to page 12 The patient, incidentally, was a heavy smoker, and this accounted for her chronic bronchitis The lucency at the center of the mass suggests the possibility of a lung abscess But the fever in this case was the result of an ascending urinary tract infection Diagnosis: The pulmonary lesion was, unfortunately, a bronchial carcinoma (21 ) with central necrosis (64) (Fig 215.2b) Ill Solution to p.138: Admittedly, the quality of the radio~ graph is not very good But if you look closely, you will notice that the left clavicle is obscuring a cavity located within an opacified area The axia l CT scan (Fig 215.3) and positive tuberculin skin test in this case confirmed open pulmonary tuberculosis You, the guards, and the prison inmates would have been at risk for infection- but you caught the problem in time Fig 215.2b IJ!I lill Solution to p.138: Residual, bilateral enlargement of the hilar lymph nodes is still apparent, although the dominant finding is multiple focal opacities indicating pulmonary mvolvement by sarcoidosis Clinically experienced readers will pardon us for giving obvious clues in the history (typical age of predilection and associated symptom), but it 1s important for less experienced readers to become familiar with this set of findings 11:1 lilim Solution to p.138: The radiograph shows multiple ring shadows with sharp inner margins and somewhat ill-defined outer margins, which are typical of abscess cavities You saw the PA radiog raph of this HIV- and HCVinfected patient earlier on page 135 El Fig 215.3 11:1 Solution to p.138: A large hyperlucent cavity is ~ present in the right apicolateral region, surrounded by an ill-defined area of increased tlensity in the right UZ with upward retraction of the right hilum and a pronounced ipsilateral mediastinal shift The focal opacities and pleural fibrosis are located mainly in the upper zones The differential diagnosis would include an abscess following an upper lobectomy, a BC, or tuberculosis The latter was the correct diagnosis in this case (fig 216.1) m Solution to p.138: Unfortunately, it is not unusual for radiograph request forms to contain scant information on the jJattent's history (Try to avoid this in your own practice!) The radiograph shows bilateral hilar lymph node enlargement and calcifications (") plus unsharpness of the right cardiac border with right pericardiac opacity The patient had resolving ML atelectasis (36) in a setting of sarcoidosis (Fig 216.3) Additionally, there are regional hyperlucencies consistent with pulmonary emphysema Fig 216.1 Fig 216.3 ~~ Solution to p.1 40: The three vertica l lucent bands are, from anterior to posterior, the trachea and the spaces between the scapulae The relatively dense cortical lines of the scapulae create the appearance of intervening hyperlucent zones m Fig 216.2 m Solution to p.138: This radiograph shows a complex pattern with a calcified pleural peel ( +) on the right side and numerous focal opacities in the lung The area of increased density at the right apex also harbors a BC (') which was responsible for the sympathetic nerve lesion (Fig 216.2) Postinflammatory calcification is also noted in the left hilar lymph nodes Solution to p.140: Differentiating between a pneumothorax and the medial scapular border With a mantle pneumothorax, the area lateral to the pleural boundary line appears hyperlucent, or darker than the lung medial to it, and is avascular (see p 120) With insufficient lateral rotation of the scapula (see p 24), the area lateral to the scapular boundary line appears hypolucent or lighter than the area medial to it This is the exact opposite of the relative densities that are seen with a pneumothorax f"-11 liiii Solution to p.140: Companion shadow of the clavicle This line is horizontal and para llel to the clavicle and is caused by skin and subcutaneous tissue that are tangential to the roentgen ray beam (see p 52) Answer Key 217 m Solution to p.154: Differentiating criteria Silicosis Asbestosis Sites of predilection for fibrotic changes: UZ, MZ LZ, MZ Spirometric ventilation defects? Obstructive Restrictive Very typical features and their location: Eggshell lymph node calcifications Bilateral, perihilar Pleural plaques Usually basal and anterolateral Table 217.1 liDJ Solution to p.154: You will find the signs of pulmonary congestion listed in Table 143.3 (p 143) and also on the pull-out sheet, which consists of four pocket-sized checklist cards ~ Solution to p.154: A pattern of fine confluent and Ul linear opacities is always suspicious for inflammatory infiltration when it is unilateral or localized and there are no signs of cardiomegaly or pulmonary vascular dilatation (if evaluable, since vascular markings are often effaced within areas of pneumonia-unlike pleura l effusions) A positive air bronchogram is typical of pneumonia, but occasionally it may occur in association with peribronchial edema due to congestion With an interstitial infiltration pattern, the differential diagnosis should also include fungi, viruses, parasites, and atypical pathogens Equivocal cases should be investigated by microbiological analysis of sputum, bronchial secretions, or pleural aspirate and serological testing for elevated antibody titers, eosinophilia, etc JZ11 lill1 Solution to p.154: Pneumocystis carinii pneumonia (PeP) typically develops in immunocompromised patients (corticosteroids, HIV, chemotherapy) Other typical features are an interstitial pattern of markings and the absence of concomitant pleural effusions or hilar lymph node enlargement (seep 116) Early detection is essential, as it may warrant the prompt discontinuation of chemotherapy, for example, and the initiation of antibiotics EIJ Solution to p.155: A comparison of the two sides in Figure 155.1 shows ground-glass opacity of the right lung with no signs of congestion (the left hilar vessels are not dilated, and there are no Kerley lines) The diaphragm leaflets are elevated on both sides (supine radiograph or poor depth of inspiration), but in themselves they cannot account for the increased linear and reticular markings in the right perihilar region or the unsharpness of the right cardiac border (silhouette sign, see p 28) The left hilum appears normal Diagnosis: Right middle lobar pneumonia Associated findings: The catheter introduced through the left jugular vein is positioned slightly too high, and the catheter on the right side has been advanced too far into the right atrium and should be withdrawn by about 3-4 em The third catheter is a gastric tube ~~ Solution to p.155: The child in Figure 155.2 shows increased linear and reticular markings in the left lung and, to a lesser degree, in the right midzone with no cardiomegaly and no detectable pleural effusion The clinical presentation is very helpful in making the correct interpretation Diagnosis: Varicella pneumonia, more pronounced on the left side than on the right EliJ Solution to p.155: Both radiographs in Figure 155.3 are significantly rotated, as indicated by the displacement of the trachea toward the right side and the position of the clavicles Because of this rotation, the left hilum is obscured by the cardiac silhouette in Figure 155.3a and there is apparent accentuation of the right hilum The radiograph taken the next day show a marked progression of pleural effusions with pronounced cardiomegaly Positive air bronchograms are not seen within the opacities The rapid progression is not consistent with inflammatory infiltrates Diagnosis: Progressive pulmonary venous congestion Caution: With possible widening ot the superior mediastinum, you should recommend a follow-up examination after cardiac recompensation Mediastinal hematoma should be considered in postoperative cases E1 ' m Solution to p.156: Despite the marginal quality of the l6il radiograph, you can see faint linear markings in both basal lung regions and concomitant effusions The cardiac size is borderline, and there are no signs of congestion Malignant cells were detected in pleural aspirate Diagnosis: Carcinomatous lymphangitis in the lung due to metastatic breast cancer ~ Solution to p.156: The radiograph in Figure 156.2 Ul shows a diffuse linear and reticular pattern of induration involving both lungs Diagnosis: Pulmonary fibrosis In exploring the history, you would want to look for possible causes (exposure to organic or inorganic dusts, seep 150) and ask about medications and previous infections You should also try to exclude collagen diseases and metabolic defects (cystic fibrosis, alpha-1-antitrypsin deficiency, etc.) RI!P.I lialiil Answer to the question in the text: The following shotgun pellets can be identified in the extrapulmonary soft tissues: (a) one in the right diaphragm leaflet, (b) one in the upper part of the right lateral chest wall, and (c, d) two closely adjacent pellets in the soft tissues of the right side of the neck Three intrapulmonary pellets (e, f, g) are lodged in the right lung and one (h) is in th e left lung r=P-1 li6il Solution to p.156: Of course, the goal in this case was not to make a correct diagnosis Both radiographs in Figure 156.3 show linear and reticular opacities chiefly involvmg the left UZ and MZ, and the right MZ, the latter showing confluent small opacities The second radiograph shows lateral hyperlucency on the right side with no residual pulmonary vascular markings CT scans were also obtained and showed pleural thickening, enlarged mediastinal lymph nodes, and cavitating lesions in the left LL The differential diagnosis includes pulmonary involvement by lymphoma, Kaposi sarcoma, atypical mycobacteria, and right-sided pneumothorax Recommendation: Microbiological or serological tests to identify the infecting organism and determine its antibiotic sensitivity, and closed pleural drainage on the right side close to the left mediastinal border (Fig 218.1a) The lateral radiograph (Fig 218.1b) shows an additional pellet (i) close to the anterior diaphragm, which is easily missed in the PA radiograph The pellet in the chest wall (b) and the intrapulmonary pellets (e-h) are also clearly visualized, but pellets c and d are obscured by the soft-tissue shadows of the neck and cannot be positively identified -a Fig 218.1a Fig 218.1b EJl Solution to p.182: The PA radiograph (Fig 219.1) shows a pacemaker ( t ) and also a port system for ciH:~mulher apy auminislr aLion The reservoir ( Jf ) of the port system and the catheter ( ) can be identified The catheter tip ( + ) is correctly positioned m the SVC This pacemaker is a VVI device with a cable whose tip (~)is on the floor of the right ventricle The radiograph also shows cerclage wires (52) from a previous sternotomy The gastric bubble (18) is clearly visible below the left hemidiaphragm Fig 219.1 Solution to p.182 : A pacemaker unit with two Iiiii electrodes, one in the right atrium ( • ) and one in the right ventricle ( + ), is projected over the left lung Within the cardiac silhouette are two tilting-disk mechanical heart valves ( }placed in the aortic and mitral valve positions The cerclage wires (52) are also well defined An ECG lead l•l is projected over the right lung, and a tracheostomy tube (~}is correctly positioned with its tip above the carina By looking closely, you can identify an indwelling gastric tube (')to the left of the tracheostomy tube (Fig 219.2) m Solution to p.182: The PA radiograph shows a PDA coil ('Y) that was implanted to occlude a patent ductus arteriosus The spiral shape of the device ('Y) is seen more clearly on the lateral radiograph The coil is correctly positioned in the patent ductus (Fig 219.3) lill a Fig 219.3 Fig 219.2 I 11:1 Solution to p.196: The patient had a borderline personality d1sorder and a history of repeated selfinflicted inJuries, some severe Close scrutiny of this radiograph reveals that a fine needle has been passed into the right superior thoracic aperture, causing a significant pneumothorax and hemothorax on the right side The "opacity" in the right pericardiac area IS caused by bunched pulmonary vessels (an effect of elastic recoil toward the hilum) liY Fig 220.1a fl 11:1 tail Solution to p.196: The patient in Figure 196.2 tumbled several meters down a steep slope while hiking in the Sw1ss Alps The supine radiograph shows definite mediastinal widenmg consistent w1th a paravertebral and/ or mediastinal hematoma A CT examination was also performed (Fig 220.1a-c), confirming the suspected hematoma and also showing a longitudinal fracture of the manubrium sterni ( • ) with a retrosternal hematoma ( ) a comminuted fracture of the T3 vertebral body (•) with no paravertebral hematoma, fractures of the first through fourth ribs on the left side, and of the first and second ribs on the right side Fig 220.1c Fig 220.1b Solution to p.203: The tip of the endotracheal tube is projected onto the sternoclavicular joi nts and is an adequate distance from the carina The chest tube is correctly positioned on the left side The tip of the pulmonary artery catheter inserted by the left subclavicular route is correctly positioned in the right pulmonary artery The tip of the eve inserted by the left subclavicular route is correctly positioned in the SVC The depth of the gastric tube cannot be assessed in this case because of the superimposed cardiac silhouette Its extracorporeal portion is projected over the right UZ fliJ Solution to p.208: Because the ventilation pressure is lost when the patient is extubated, the chest radiographs of many freshly extubated patients appear slightly congested compared with the previous ventilated radiographs (see p 200) Also, most extubated patients have a decreased depth of inspiration leading to apparent widening of the cardiac silhouette and bilateral accentuation of the hilar vessels (all effects are increased by the supine position, seep 24) Ill lilil Solution to p.208: Foreign material: The radiograph shows a Tracheoflex tracheostomy tube in the correct position The depth of the gastric tube is obscured by the cardiac silhouette and cannot be assessed Lung: An extensive positive air bronchogram (see p 144) is visible in the left retrocardiac region Multiple fine opacities are visible in the right lung The left lung is generally more lucent than the right lung, probably the result of an angled scatter- reduction grid in a rotated projection Diagnosis: Left lower lobe pneumonia, possible right lower lobe pneumonia Follow-up is recommended Answer Key m Solution to p.208: Foreign material: The endotracheal tube is correctly positioned The pulmonary artery catheter was inserted by the left subclavicular route, and its tip is visible in the right pulmonary artery The CVC was introduced through the right jugular vein, and its tip is projected at the junction of the right brachiocephalic vein with the SVC lung: Both lungs are fully expanded with no signs of pneumothorax A pattern of confluent small and larger opacities is visible in the MZ and LZ (lingula + LL) of the left lung The calibers of the pulmonary vessels are normal, at most showing a small degree of perihilar accentuation Heart: Mild cardiomegaly predominantly affecting the left side Summary: The increased density of the left lung may be caused by residual lavage fluid, and there is suspicion of residual inflammatory infiltrates in the lingula and left LL II!' Solution to p.208: When you look closely at this expiratory (!) radiograph, you will observe posterolatera l fracture lines (29) in at least three ribs (fifth through seventh) on the right side These fractures are responsible for the hemothorax that is causing haziness on the right side Foreign material: The tip of the endotracheal tube {48) is correctly positioned approximate ly em from the tracheal bifurcation (14c) The pleural drain on the right side (67) extends posteriorly to the floor of the costodiaphragmatic recess; it appears too low only because of the poor depth of inspiration The other lines represent ECG leads (52) Diagnosis: Posterolateral fractures of the fifth through seventh ribs with a right hemothorax lilil 221 fl:ll Solution to p.208: Foreign material: The endotracheal tube (48) is correctly positioned The tip of the pulmonary artery catheter is visible at the orig in of the right pulmonary artery ( ).A Demers catheter(*) has been introduced by the left subclavicular route for hemodialysis (see p 165) Its tip ( t ) is projected at the center of the right atrium A CVC (59) has been passed through the right jugular vein, and its tip is also in the right atrium A fourth CVC, introduced from the left side, is also in the right atrium and should be withdrawn by approximately em from its current position The left pleura l dra in (67) is correctly positioned, and the sternal cerclage wires appear to be intact and undisplaced The radiopaque marker on the IABP (")is projected onto the aortic arch or proximal descending aorta (a lateral radiograph is not available) lung: The left lung is fully expanded (with possible slight residual pneumonia in the left apica l lobe) Dilatation of perihilar vessels and Kerley B lines are noted in both lungs There is no evidence of inflammatory infiltrates Heart: The heart shows mild (for a supine radiograph), predominantly left-sided cardiomega ly with a subtle pneumoperica rdium (38, probably due to postoperative residua l air) Summary: Signs of predominantly central pulmonary edema (left-sided heart failure? overhydration? renal function?) Three of the catheters are in the right atrium (see above) lill El Fig 221 I:P.I If you would like to test your knowledge further, we suggest turning back to the Chapter Goa ls listed at the beginning of each chapter Read through each of the learning points and provide detailed answers or descriptions to see how well you have accomplished the various goals Good luck! Ia: Fig 221 Radiation Safety Always consider the ALARA principle ("as low as reasonably achievable") before exposing any patient to diagnostic radiation The effective dose is the most useful parameter for assessing exposure, as it takes into account the individual radiosensitivi- ties of different tissues The unit of measurement for the effective dose is the millis1evert (mSv) In the table below, the dose levels of conventional chest radiographs are compared with those of computed tomography (CT) scanning and with the average annual exposure to ionizing radiation Effective Dose E Radiation Source Average total annual exposure in Germany Natural exposure (radon, terrestrial cosmic, etc ) Fallout from Chernobyl, nuclear weapons testing, etc Ionizing radiation 1n medicine, average total Thoracic CT (breast, lung); dose depends on the examination technique Conventional chest radiographs in two planes Percentage -4.20 mSv - 2.40 mSv -0.03 mSv - 1.50 mSv -5-10 mSv -0.20 mSv 100.0% 57.0% 0.7% 35.7% 120-240% 5.0% The effective dose from a single posteroanterior ( PA) radiograph without a lateral projection is substantially lower These figures not mean that the radiation dose from conventional chest radiographs is harmless, but they allow a rational assessment of the exposure level, which is quite low in relation to other sources Technical Principles The roentgen ray film itself is mounted in a light-proof cassette between two intensifying screens that are in direct contact with the film These intensifying screens are made of substances that emit light when exc1ted by roentgen rays This secondary light emission produces up to 95% of film blackening; only about 5% is produced by the direct action of the roentgen rays themselves This secondary light is emitted in random directions, however, and so it could cause undesired blurring of the exposed film To obtain a high-quality image, then, it is essential that the intensifying screen be pressed tightly against the film This film-screen combination has made it possible to reduce the patient dose substantially below the levels required in earlier techniques (see below) As a rule, film-screen systems with a film speed of 400 are currently used for chest radiographs (a tradeoff between image resolution and Intensification) The film itself consists of a base material that is coated usually on both s1des, with a radiation-sensitive emulsion of silver bromide or silver chloride Primary roentgen ray quanta or secondary light quanta incite a chemical reduction process that causes film blackening, and this effect is amplified when the film is processed Thus, body areas that are more transparent to roentgen rays, such as aerated lung tissue, cause a greater degree of film blackening than less permeable structures such as bone (see p 8) During fixation of the exposed film, nonreduced silver salts are removed from the emulsion As a result, areas that receive little or no exposure to roentgen rays appear lighter on the image, while more heavily exposed areas appea r dark This gives the radiograph the appearance of a "negative" image Digital Systems Increasing ly, analog film-screen combinations (see above) are being replaced by digital systems, whose technical details are beyond our present scope The main advantages of digital systems are the ability to postprocess the image data (brightness contrast etc.) and a reduced risk of overexposure or underexposure in very low or very high dose ranges Lower doses result in a "nosier" image, but, unlike analog systems, provide just as much image information as higher doses Moreover digital images can be stored as computer files in hospital archives and can be quickly accessed by authorized colleagues for evaluation and consultation Quality Criteria Technically acceptable chest radiographs should have the following characteristics: PA radiographs: • The scapulae are not supenmposed over the upper lung zones (they are adequately rotated out of the field) • The proJection is not rotated, i.e., the spinous process of the T3 vertebra is centered and is equidistant from the clavicles • Coverage: The 1mage encompasses both lateral costophrenic angles, all of the thoracic organs, and the soft tissues of the neck • Adequate depth of inspiration: The diaphragm is not superimposed over the posterior segments of the ninth ribs Additional rules for analog images: • The image is not overexposed if peripheral pulmonary vessels can be seen • The image is not underexposed if the spinal column and large lower lobe vessels can be seen within th lateral radiographs: • Arms are elevated so that the (upper) arms are not superimposed over the lungs • The projection IS not rotated i.e., the right and left ribs are projected over one • Suffictently short exposure time: The heart, diaphragm, and great vessels are sharply outlined • Not overexposed Pulmonary vessels are visible in the retrocardiac space (RCS) • Not underexposed: Pulmonary vessels are projected over the cardiac silhouette n1t ~ "4-_95" ~~ ~ ~~ q\'-\~ "~8 ~ MAY 007 For entnes that appear on more than one page, the boldfaced numbers indicate page(s) on which the term is described in particular deta1l AAI pacemaker 167, 169 Abscess· Pulmonary abscess 135, 145 Med1ast1nal abscess 79 Fungal abscess 136 Acm1 16 Acrom1oclav1cular JOint 40·41 AdenomatoSIS of the lung 129 Agenesis of the lung 110 Air bronchogram 143, 144 Air-fluid levels 136, 153, 192 Alpha·! antitrypsin deficiency 151 Alveoli 16 Am1odarone,lung changes due to 147 Amputation, of the arm 37 Anatomy 7·22 Innervation of the lung 22 Interstitium 21 Oiv1s1ons of the lung 10, 16 Pulmonary vessels 18, 22 LymphatiC dramage 21 Mediastinum 20 Segments 12, 14·15 Skeleton B 39 Tracheobronchial tree 13 Ang1ography of the lung 19 Ankylosmg spondyht1s 47 147 AnthracOSIS 150 Annuloplasty 175 Ant1glomerular basement membrane d1sease 147 Aort1c balloon pump 171 Aortic aneurysm 93·94 Aortic coarctation 42 88 Aortic d1ssection 94 Aortic valve d1sease 83·85, 95 Aortic stent 171 AROS 201 ·202 Artenovenous malformation 125 AsbestosiS 53, 56, 149 Aspergilloma 136 Asp1rat1on 119 Contrast med1um 124 Mecon1um 133 Fore1gn body 179 AspergillOSIS 136, 147 AtelectaSIS Lobar 111-113, 147 Segmental 114-115 Round 140 Atnal dilatation, left 84, 141 AVM 125 Azygos lobe I vem 140 Balloon pump (aortic) 171 Barrel chest 118 B1furcat1on angle (tracheal) 13, 72 175 Bileaflet heart valve 173 Bioprosthet1c heart valves 174 Blalock-Taussig operat1on 87 Blood divers1on, upper-lobe 25, 141 Blunting of costophrenic angle 106 Boeck disease (sarcoidosis) 74, 131, 133, 150 Bronchial carcinoma 22 76, 117, 127-129, 152 Bronchiectasis 135, 151 Bronchioli 16 Bronchogram (air) 143, 144 Bullae 119 Butterfly pattern of edema 142 Caged·ball heart valve 174 Card1ac silhouette, age effects 27 Cardiac valve disease 82-87 Card1ac valve replacement 172·176 Cardiomegaly 27, 81, 141-143 Cardiothoracic ratio 27, 81 Cardiomegaly 27, 81,141-143 Cardioversion 170 Caseation (in tuberculoSIS) 132 Catheter insertion (CVC) 159·161 Catheterization 130 Catheter, umbilical 202 Cavities, intrapulmonary 135 Central necrosis, in bronch1al carcmoma 129 Central venous catheter (CVCl 158-163, 199 Insertion 159·161 Checking the pos1t1on of 162, 166 Cervical rib 39 Checklists Fore1gn bodies 181 Signs of congestion 143 Chest wall hematoma 37 Chondrosarcoma 124 Chondrosis 45 Churg·Strauss granulomatosis 147 Clavicle, fracture of 40 Coarctation of the aorta 42, 88 Colon segment interposed (for esophageal carcmoma) 97 Compression atelectasis 106 Congestion, pulmonary venous 77 141-143, 200 Checklist of s1gns 143 Contrast examination (oral of the esophagus) 84, 97, 141 Contrast medium, aspiration of 12 Contusion pulmonary 130, 189 Cor bovinum 108 Corona radiata 129 Costophrenic angle, blunting of 106 Crescent sign 107 Crying lung (in children) 31 CTR 27,81 Cutaneous emphysema 193 Cystic fibrosis 151 DOD pacemaker 167-168 De Bakey class1f1catlon 94 Defibrillators 170 Demers catheter 158 DepressiOn of the hem1d1aphragm 191 D1alysis catheter 165 Diaphragmatic hermas 98, 109 D1sc space infection 79 DISH (Forestier disease) 46 Dose, radiat1on 222 Drug-mduced pneumoma 147 Ductus arteriosus 86 Dyselectasis 111 , 147 Edema, pulmonary 141-143, 200 Effective radiation dose 222 Effusions 90, 106-108, 125, 141, 153,200 Quantification of 108 Elevation of the hemidiaphragm 58 Embolism, pulmonary 19, 207 Risk of 175 Emphysema (cutaneous) 38 99, 118-119, 126, 145, 193 Endobronchial tubes 177 ff Endotracheal tube 177 Enterothorax 109 Eosinophilia 132 Esophagus Atres1a 96 D1vert1cula 96 Carcmoma 97 Stent 178 Euler-LiiJeStrand reflex 29, 141 Fallot, tetralogy of 87 Farmer's lung 150 FAST 194-195 Fibrosis, pulmonary 150 Figure sign, in coarctation of the aorta 88 Film·focus distance 24 Film-screen combination 222 Fissures, pulmonary 11, 111 Fore1gn body aspiration 119, 179 Forest1er d1sease (DISH) 46 Fractures 42, 184-186 (ribs), 188 (vertebrae) Ganglioneuroma 78 Gas exchange 16 Gastric bandmg 47 Gastric pull·up transposition 97 Ghon focus (in tuberculosis) 132 Gorter 68 Granuloma, ben1gn 124 Granulomatosrs Churg-Strauss 147 Granulomatosrs Wegener 134, 147 Ground-glass opacity 21, 141, 146 Hair braids 37 Hamartoma 124, 125 Hampton's sign 207 Hematoma Chest wall 37 Extrapleural 186 Splenic 195 Hem1diaphragm Elevation of 58 Oepress1on of 191 Hem1thorax view 185 Hemopencardium 194 Hemothorax 109, 186·187, 194-195 (FAST), 207 Hernras 98, 109 Heart size of 27 81 Heart valves (prosthetic) 172-176 Hiatal hernra 98 Hrckman catheter 144, 158 HIV patients 146 Honeycomb pattern 150 Humerus, fractures of 41 Hyperkyphosrs 47 Hyperlucencres 8, 118-120 IABP 171, 208 lCD defibrillators 170 Image interpretation, sequence of 30 Innervation of th e lung 22 Intensifying screens 222 Interstitium 21 Intra-aortic balloon pump 171 Intrapulmonary cavities 135 Intubation 117, 177, 198 IROS 201-202 Kartagener syndrome 151 Kerley lines 21, 77, 142, 143 Valvular heart disease 82·87 Koller's pouch 195 Upper-lobe blood diversion 25, 141 Kyphosis, of the thoracic sp1ne 47 Lambert canals 16 laceration, pulmonary 190 Lemon s1gn (of effusion) 125, 200 Lenk's rule 59 Leukem1a 68 Lobar anatomy 10-11 Lobules 16 lobe azygos 140 Loftier inhltrate 132 Lofgren syndrome 131 Lower-zone predominance, of pulmonary blood flow 25 Lucenc1es Lung cancer 22, 76, 117, 127-129, 152 Lung changes due to Amiodarone 147 lung, anatomical d1v1sions of 10, 16 Lung cancer, see Bronchial carcmoma Lymphatic drainage 21·22 Lymphangioma 71 lymphangitiS, carcmomatous 109, 152-153 Lymph node enlargement 72-74 lymphoma 69,74-75, 110 Magn1hcat1on effects 24 Mantle pneumothorax 190 Mastectomy 36 Meconium aspiration 133 Med1astmum Abscess 79 ClassificatiOn 65·66 Emphysema 38, 99, 193 Borders 20, 32, 64 Widemng 47 ff Sh1ft 99-100, 106, 120, 191 Menetner disease 48 Mesothelioma 59 Metallic P1ercings 125 Metastases Pulmonary 126, 134 lymph nodes 72-74 Skeletal 43-44 M1dline sh1ft 99-100, 106, 120, 191 M1sd1rected mtubauon 117, 177, 198 M1tral valve d1sease 82, 84·85 Morrison's pouch 194 MRI compatibility 176 Muscular hypertrophy, atrophy 37 Mycolic abscess 136 Neck dissection 37 Necros1s 129 (in lung cancer), 136(abscess) Neuroblastoma 78 Nipples 37 Notchmg of the ribs 42, 87-88 · - Oral contrast examination (of the esophagus) 84, 97, 141 Opac1t1es, on chest radiographs 8, 26, 36 Opac1ty, ground-glass 21, 141, 146 Osteochondrosis 45 Osteolytic lesions 43-44, 58 Osteosarcoma 124 Pacemaker systems 167-170 Pancoast tumor 58, 129 Paras11e 132 PEEP vent1lat1on 140 Perfus,on 29 Pencard1um 90-92 Pers1stent ductus arteriosus 86 Phren1c nerve paralysis 58, 115, 129 P1ano key s1gn 40 Piercing 124 Plaques 53, 56, 149 Plasmacytoma 115 Pleural effusions 106-108, 125, 141, 153 Pleural fibrosis 54-55 Pleural folds 51 -52, 140 Pleural mesothelioma 59 Pleural plaques 53, 56, 149 PNET 110, 117 Pneumatocysts 16 Pneumocomosis 148 150 Pneumocystis carimi 146 Pneumomed1astmum 38, 99, 193 Pneumon1a 109, 116, 144-147 fungal 133, drug-induced 147 PneumonitiS (postirradiatiOn) 153 Pneumopericardium 91 Pneumothorax 120, 190-192 Port·A·Cath system 153, 158, 164 Positive an bronchogram 143, 144 PostirradiatiOn changes 153 Pnmary complex hn tuberculosis) 119, 132 Prosthetic heart valves 172-176 "Pruning" of pulmonary vessels 118 Pulmonary adenomatOSIS 129 Pulmonary agenesis 110 Pulmonary atresia 77 Pulmonary blood flow, lower-zone predominance, of 25 Pulmonary catheter 130, 166 199 Pulmonary contusion 130 189 Pulmonary edema Alveolar 143 In ICU patients 200 Interstitial 141, 142 Pulmonary embolism 19, 207 Pulmonary fibrOSIS 150 Pulmonary metastases 126 134 Pulmonary valve stenosiS 87 Pulmonary vems, anomalous termination of 140 Pulmonary vessels 18, 22 · Quality criteria 222 Quartz dust inhalat1on 148-150 Quiz questions 32-34, 48·49, 62, 101·103, 121·122, 137·138, 140, 154-156, 196,209-221 Radiation 153 Radiation dose 222 Radiation pneumonitiS 153 Radiation safety 222 Radiographic techmque 24 Radiographic interpretation, sequence of 30 RCS (retrocardiac space) 20 Replacement of cardiac valves 172-176 Rib fractures 42, 184·186 R1b notching, in coarctation of the aorta 42, 87-88 Rockwood classification 41 Round atelectasis 140 ASS (retrosternal space) 20 Sarcoidosis (Boeck disease) 74, 131, 133, 150 Scar emphysema 150 Scatter-reduction gnd 26, 108, 118 Scheuermann disease 46 Schmorl nodes 48 Scmtigraphy (rad1onuclide imaging) 153,207 Scoliosis 46 Segmental anatomy 12, 14 15 Seldinger techmque 159-161 Seminoma, metastases from 134 Sheldon act 158, 165 Sideros1s 150 Signet rmg Sign 151 Silhouette s1gn 28, 116, 145 SiliCOSIS 149 Sjogren syndrome 147 Skeletal dysplasia 42 Skeleton Acromioclavicular joint 40-41 Clavicular fracture 40 Degeneration 45-46 Humeral fracture 41 Metastases 43·44 R1b fractures 42, 184-186 Sternal fracture 188 Thoracic skeleton anatomy of 8-9 Vanants 39 Vertebral body fracture 188 Small cell lung cancer 127 If Soft-tissue emphysema 126 spme, thoracic kyphosis of 47 Spirometry 149 Splenic hematoma 195 Splemc cysts 48 Spondylitis, ankylosmg 47, 147 SpondylOSIS deformans 45 Stanford classificatiOn 94 Stent AortiC 171 Esophageal 178 Sternal fracture 188 Supme radiographs 25 Surfactant 16 Tangential shadows Technical pnnciples of radiography 222 TEE (transesophageal echocardiographyl 207 Tens1on pneumothorax 120, 191 Teratoma 71 ThoraCIC outlet syndrome 39 Thromboembolism risk of 175 Thymus 70 TIItlng·dJsk valves 173 TNM claSSification of lung cancer 128 lossy class1f1cation 40-41 Tracheostomy tube 177, 178 Tracheal spot films 68 Tracheobronchial tree 13 Tracheomalacia 68 Tracheotomy 177 Transpos1t1on of the great artenes (TGA) 89 Triangle of the vena cava 20 Tncusp1d valve disease 86 Tuberculosis Caseation 132 Cavity 135 Ghon focus 132 Lymph nodes 73-74 Miliary form 133 Primary complex 119, 132 Valsalva maneuver 68 Valve replacement 172-176 Valve disease 82-87 Vanants 39, 140 Vertebral arch, mcomplete closure of 39 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( Right middle lobe infiltrate ) ( Right lower lobe infiltrate ) ... readers may send to the publisher on how this workbook might be improved (see p 2) The Authors October, 2006 ~~r The~ ~Hest X- Ray A Systematic Teaching Atlas fj ng ) ~ rh!eme Getting the Most out of... of the pulmonary hilum (Fig 10.1) Just below the UZ is the middle zone (MZ), wh1ch extends down to a line separating the middle and lower thirds of the lung, approximately at the lower end of the. .. surrounds the bronchovascular bundles and accompanies them from the hilum mto the parenchyma of the lung The lymphatics in this compartment run directly to the central hilum Withm the parenchyma, the