(BQ) Part 1 book The chest X-ray - A systematic teaching atlas presents the following contents: Thoracic anatomy, image interpretation, chest wall - soft tissues and bone; pleura, mediastinum.
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 Peri cardium Pericardia! effusions may have various causes, including viral and tuberculous infections, rheumatological diseases, uremia, postmyocardial infarction syndrome, and postcardiotomy syndrome Other possible causes are traumatic hemorrhage (e.g., due to aortic dissection [5.14]) and postirradiation changes [5.15] Cardiomegaly in the setting of a pericardia! effusion may produce a "tent" appearance with an obscured left cardiac border ( 11 in Fig 90.1a) The lateral radiograph (Fig 90.1b) shows global enlargement of the cardiac silhouette with narrowing of the retrosternal space (RSS) (12) and retrocar- diac space (RCS) (13) These contour changes are nonspecific, however [5.16], and the differential diagnosis should always include myogenic dilatation of the left ventricle CT (Fig 90.1c) or echocardiography (Fig 90.1d) can establish the correct diagnosis These modalities can detect even very small amounts of pericardia! fluid (40) With a large effusion causing incipient pericardia! tamponade (see FAST, p 194-195), the decreased cardiac output may cause a decrease in pulmonary vascular markings (see p 25) with prominence of the SVC along the right mediastinal border (see also Fig 25.2) Fig 90.1a Fig 90.1b Fig 90.1 c Fig 90.1 d I • Chronic constnctive pencard1t1s may develop as a sequel to pericarditis or pericard1al effusion (Fig 91 1) In typical cases a disproportion ex1sts between the clinical manifestations of nght-sided heart fa1lure and the normal-sized heart Contraction of the pericardium due to scarring may be associated with the formation of peripheral eggshell calcifications (50) Pneumopericardium (Fig 91 2) may develop postoperatively or following the removal of a pericardia! drain ( t in Fig 91 3) The trapped air forms a double contour along the card1ac borders ( ) and does not extend above the hilar region This latter feature distingUishes 1t from pneumomediastinum and from an esophageal reconstruction (see p 99) by gastric transposition ( ~ ),for example (Fig 91 4) 50 \ Fig 91 Fig 91.2 t t Fig 91 Fig 91.4 Less commonly, pericardia! cysts (49) may be diagnosed as an incidental finding (Fig 92.1a) Most of these cysts result from a congenital disturbance of pericardia! development Pericardia! cysts appear radiographically as a sharply circumscribed round or teardrop-shaped change in the cardiac contour The radiographic density (attenuation) of the cyst contents can be evaluated by CT The densitometry image after contrast administration in Figure 92.1 b shows near-water attenuation values that are consistent with a benigncyst: A mean value of 8.8 HU (Hounsfield units) with a standard deviation (S O) of 6.7 HU Approximately 70% of pericardia! cysts are located in the right cardiophrenic angle (Fig 92.1a) and only about 20% in the left cardiophrenic angle (Fig 92.2a) [5.17] CT demonstrates the close relationship of the cyst to the pericardium (Fig 92.2b), thereby differentiating it from a loculated subpulmonic pleural effusion ,, , ,, f! ,: • 49 Fig 92.1 a Fig 92.1 b 49 ·~ Fig 92.2a Fig 92.2b Aorte Degenerative, inflammatory, or traumatic lesions of the aortic vessel wall may give rise to a thoracic aortic aneurysm (TAA) An aneurysm of the ascending aorta (Fig 93.1) often produces a right-sided bulge (+ )on the PA radiograph, while a TAA of the descending aorta (Fig 93.2) tends to cause a bu lge on the left side ( + ) Several morphological criteria have been established for aneurysm screening on chest radiographs [5.18] (Table 93.3) In the latera l projection, measure the greatest distance between the anterior and posterior wa lls (DA ) of the descending aorta (Fig 93.4) This value, if measurable, should be less than 4.5 em In the PA projection, measure the greatest distance between the left tracheal border and mediastinal border (DrMl in the horizontal plane (Fig 93.5) This distance should be less than em Additional signs are an ascend ing aorta that forms the upper right border of the cardiovascular silhouette( + in Fig 93.1) and a convex bowing of the trac hea 93 toward the right side ( + in Fig 93.5) Occasionally, the left main bronchus is also displaced downward by the dilated aorta ( ' in Fig 93.1) Taken together, these criteria often permit an accurate evaluation of the aortic diameter A norma l set of values can exclude an aneurysm ofthe aortic arch and descending aorta with a high degree of confidence All of the criteria should be analyzed, and no single criterion is diagnostic in itself [5.20] Other imaging modalities such as CT or transesophagea l echocardiography (TEE) are used to make a precise determination of luminal diameter, craniocaudal extent (involvement of supra-aortic branches?), and the shape of the aneurysm (saccular or fusiform?) The axial CT scan in Figure 93.6 shows peripheral thrombosis (51) of the aneurysm involving the aortic arch (6) and descending aorta (8) Radiographic Signs of Aortic Aneurysm Ill • DAo > 4,5 em 1n lateral projection • DrM > 5,0 em • Ascending aorta forms upper right border of ca rdiovascular silhouette • Trachea displaced to the right side • Left main bronchus displaced upward Fig 93.1 Fig 93.2 Table 93.3 Fig 93.4 Fig 93.5 Fig 93.6 An aortic dissection (Fig 94.1) does not necessarily cause widenmg of the mediastinal shadow CT is used to evaluate its extent and make a clinical classification (Fig 94.2) The intimal flap ( ) 1s clearly defined in the CT scan (Fig 94.3a) Multiplanar reconstructions of the CT data can supply valuable information for preoperative planning (Fig 94.3b) In the case illustrated, the patient had a dissecting aneurysm of ~~ the descendmg aorta (8) that did not involve the ascending aorta (7) A pericardia! or left-sided pleural effusion may be noted in the chest radiograph of an asymptomatic dissection [5.14) Endovascular stent msertion is available as a minimally mvasive option for the treatment of aneurysms and dissections (see Fig 171.4a, b in Chapter 9) Stanford Stanford Stanford A A , _f\;1 1\ fJ\ De Bakey De Bakey De Bakey Fig 94.1 Fig 94.2 Fig 94.3a Fig 94.3b I , • I (/' Calcifications 1n aortic sclerosis ( ") while a common mc1dental findmg in older patients (Fig 95.1) are associated with an increased nsk of coronary heart disease (CHO) and should therefore be ment1oned in the radiology report [5.19] In the patient in Figure 95.2, this association provided an indication for a coronary artery bypass graft The sternal cerclage w1res (52) from the operation are visible in the radiograph I 52 _ \ I Fig 95.1 Fig 95.2 Vanants of vascular anatomy can also affect the mediastinal Silhouette The patient in Figure 95.3 had a right descending aorta, Indicated by the absence of the typical aortic knob ( ~ ) above the left main bronchus (14b) and the visible segment of descending aorta along the right mediastina l border (" ) In Figure 95.4, the right-sided aortic arch has caused pronounced displacement of the trachea (14) toward the left side (o+ ) + Fig 95.3 Fig 95.4 Esophageal diverticula may develop at any level of the esophagus Cerv1cal Zenker diverticula (Fig 96.1a) are the most common form, accounting for 70% of cases When large enough, they may cause w1dening of the superior mediastinum ( ) Typical, contrast-filled outpouchings can be seen at fluoroscopy (Fig 96.1b) Esophageal diverticula appear on CT (Fig 96.1c) as sharply circumscnbed masses ( + ) located between the trachea (14) and thorac1c spme (26) Esophageal atresia can also be demonstrated after the ingestion of a water-soluble contrast med1um This condition can also be diagnosed by passmg a boug1e down the esophagus under radiographic control When atres1a IS present, the bougie will loop back upward (' ) after entering the blind esophageal pouch (Fig 96.2) Fig 96.1 a Fig 96.1b Fig 96.1 c Fig 96.2 , ~~ , I , \ Esophageal carcinomas rarely grow large enough to be visible on chest radiographs, and only a few are detected incidentally by the presence of mediastinal widening (' in Fig 97.1a) Th1s tumor should not be mistaken for a retrosternal goiter (see Fig 68.1) or Zenker diverticulum (see Fig 96.1a), especially in the upper part of the esophagus Fluoroscopy after oral contrast administration (Fig 97.2a) in this pat1ent shows contrast material coating the tumor surface and outhnmg 1ts trregular surface structure This pattern differs markedly from the straight tracks of contrast medium that appear in the normal esophagus (Fig 97.2b) Additionally, the axts of the diseased esophagus ( ~ )deviates from its normal craniocaudal alignment • Fig 97.2b Fig 97.1 Fig 97.2a After the involved segment is resected, alimentary continu ity can be restored by a gastric pull-up transposition( ++) or Similar procedure (Fig 97.3) If continuity is restored with an interposed colon segment, the air-containing bowel segment (" )will generally be found d1rectly behind the sternum (Fig 97.4) and not in the normal retrocardiac position occupied by the esophagus CT and endosonography can be used to evaluate circumscribed sites of esophageal wa ll thickening caused by recurrent neoplasia or surrounding lymph nodes Fig 97.3a Fig 97.3b Alimentary transit can be preserved or restored by stent implantation in patients who have an inoperable esophageal tumor (see Fig 171 4a, b tn Chapter 9) Fig 97.4 A hiatal hernia is present when portions of the stomach have hern1ated mto the chest through the esophageal hiatus of the diaphragm The hern1a may cause central widening of the inferior mediastinum Often this produces a double contour {")of the card1ac silhouette {Fig 98.1) on the PA radiograph, which may be mistaken for free mediastinal or pericardia! air {38) {pneumopericardium, Fig 98.2) D1fferentiat1on 1s based on the lateral radiograph {Fig 98.3) or CT scans {Fig 98.4), which can demonstrate intrathoracic portions of the stomach {18) occupying the RCS anterior to the vertebral column Diaphragmatic hernias may also be mistaken for unilateral elevation of the hemidiaphragm on conventional radiographs (see Figs 58.3a, 75.1b) Fig 98.1 Fig 98.2 Fig 98.3 Fig 98.4 ~· Pneumomediastmum (mediastinal emphysema) is caused by air entering the mediastinal connective tissues, causing enhanced delineation of the mediastinal structures On PA radiographs, th1s 1s often manifested only by a hyperlucent double line along the mediastinal border (" " " in Fig 99.1) A (38) may also spread upward through the diaphragmatic crura (17) into the mediastinum, usually due to the perforation of a hollow abdominal viscus by a gastric or duodenal ulcer or tumor Th1s air may accentuate the lateral border of the descending aorta, for example (" " " in Fig 99.2) In doubtful cases a lateral radiograph in the supine position may show a1r separating the heart from the posterior surface of the sternum, or CT scans may help to advance the diagnosis Examples of posttraumatic pneumomediastinum are shown on p 193 and p 202 38 17 " /\ ~ 17 Fig 99.2 Fig 99.1 Mediastinal Shift Three reference points are useful to check for a mediastinal sh1ft on frontal radiographs (Table 99.4) The first is the trachea (14), which should run approximately vertically in the upper part of the mediastinum (Fig 99.3) The second reference point is the knob of the aortic arch (6), which appears just to the left of the vertebral column The carina ( t) is normally located slightly to the right of the midline due to the left-sided position of the aortic arch The third reference point is the border of the right atrium (2), which appears to the right of the vertebral column Any displacement of these reference points may indicate a mediastinal shift The mediastinum may be shifted as a result of pressure or traction (Table 99.5) Diagnosis of Mediastinal Shift Three reference points: Fig 99.3 Vertical course of the trachea (junction with the carina is JUSt to the right of the midline) Left paravertebral knob of the aortic arch (approximately at the level of the posterior part of the fifth rib) Right cardiac border to the right of the vertebral column Table 99.4 Causes of Mediastinal Shift Contralateral pressure: • Tension pneumothorax • Diaphragmatic hernia • Assymetrical emphysema lspilateral traction : • Atelectasis (bronchial obstruction) or previous lobectomy • Pleural adhesions • Unilateral pulmonary hypoplasia (rare) Table 99.5 II The mass effect from a pneumothorax or pleural effusion, for example, may exert pressure that shifts the mediastinum toward the contralateral s1de (Fig 100.1a) compared with the normal mediastinal position (Fig 100.1b) Meanwhile, the traction exerted by an atelectatic lung area, for example, may shihthe mediastinum toward the ipsilateral side (Fig 100.1c) " These true sh1hs of the mediastinum require differentiation from "pseudo-shifts." Deformities of the thoracic skeleton (e.g., funnel chest) may lead to rotation and displacement of the heart that can simulate widening or shifting of the media- Increased volume Contralateral pressure Fig 100.1a stinum In other cases, however, deformity-related ventilation defects or postinflammatory processes may cause a true mediastinal shift A rotated position of the chest in the roentgen ray beam can also mimic a mediastinal shift Another differentiating criterion is to determine whether the mediastinum moves with respiratory excursions At fluoroscopy, dynamic position changes associated with a ballvalve stenosis (e.g., caused by an aspirated peanut) can be distinguished from a static mediastina l shift due to atelectasis or pu lmonary hypoplasia Decreased volume Ipsilateral traction Normal - Fig 100.1c Fig 100.1b The involvement of an entire lung leads to a complete mediastinal shift in which all three reference points are displaced in the same direction Figure 100.2 shows hypoventilation (36) of the right lung with a mediastinal shift to the right side ( + ) This condition was caused by bronchial obstruction secondary to a perihilar lymphoma (21), resulting in atelectasis of the right middle lobe There is compensatory hyperinflation of the leh lung, which shows mcreased lucency When only one upper lobe is affected, the result may be a partial mediastinal shift like that shown in Figure 100.3 In this case only the trachea (14) is shifted, while the aortic arch (6) and right cardiac border maintain their normal positions Th e cause of this partial shift was upper lobe atelectasis (36) An extreme shift of the mediastinum to one side of the chest gives a clear projection of the thoracic vertebral bodies, similar to the appearance of unilateral pulmonary aplasia (see Fig 110.3 in Chapter 6) '· 14 36 21 36 Fig 100.2 Fig 100.3 Complete all three quiz pages before checking the answers at the end of the book This active approach is the best way to Jearn • What landmarks define the anatomical boundaries of the anterior middle and posterior mediastinum in the classificatiOn used here? Name several (at least three) frequent causes of a mass in the anterior mediastinum: : • Name at least two frequent causes of a mass in the middle mediastinum: r What findings can you recognize? Analyze these PA and lateral radiographs from the same patient (fig 101.1 ) Fig 101.1a Fig 101 1b What findings can you recognize? Analyze these radiographs from different patients: "·',, • I ·~· ~ M 11 Fig 102.2 Fig 102.1 What findings can you recognize? These radiographs are from the same patient (Fig 102.3): Fig 102.3a Fig 102.3b IJ Can you remember at least two causes of bilateral enlargement of the hilar lymph nodes? How isolated enlargements of the four cardiac chambers (RA, LA, RV, and LV) appear in the chest radiograph? Write your answers in Table 103.1: RAt= m lilii What type of valvular heart disease leads to narrowing of the RSS? Of the RCS? RSR • = RCR = t = LA RV t = LV t = Table 103.1 • L1st the signs of pericardia! effusion on the standard chest radiograph and their possible causes Wait until you complete your list before comparing your answers with page 90 and page 91 or with the answer key at the end of the book I Radiographic signs: Causes: 1 2 3 4 What are the signs of aortic dilatation on chest radiographs? Lateral radiograph PA rad1ograph m Name the criteria for diagnosing coarctation of the aorta on the chest radiograph: E1 Easy-to-use teaching manuals: Convenient learning tools for diagnostic imaging All three large-format workbooks: Teaching Manual of Color Duplex Sonography · .a - I ~ ' ~ ~ '!lluf'mr Teaching Manual of Color Duplex Sonography Ultrasound Teaching Manual Computed Tomography Teaching Manual 2nd edition 2nd edition 3rd edition • are extensively illustrated with detailed anatomical sketches • contain a comprehensive atlas of normal findings and variants • cover most common patllOIogies and differential diagnoses • come with additional pocket-sized cards with checklists and normal values - very convenient for quick review/reference • include numerous quiz cases and self-assessment sections I Easy ways to order: Worldwide D u Visit our homepage www.thieme.com The Americas fU1 u Fax +1-212-947-1112 ~ Thieme New York 333 Seventh Avenue New York, NY 10001, USA ~ E-mail lll:ifl customerservice@thieme.com ~ Call toll-free within the USA 1:1 I • I 1·800-782-3488 South Asia fii"1 Fax • all common vascular COSapplications • recem developmems (THI, pulse inversion, contrast agents, and more) 20041116 pages 1450 illustrations, most In color I softcover The Americas: USS 49.95 ISBN 978·1·58890·278·8 Rest of World: C44.95 ISBN 978·3·13 127592·9 • perfect guide to using ultrasound scanners • helpful tips and tricks for the beginner 20051132 pages 1741 illustrations I softcover The Americas: USS 49.95 ISBN 978·1·58890-279-5 Rest of World: € 44.95 ISBN 978·3·13·111042-8 • bas1c rules and pitfalls of CT reading • detailed protocols for most common applications • multi-row detector CT IT-angiography and more 20071180 pages (approx) I 600 illustrations (approx) I +91-11-23263522 Thieme South Asia Ansari Road, Daryaganj New Delhi·11 0002 · India ~ E-mail lll:ifl thieme_vitasta@eth.net Rest of World fU1 softcover u The Americas: USS 49.95 (approx) ISBN 978-1·58890·581·9 l.iiiill Rest of World: €44.95 (approx) ISBN 978·3·13·124353·9 Visit our homepage www.thieme.com u Fax +49-711-8931-410 ~ Thieme International P.O.Box30 11 20 70451 Stuttgart· Germany ~ E-mail custserv@thleme.de lll:ifl ~Thieme ... Emphysema, Bullae (Tension) Pneumothorax Quiz - Test Yourself ! 10 5 10 6 10 7 10 8 11 0 11 1 11 2 11 3 11 4 11 5 11 6 11 7 11 8 11 9 12 0 12 1 - - ~ Table of Contents Chapter Focal Opacities Chapter Goals Differential... Pacemakers Biventricular Pacemakers Intra-Aortic Balloon Pump (IABP) 15 7 15 8 15 9 16 2 16 3 16 4 16 5 16 6 16 7 16 8 16 9 17 0 17 1 Prosthetic Heart Valves Mechanical and Biological Valves lilting-Disk and... lymphangitis Quiz- Test Yourself! Chapter 12 3 13 9 14 0 14 1 14 2 14 3 14 4 14 6 14 7 14 8 14 9 15 0 15 1 15 2 15 4 Foreign Bodies Chapter Goals Central Venous Catheters (CVCs) Catheter Types and Applications Catheter