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Radiologic Signs: Chest

Joseph Rumir M. Soquea, M.D.

Normal CXR PA

Anatomy of CXR PA

Lung Margins

Normal CXR Lateral view

Air Bronchogram
Causes: 1. Lung consolidation 2. Pulmonary Edema 3. Nonobstructive pulmonary atelectasis 4. Severe interstitial disease 5. Neoplasm 6. Normal expiration

An air bronchogram is a tubular outline of an airway made visible by filling of the surrounding alveoli by fluid or inflammatory exudates.

Silhouette sign
described by Dr. Ben Felson elimination of the silhouette or loss of lung/soft tissue interface (border) caused by a mass or fluid in the normally air filled lung commonly applied to the heart, aorta, chest wall, and diaphragm

ATELECTASIS

collapse or incomplete expansion of the lung or part of the lung Causes: 1. endobronchial lesion (most common) 2. mass 3. pleural effusion 4. cicatricial type secondary to scarring, TB, or status post radiation (unusual type) linear increased density on chest x-ray xthe density is associated with volume loss indirect signs of volume loss 1. vascular crowding or fissural 2. tracheal, or mediastinal shift, towards the collapse

CXR PA - Atelectasis

Bowing sign
Oblique fissure bows forward Forward movement of the oblique fissure

Left lung Atelectasis


Left Upper Lobe Atelectasis
anterior shift of the upper lobe due to left upper lobe collapse loss of the left upper cardiac border expanded lower lobe will migrate to a location both superior and posterior to the upper lobe to occupy the vacated space

Atelectasis Left Lower Lobe

similar in appearance with RLL atelectasis silhouetting of the corresponding hemidiaphragm, crowding of vessels, and air bronchograms substantially collapsed lower lobe will usually show as a triangular opacity situated posteromedially against the mediastinum.

Atelectasis LLL

Right Lung Atelectasis


Right Upper lobe Atelectasis
lobe migrates superomedially toward the apex and mediastinum the minor fissure elevates inferior border of the collapsed lobe is a well demarcated curvilinear border arcing from the hilum towards the apex with inferior concavity

Right Middle Lobe Atelectasis

may cause minimal changes on the frontal chest film loss of definition of the right heart border more easily seen in the lateral view as a wedge of opacity pointing to the hilum.

Right Lower Lobe Atelectasis


Silhouetting of the right hemidiaphragm and a triangular density posteromedially persistance of the right heart border.

PULMONARY EDEMA

Two types of Pulmonary Edema


A.) Cardogenic edema - caused by increased hydrostatic pulmonary capillary pressure. cephalization of the pulmonary vessels Kerley B lines or septal lines peribronchial cuffing, "bat wing" pattern patchy shadowing with air bronchograms and increased cardiac size B.) Noncardogenic pulmonary edema - caused by either altered capillary membrane permeability or decreased plasma oncotic pressure. Causes: 1. near-drowning near7. altitude sickness 2. oxygen therapy 8. renal disorder 3. transfusion or trauma 9. drugs 4. CNS disorder 10. inhaled toxins 5. ARDS 11. allergic alveolitis 6. aspiration 12. contrast or contusion

Cephalization of pulmonary veins and indistincness of vascular margins

Bat wing pattern . Fulminant pulmonary edema from CHF

Congestive Heart Failure


heart fails to maintain adequate forward flow progress to pulmonary venous hypertension and pulmonary edema with leakage of fluid into the interstitium, alveoli and pleural space Cardiomegaly - earliest CXR finding Cephalization - upper zone veins dilate and are equal in size or larger than the lower zone veins Kerleys lines bat wing pattern of density

Kerly B lines
Causes: 1. pulmonary edema 2. lymphangitis carcinomatosa 3. malignat lymphoma 4.viral & mycoplasmal PNM 5. interstitial pul fibrosis 6. sarcoidosis & pneumoconiosis horizontal lines less than 2cm long commonly found in the lower zone periphery these lines are the thickened, edematous interlobular septa

PNEUMONIA

Pneumonia
airspace disease and consolidation air spaces are filled with bacteria or other microorganisms and pus NOT associated with volume loss (space occupying lesion w/out volume loss) Causes 1. bacteria 2. viruses 3. mycoplasmae 4. fungi Other causes of airspace filling not distinguishable radiographically: 1. fluid (inflammatory) 2. cells (cancer) 3. protein (alveolar proteinosis) 4. blood (pulmonary hemorrhage)

X-ray findings
airspace opacity lobar consolidation interstitial opacities.

The characteristic chest x-ray appearance of some PNM: xLobar - entire lobe consolidated and air bronchograms common Lobular - multifocal, patchy, sometimes w/out air bronchograms Interstitial - starts perihilar and can become confluent and/or patchy as disease progresses, no air bronchograms Diffuse pulmonary infections - community acquired (Mycoplasma, resolves spontaneoulsy) nosocomial (Pseudomonas, debilitated, mechanical vent pts, high mortality rate, patchy opacities, cavitation, ill-defined nodular) immunocompromised illhost(bacterial, fungal, PCP

CXR PAL RML Pneumonia

CXR PAL RUL Pneumonia

TUBERCULOSIS

Radiographica representation: consolidation adenopathy pleural effusion. Ghon focus - area of consolidation that most commonly occurs in the mid and lower lung zones. Ghon complex - addition of hilar adenopathy to a Ghon focus Radiographic features of post-primary TB: postfocal patchy airspace disease "cotton wool" shadows cavitation fibrosis nodal calcification flecks of caseous material occur most commonly in the posterior segments of the upper lobes, and superior segments of the lower lobes

CXR PA - PTB

Pulmonary Hemorhrrage
Causes 1. Trauma 2. Goodpastrue's syndrome 3. bleeding disorders 4. high altitude 5. mitral stenosis.

appearance is like that of other airspace filling processes (pneumonia, edema) has opacity often with air bronchograms blood fills the bronchi and eventually the alveoli may clear more quickly than other alveolar densities such as pneumonia

PULMONARY EMBOLISM

primary source is thrombus from the deep veins of the legs primary purpose of a chest film in suspected PE is to rule out other diagnoses as a cause of dyspnea or hypoxia most CXRs in patients with a PE are normal Signs in PE 1. Westermark's sign (oligemia in area of involvement) 2. increased size of a hilum (caused by thrombus impaction) 3. atelectasis with elevation of hemidiaphragm 4. linear or disk shaped densities 5. pleural effusion 6. consolidation 7. Hampton's hump (rounded opacity) pulmonary infarctions - multifocal consolidation at the pleural base in the lower lungs

CXR PA Pulmonary Embolism

Hamptons Hump Wedge shaped consolidation Lung periphery Pleural based Rounded convex apex towards hilum

PLEURAL EFFUSION

Common causes for a pleural effusion 1. CHF 2. infection (parapneumonic) 3. trauma 4. tumor (if malignant usually unilaterally large effusions) 5. autoimmune disease 6. renal failure Upright film 1. blunting on the lateral and if large enough, the posterior costophrenic sulci 2. large effusion can lead to a mediastinal shift away from the effusion and opacify the hemothorax 3. approximately 200 ml of fluid are needed to detect an effusion in the frontal 4. approximately 75ml for the lateral Supine film 1. graded haze that is denser at the base and the vascular shadows can usually be seen through the effusion 2. can veil the lung tissue and thicken fissure lines 3. may be no apparent blunting of the lateral costophrenic sulci Lateral Decubitis film 1. confirmation of effusion in a bedridden patient (fluid will layer out on the affected side [unless the fluid is loculated])

CXR PAL Pleural Effusion

PNEUMOTHORAX

air inside the thoracic cavity but outside the lung spontaneous pneumothorax (PTX) - occurs without an obvious inciting incident Causes of spontaneous PTX 1. idiopathic, asthma 5. Marfans syndrome 2. COPD 6. cocaine 3. pulmonary infection 7. iatrogenic 4. neoplasm 8. trauma tension PTX - air enters the pleural cavity and is trapped during expiration CXR 1. air w/out lung markings in the least dependant part of the chest 2. air is found peripheral to the white line of the pleura 3. upright film air is most likely seen in the apices 4. best demonstrated by an expiration film Hydropneumothorax 1. both air and fluid in the pleural space 2. air-fluid level on an upright or decubitus film air3. Causes - trauma - rupture esophagus - thoracentesis - empyema - surgery

Pneumothorax

Tension PTX

CXR PAL - Hydropneumothorax

Right Decubitus - Hydropneumothorax

EMPHYSEMA

CXR - diffuse hyperinflation with flattening of diaphragms - increased retrosternal space - bullae (lucent, air-containing spaces that have no vessels airthat are not perfused) - cor pulmonale - enlargement of PA/RV (secondary to chronic hypoxia) different types 1. panlobular 2. intralobular 3. paraseptal "Saber sheath" tracheal deformity is when the coronal diameter is less than 2/3 that of the sagittal. In smokers, upper lung zones are commonly more involved than the lower lobes. Chronic bronchitis commonly occurs in patients with emphysema and is associated with bronchial wall thickening

Normal Tracheal Shape

Saber Sheath Trachea

CXR PAL Emphysema

Anterior Mediastinal Mass 1. lymphadenopathy 3. Teratoma 5. aortic aneurysm 7. epicardial fat pad.

2. Thymic tumors 4. Thyroid mass 6. pericardial cyst

T-cell Lymphoma

Middle Mediastinal Mass


most common cause is lymphadenopathy due to metastases or primary tumor other causes are hiatial hernia, aortic aneurysm, thyroid mass, duplication cyst, and bronchogenic cyst

Posterior mediastinal Mass


neoplasm, lymphadenopathy, aortic aneurysm, adjacent pleural or lung mass, lateral meningocele, and extramedullary hematopoiesis

Pneumomediastinum
streaky lucencies over the mediastinum that extend into the neck elevation of the parietal pleura along the mediastinal borders Causes - asthma - surgery (post-op complication) (post- traumatic tracheobronchial rupture - abrupt changes in intrathoracic pressure (vomiting, coughing, exercise, parturition) - ruptured esophagus - barotrauma - cocaine In pneumopericardium, air can be present underneath the heart, but does not enter the neck

CXR PA - Pneumomediastinum

Diaphragmatic Hernia
3 types 1. hiatal hernia - the stomach slips through the esophageal hiatus into the hest 2. Bochdalek hernia is through a weakness in the diaphragm, and usually occurs on the left side posteriorly 3. Morgagni hernias typically occur medially

Alveolar cell carcinoma


Bilateral Miliary acinar nodules Many larger than interstitial nodules Nodules of varying size with irregular margins

Egg shell calcification


Only the periphery of the lymph node is calcified classical for silicosis

Halo Sign
In a cavity with a fungus ball, there is a crescentic lucent space along the upper portion of the density giving the appearance of a halo

Honeycombing
Seen in end stage lung disease Indicative of diffuse interstitial fibrosis Due to bronchiolectasia Most of the time in bases Upper lobe distribution seen in eosinophilic granuloma

Non anatomical lines


Linear showdows not corresponding to any anatomical tructures

Diffrential Dx: Pleural fibrosis Extrathoracic density Bleb wall Lung fibrosis

Pulmonary Artery overlay sign


the same concept as a silhouette sign. If you can recognize the interlobar pulmonary artery, it means that the mass seen is either in front of or behind it

Dissecting Aneurysm

S Curve of Golden
When there is a mass adjacent to a fissure, the fissure takes the shape of an "S".

RUL mass with atelectasis

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