M-1 CHEST RADIOLOGY

1. M-1 CHEST RADIOLOGY Francis H. Neuffer, MD USC-SOM 2009 Click for speaker notes

2. OBJECTIVES • Understand chest X-ray anatomy • Relate catheters and medical devices to anatomy • Identify landmarks at standard CT section levels • Correlate common pathology to anatomy

3. NORMAL CHEST X-RAY PA LATERAL Two (2) projections are needed for most x-rays to locate structures in 3 planes (1)Right or Left , (2) Anterior or Posterior) or (3) Superior or Inferior.

4. NORMAL PEDIATRIC CHEST WITH THYMUS 6 MONTHS OLD Adult chest Normal pediatric chests will often have thymic tissue which looks masslike on a chest x-ray. This tissue involutes in the adult and is not seen. 4

5. NORMAL HEART BORDERS Note cardiac chambers that account for margins on the chest X-ray

6. LEFT 4TH RIBPOSTERIOR AND ANTERIOR PORTIONS POSTERIOR 4 ANTERIOR P A

7. LT. 7 Rib fracture on the left are associated with a small pleural effusion blunting the costophrenic angle. Compare with normal RT. side.

8. BRONCHOGRAM—CONTRAST OUTLINING AIRWAY TRACHEA LT. MAIN BRONCHUS RT. MAIN BRONCHUS CARINA HORIZONTAL FISSURE minor OBLIQUE FISSURE major OBLIQUE FISSURE (major) This exam shows barium contrast outlining the bronchial tree. This is an old exam not done now with CT imaging replacing it. It does demonstrate the anatomy of the hila which is superimposed over the pulmonary arteries and veins. This is why anatomy here on the chest X-ray is difficult in this region.

9. ENDOTRACHEAL TUBE IN POST OPERATIVE PATIENT

10. NOTE THE ENDO TRACHEAL TUBE! Distal endotracheal tube in right main stem bronchus does not allows for ventilation of the left lung. The air in the left lung is absorbed into the blood stream and the lung collapsed into an airless state without effective aeration. Prompt retraction of the endotracheal tube will rectify this. 10

11. NORMAL CHESTANATOMY LATERAL CHEST XRAY Diaphragm-AP view AORTIC ARCH LT. TRACHEA HORIZONTAL FISSURE Diaphragm- Lateral view OBLIQUE FISSURE LT. RT. HEMI DIAPHRAGM RT. LT. HEMI DIAPHRAGM LT. COLON GAS

12. FRONTAL LATERAL Air stripe WHAT AND WHERE IS IT? Coin in esophagus shows a wider diameter than possible in the trachea and is posterior to the tracheal air stripe on the lateral chest x-ray. 12

13. FISSURES DIVIDE LUNGS INTO LOBES RIGHT lung has: UPPER MIDDLE lobes LOWER LEFT lung has: UPPER lobes LOWER HORIZONTAL FISSURE With heart failure edema builds up in lungs and edema along fissures allows them to be seen more easily on chest x-ray

14. NUCLEAR MEDICINE LUNG SCANS Lt Nuclear medicine images are obtained using breathing of radioactive particles to assess ventilation and by injection of radioactive particles to assess perfusion. Pneumonias would show a defect in ventilation and emboli would show a defect in perfusion.

15. MR ARTERIOGRAM FLOW STUDY

16. PULMONARY ARTERIOGRAM CATHETER LT. BRACHIOCEPHALIC VEIN LT. PULMONARY ARTERY LT. UPPER LOBE VESSELS RT. UPPER LOBE VESSELS RT. MIDDLE LOBE VESSELS RT. PULMONARY ARTERY MAIN PULMONARY ARTERY RT. LOWER LOBE VESSELS LT. LOWER LOBE VESSELS Intravenous contrast has been injected from a catheter placed from a Lt. subclavian site with the tip of the catheter in the main pulmonary artery. Rapid imaging while the opacified blood flows though the pulmonary arterial tree gives this image. It is used to assess for pulmonary emboli due from blood clots migrating to the lungs. Typically these are from lower extremity venous thrombi.

17. PULMONARY ARTERY CATHETER SWAN CATHETER INT. JUG. VEIN SVC PA RT. PUL .ART. RA RV Note that catheter extends distally into Rt. Ventricle into the Main pulmonary artery to the Rt. pulmonary artery. The catheter crosses the tricuspid and pulmonary valves to reach the distal site.

18. INT. JUG. VEIN UPPER EXTREMITY VENOUS DRAINAGE SUBCLAVIAN VEIN BRACHIOCEPHALIC VEIN SVC ELECTRODES (NOTE CATHETERS) The catheters are outlining the path of blood flow into the chest.

19. RT. COMMON CAROTID LT. COMMON CAROTID LT. SUBCLAVIAN ARTERY RT. SUBCLAVIAN ARTERY BRACHIOCEPHALIC ARTERY AORTA LT. PUL ARTERY RT. PUL ARTERY AORTA LT ATRIUM SUBTRACTION IMAGE AORTA MR CONTRAST ARTERIOGRAM Here a MR angiogram can show the aortic arterial flow and branches. Subtraction image is a catheter exam showing flow . The bony structures are removed to better show vascular detail.

20. OBLIQUE ESOPHAGUS TRACHEA OBLIQUE SPINE BARIUM FILLED ESOPHAGUS The esophagus extends through the chest. It is a muscular tube and collapsed in the resting state. Here the patient has ingested barium and is rotated to the left to show the extent of the esophagus without overlap of the spine. LEFT HEMIDIAPHRAGM FUNDUS OF STOMACH

21. X-RAY MAMMOGRAPHY CC OBLIQUE Lt. MLO Lt CC PATIENT POSITIONING FOR MAMMOGRAPHY Marker is always put on the axillary side of the breast This exam is done to screen for breast malignancy and assess palpable breast masses. In this exam the darker tissue is fat and the lighter tissue is glandular and fibrous tissue. Masses show as focal regions of lighter denser tissue. 21

22. SCREENING MAMMOGRAPHY VIEWS MLO FATTY TISSUE CC MUSCLE CC VIEW CRANIO - CAUDAL GLANDULAR AND FIBROUS TISSUE MLO VIEW MEDIO-LATERAL OBLIQUE Two images are obtained to assess tissue. A ”CC “or cranio-caudal image is a top/down projection and a “MLO” medio-lateral oblique is a side/side image. 22

23. NORMAL CC MAMMOGRAPHY 1.5 CM MASS US = SIMPLE CYST There is a rounded soft tissue mass medially in the breast. The mammogram cannot separate solid and cystic lesions. The ultrasound demonstrates a benign breast cyst that does not need biopsy. 23

24. AORTA Aorta Pulmonary artery PA RA Left Ventricle LV RV Your hands function as a cardiac model. The fingers are the atria and the dorsum of the hand is the ventricle. The thumbs are the pulmonary artery and the aorta. The arteries run along the knuckles and between the palms.

25. NORMAL HEART

26. PACEMAKER WITH RT. ATRIAL AND RT. VENTRICULAR LEADS RA RV The pacemaker supplies an impulse to drive the heart rhythm if there is a conduction abnormality in the normal course from the SA node to the AV node to the Bundle branches of the ventricles.

27. TRICUSPID AND MITRAL VALVE REPLACEMENT ARROWS SHOW DIRECTION OF BLOOD FLOW THROUGH VALVES FROM ATRIA TO VENTRICLES T M T M Right to left Posterior to anterior

28. POST OP VALVE REPAIR M- MITRAL A- AORTIC A M Post surgical aortic and mitral valve repair are shown. Note the pulmonary catheter does not go through either valve to get into the pulmonary artery. 28

29. AORTIC AND PULMONARY VALVE REPLACEMENT Pacemaker Electrode on skin P A Pacer in Rt. Ventricle Note position of valves relative to diagram and chest x-ray.

30. CORONARY ARTERY ANATOMY Note coronary arteries are in AV(atrioventricular) grooves and interventricular grooves.

31. CORONARY ARTERIES RT. LT. LAD CIRCUMFLEX The right coronary artery is located in the groove of the RT. atria and Rt. ventricle extending to the base of heart. The left coronary artery bifurcates into the left anterior descending which lies in the interventricular groove and the left circumflex which is in the Lt. atria/Lt. ventricular groove. Coronary blood flows to the posterior descending coronary artery and is typically by the Rt. circulation. This is called Rt. dominance. If the Lt circumflex artery feeds the vessel it is termed Lt. dominance.

32. LAD CORONARYARTERIOGRAM CIRCUMFLEX LEFT MAIN ARTERIAL INJECTION Coronary arteriogram -- left main coronary artery injection 32

33. CT THORACIC ANATOMY LOOK AT AN XRAY AS IF THE PATIENT IS LOOKING AT YOU. LOOK AT A CT SCAN AS IF THE PATIENT IS LYING ON THEIR BACK AND YOU ARE LOOKING FROM THEIR FEET TO THEIR HEAD. Anterior projection CT images are viewed from the feet. Note RT/LT markers on images if question remains.

34. RT SCAN LEVELS GREAT VESSELS AORTIC ARCH PULMONARY/CARINA ATRIA VENTRICULES CT CHEST ANATOMY 34

35. RT SCAN LEVEL RT CT CHEST ANATOMY

36. CHEST-- CT RT BRACHIOCEPHALIC ARTERY LT. COMMON CAROTID ART. SVC LT. SUBCLAVIAN ART. TRACHEA

37. SCAN LEVEL CT CHEST ANATOMY

38. CHEST -- CT INTERNAL MAMMARY (THORACIC) ARTERY AND VEIN SVC AORTIC ARCH ESOPHAGUS SCAPULA

39. SCAN LEVEL CT CHEST ANATOMY

40. CHEST -- CT STERNUM ASCENDING AORTA LT. PULMONARY ARTERY CARINA DESCENDING AORTA

41. CHEST - CT LT. ATRIUM SCAN LEVEL

42. ASCENDING AORTA RT ATRIUM LT ATRIUM DESCENDING AORTA

43. SCAN LEVEL CT CHEST ANATOMY

44. CHEST -- CT RT. VENTRICLE SEPTUM DOME OF DIAPHRAGM LT. VENTRICLE DESCENDING AORTA

45. INTERESTING CASES INFECTION NEOPLASTIC CARDIOVASCULAR TRAUMA

47. WHERE IS IT? Right middle lobe pneumonia has changed the normal air density of the lung to soft tissue density of pneumonia. The borders of the fissures are now clearly seen and the right heart border is no longer visualized since no air is there to outline it.

48. WHICH LOBE? Note how the Rt. upper lobe(RUL) pneumonia shows feature similar to the Rt. Middle lobe(RML) disease.

49. Pneumonia compared with normal thymus

50. NUCLEAR MEDICINE FDG-PET SCAN CXR PET The mass in the RT. upper chest shows increased signal on the nuclear medicine scan. This scan shows radioactive glucose metabolism and indicates a lesion that is very active more so that normal tissue and supportive of malignancy.