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CHEST RADIOLOGY

CHEST RADIOLOGY. Dr. Hari Soekersi , Sp.Rad . NORMAL FOUR VIEWS OF THE HEART. 1. Posteroanterior Projection. 2. Lateral Projection. Right Anterior Oblique Projection. 3. Left Anterior Oblique Projection. 4. POSTEROANTERIOR PROJECTION. Right innominate vein Superior vena cava

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CHEST RADIOLOGY

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  1. CHEST RADIOLOGY Dr. HariSoekersi, Sp.Rad.

  2. NORMAL FOUR VIEWS OF THE HEART 1 PosteroanteriorProjection 2 Lateral Projection Right Anterior Oblique Projection 3 Left Anterior Oblique Projection 4

  3. POSTEROANTERIOR PROJECTION • Right innominate vein • Superior vena cava • Right main branch of the pulmonary artery • Upper and lower lobe veins • Right atrium • Tricuspid valve • Inferior vena cava • Arch of the aorta • Left main branch of the pulmonary artery • Main pulmonary artery • Left upper lobe vein • Appendage of the left atrium • Mitral valve • Left ventricle • Right ventricle

  4. POSTEROANTERIOR PROJECTION

  5. POSTEROANTERIOR PROJECTION

  6. POSTEROANTERIOR PROJECTION Aorta Pulmonary artery Superior vena cava Appendage of the left atrium Right Atrium Left Ventricle

  7. LATERAL PROJECTION • Superior vena cava • Ascending aorta • Main pulmonary artery • Right atrium • Tricuspid valve • Right ventricle • Aortic arch • Left main branch of the pulmonary artery • Left atrium • Mitral valve • Left ventricle • Descending aorta • Inferior vena cava

  8. LATERAL PROJECTION

  9. LATERAL PROJECTION

  10. LATERAL PROJECTION Root of the main pulmonary artery Left Atrium Right Ventricle Left Ventricle Because these structures are in contact with mediastinal fat, their margin may be indistinct

  11. RIGHT ANTERIOR OBLIQUE PROJECTION • Anterior wall of the trachea • Innominate vein • Anterior border of the superior vena cava • Superior vena cava • Right main branch of the pulmonary artery • Thoracic aorta • Left atrium • Right atrium • Inferior vena cava • Left innominate vein • Arch of the aorta • Left main branch of the pulmonary artery • Main stem of the pulmonary artery • Left main bronchus • Tricuspid valve • Mitral valve • Right ventricle • Left ventricle

  12. RIGHT ANTERIOR OBLIQUE PROJECTION

  13. LEFT ANTERIOR OBLIQUE PROJECTION • Superior vena cava • Right main branch of the pulmonary artery • Ascending aorta • Main pulmonary artery • Right atrial appendage • Tricuspid valve • Right ventricle • Left subclavian artery • Posterior border of the trachea • Left main branch of the pulmonary artery • Left main bronchus • Left atrium • Mitral valve • Left ventricle • Inferior vena cava

  14. LEFT ANTERIOR OBLIQUE PROJECTION

  15. ANATOMY OF THE HEART

  16. 10. Coronary artery 1. Endocardium of atrium 2. Myocardium of atrium 11. Coronary sinus 12. Coronary vein with valve 13. Epicardium of atrium 3. Annulus fibrosus 14. Subepicardial connective tissue and fat • 4. Mitral valve : • Endocardium • Connective tissue core 15. Perimysial septa with blood vessels 5. Chordatendina 16. Epicardium and subepicardium of ventricle 17. Columnaecarneae 6. Endocardium of ventricle 18. Apex of papillary muscle 7. Myocardium of ventricle 8. Purkinje fibers (conduction fibers) 9. Plate A HISTOLOGY OF THE HEART

  17. PLAIN FILMS DIAGNOSIS OF CARDIAC DISEASE Analyze each case with six steps: 6 2 1 5 3 4

  18. PLAIN FILMS DIAGNOSIS OF CARDIAC DISEASE Analyze each case with six steps: EVALUATION OF THE THORACIC CAGE FOR SIGN OF PREVIOUS SURGERY OR OTHER ABNORMALITIES IDENTIFICATION OF THE POSITION OF THE STOMACH BUBBLE AND HEPATIC SHADOW TO DETERMINE BODY SITE EVALUATION OF GREAT VESSELS FOR SIZE AND POSITION EVALUATION OF SPECIFIC CHAMBER ENLARGEMENT EVALUATION OF CARDIAC SIZE AND CONTOUR EVALUATION OF PULMONARY VASCULARITY

  19. 1 EVALUATION OF THE THORACIC CAGE FOR SIGN OF PREVIOUS SURGERY OR OTHER ABNORMALITIES Signs of previous surgery - periosteal elevation - asymmetry thoracic cage - smaller and slightly deformed rib - resected rib in previous thoracotomy

  20. 1 EVALUATION OF THE THORACIC CAGE FOR SIGN OF PREVIOUS SURGERY OR OTHER ABNORMALITIES Congenital heart disease: - premature fusion of sternum→ cyanotic form - hypersegmentation of sternum → Down’s syndrome - bulging of sternum → enlarged right ventricle

  21. COMPLETE FUSION OF STERNAL SEGMENTS

  22. HYPERSEGMENTATION OF THE STERNUM

  23. ATRIALSEPTAL DEFECT WITH ENLARGED RIGHT VENTRICLE AND ANTERIOR BULGING OF THE STERNUM

  24. 2 IDENTIFICATION OF THE POSITION OF THE STOMACH BUBBLE AND HEPATIC SHADOW TO DETERMINE BODY SITE Abnormal hepatic and stomach position show abnormalities in position of the viscera  congenital cardiac disease

  25. SITUSSOLITUS WITH DEXTROCARDIA Stomach bubble is under the left diaphragm Liver is on the right Heart is on the right with cardiac axis directed to the right

  26. SITUSINVERSUS WITH DEXTROCARDIA Stomach bubble is under the right diaphragm Liver is on the left Heart is on the right with cardiac axis directed to the right

  27. ISOLATED LEVOCARDIA OR SITUSAMBIGUS Stomach bubble is under the right diaphragm Liver is on the left Normal heart position

  28. ? ? DEXTROCARDIA ? DEXTROVERSION Dextrocardia : Location of the heart in the right side of the thorax, the apex pointing to the right Dextroversion : Location of the heart in the right chest, the left ventricle remaining in the normal position on the left with the apex pointing the the left

  29. 3 EVALUATION OF GREAT VESSELS FOR SIZE AND POSITION Enlargement of the pulmonary artery segment Prominent pulmonary arterial segment along the left upper cardiac border In TGV and truncusarteriosusabnormal position (concave) Enlargement of the aorta Three portions of the aorta can be evaluated: ascending aorta, aortic arch dan descending aorta.

  30. ENLARGEMENT OF PULMONARY ARTERY SEGMENT

  31. TRANSPOSITION OF GREAT VESSELS

  32. TRANSPOSITION OF GREAT VESSELS

  33. TRUNCUSARTERIOSUS

  34. TRUNCUSARTERIOSUS

  35. ENLARGEMENT OF THE AORTA Usually, the ascending aorta does not extend beyond the right upper mediastinal shadow. Here, there is enlargement of the aorta.

  36. 4 EVALUATION OF SPECIFIC CHAMBER ENLARGEMENT Signs of left atrial enlargement Signs of left ventricular enlargement Signs of right atrial enlargement Signs of right ventricular enlargement

  37. SIGNS OF LEFT ATRIAL ENLARGEMENT Posteroanterior projection • Displace the barium-filled esophagus below the carina to the right • Prominent bulge along the mid-left cardiac border • A double density along the right cardiac border • Widening of the angle of the carina >900 Lateral projection • Posterior displacement of both walls of the barium-filled esophagus

  38. SIGNS OF LEFT ATRIAL ENLARGEMENT Left anterior oblique projection Elevate the left mainstem bronchus and obliterates the spaces between the posterior cardicac margin and the left mainstem bronchus

  39. LEFT ATRIAL ENLARGEMENT

  40. SIGNS OF LEFT VENTRICULAR ENLARGEMENT Posteroanterior projection • Left ventricular dilatation produces downward displacement of the apex toward diaphragm. • Left ventricular hypertrophy produces a round left cardiac border Left anterior oblique projection Posterior cardiac margin to overlap the vertebral column

  41. LEFT VENTRICULAR DILATATION

  42. LEFT VENTRICULAR HYPERTROPHY

  43. SIGNS OF RIGHT ATRIAL ENLARGEMENT Posteroanterior projection Difficult  increased convexity of the lower right heart border on PA projection

  44. RIGHT ATRIAL ENLARGEMENT

  45. SIGNS OF RIGHT VENTRICULAR ENLARGEMENT Posteroanterior projection • Rounding and elevation of the cardiac apex • Lateral projection • Retrosternal space is obliterated • Left anterior oblique projection Increased convexity of the anterior cardiac border

  46. RIGHT VENTRICULAR ENLARGEMENT

  47. 5 EVALUATION OF CARDIAC SIZE AND CONTOUR Index of cardiac enlargement is the cardiothoracic ratio. In infants: 0.55 In adults : 0.45 The lateral and oblique views must be considered

  48. CARDIOTHORACIC RATIO (Cardiac width / Thoracic cage width) x 100%

  49. 6 EVALUATION OF PULMONARY VASCULARITY In normal  the pulmonary vascular marking taper gradually toward the periphery of the lung fields, and more prominent in the lower lung fields. The vessels in the right hillum is larger than in the left

  50. SIX DIFFERENT VASCULAR PATTERNS ARE RECOGNIZED • Normal pulmonary vascularity • Increased pulmonary vascularity due to increased pulmonary blood flow. - the peripheral arteries are sharply outlined and dilated and distributed equally to both the upper and lower lobes. - ex. VSD, PDA, truncusarteriosus, transposition of the great vessels.

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