This presentation is almost a complete Pictoral view of Radiograph chest.
This presentation will help radiologist in daily reporting.
This presentation will help physicians, surgeons, anesthetist and almost all medical professionals in diagnosing commonly presenting cardiac diseases.
This will also help all in preparaing TOACS examination.
5. ROTATION
The medial ends of both clavicles
should be equidistant from the
spinous process of the vertebral
body projected between the
clavicles
6. The increase in blackness
(radiolucency) of one
hemithorax is always on
the side to which the
patient is rotated,
irrespective of whether the
CXR has been taken PA or
AP
7. DEGREE OF INSPIRATION
It is ascertained by counting either the
number of visible anterior or posterior
ribs
Adequate inspiratory effort – five to
seven complete anterior or ten posterior
ribs are visible
Poor inspiratory effort - fewer than five
anterior ribs
Hyperinflated lung-more than seven
anterior ribs
8. IMPORTANCE OF AN INSPIRATORY FILM
POOR INSPIRATORY FILM NORMAL INSPIRATORY FILM
1
2
3
1. Mediastinal Widening 2.Cardiomegaly 3.Lower lobe patchy opacification
9. PROJECTION OF X-RAY
Projection is defined as the direction of x-ray with
relation to the patient
If the direction of x-ray projection is from front – AP
projection
If the direction of x-ray projection is from behind –PA
projection
11. PA VIEW AP VIEW
In erect patients
Vertebral spines more
prominent
Scapulae clear of lungs
Clavicles are horizontal
In supine patients
Vertebral bodies clear
Apparent cardiomegaly
Scapulae overlap
Clavicles are oblique
12. ERECT SUPINE
Gas bubble in fundus with a
clear air fluid level
Gas bubble in antrum
Apparent cardiomegaly
13. EXPOSURE OF X-RAY
Normal exposure - the vertebral bodies should just be
visible at the lower part of cardiac shadow
Underexposed -If the vertebral bodies are not visible ,
insufficient number of x-ray photons have passed
through the patient to reach the x-ray film
Similarly, if the film appears too ‘black’, then too many
photons have resulted in overexposure of the x-ray film.
15. SYSTEMATIC APPROACH
Technical factors
Skeletal abnormalities and hardware
Situs: gastric air bubble, cardiac apex, and aortic knob
Heart: position, size, and shape
Great vessels: position, size, and shape
Lung fields and vascularity by zone
Search for calcifications
26. HOW TO MEASURE MAIN PULMONARY ARTERY
If we draw a
tangent line from the apex
of the left
ventricle to the
aortic knob(red line)
and measure along
a perpendicular
to that tangent
line (yellow line)
The distance between the
tangent and the main
pulmonary artery
(between two small green
arrows) falls in a range
between 0 mm (touching
the tangent line) to as
much as 15 mm away from
the tangent line
27.
28. PROMINENT MPA
Main pulmonary artery projects
more than the tangent
Causes:
1. Increased pressure
2. Increased flow
29. HYPOPLASTIC PA
MPA > 15 mm from the tangent
Concave PA segment
Causes:
1. TOF
2. TRUNCUS ARTERIOSUS
32. CARDIOMEGALY
The cardiothoracic ratio should be less
than 0.55 on PA view. i.e. A+B/C<0.55
A cardiothoracic ratio > 0.55 suggests
cardiomegaly in adults
A cardiothoracic ratio > 0.6 suggests
cardiomegaly in newborn
33. CTR is more than 50% but heart is normal
Spurious causes of cardiac enlargement
Portable AP films
Obesity
Pregnant
Ascites
Straight back syndrome
Pectus excavatum
34. CTR is less than 50% but heart is
abnormal
Obstruction to outflow of the
ventricles
Ventricular hypertrophy
Must look at cardiac contours
< 50%
ASCENDING AORTA DILATED LV CONTOUR
35. CRITERIA'S FOR CARDIOMEGALY
Cardiothoracic ratio >0.55 in adults on PA view
Cardiothoracic ratio >0.6 in newborn on PA view
Any increase in transcardiac diameter > 2 cm compared
to old x-ray
In old age and emphysema a transcardiac diameter
more than 15.5 cm in males &>12.5 cm in females
37. CRITERIA FOR RA ENLARGEMENT
Rt. Cardiac border becomes more
convex > 50% of right border
Rt. Atrial border extends >3
intercostal spaces
Measurement from mid vertical line
to max. convexity in rt. Border>5 cm
in adult & >4cm in children
Lateral view – fullness in space
between sternum and front of
upper part of cardiac silhouette
38. CRITERIA FOR LA ENLARGEMENT
Widening of carina( normal 45-75 degree)
Elevation of left bronchus
Straightening of left border
Double atrial shadow( shadow within shadow)
Grade 1 –double cardiac contour
Grade2 - LA touches RA border
Grade 3 – LA overshoots the Rt. Cardiac border
Displaces the descending aorta to the left and esophagus to
right seen in barium swallow
40. LEFT ATRIAL ENLARGEMENT
DOUBLE ATRIAL SHADOW
WIDENING OF CARINA
ELEVATION OF LEFT
BRONCHUS
Left atrial appendage
enlargement
41.
42. Widening of carina
Elevation of lt.
bronchusAneurysmal LA
Aneurysmal LA – When La enlarges to left and right and approaches within
an inch of lateral chest wall
44. LEFT VENTRICULAR ENLARGEMENT
PA view
(a)Left cardiac border gets enlarged and becomes more convex
resulting in cardiomegaly
(b)Lt. cardiac border dips into lt. dome of diaphragm
(c) rounded apical segment
(d) cardiophrenic angle is obtuse
45. LEFT VENTRICULAR ENLARGEMENT
Lateral view
(a) Left ventricle enlarges inferiorly and posteriorly
(b)Rigler’s measurement A is >17 mm
(c)Rigler,s measurement B is< 7.5 mm
(d) Eyeler’s ratio becomes > 0.42
46. RIGLER’S MEASUREMENT
Rigler’s A & B used to differentiate left
ventricular and right ventricular
enlargement
Possible only when IVC shadow is
present
Jn. Of IVC with Lt. Atrium – J point
Rigler’s A- from J point along line of IVC
draw a line of 2 cm above and mark the
point X.
47. Draw a horizontal line from pt. A to posterior
Cardiac border and mark that pt. y
Distance between points x & y is Rigler’s
measurement A
NORMAL<17 mm
Rigler’s B-from the pt. J drop a perpendicular
line to the dome and this distance is Rigler’s
measurement B
NORMAL>7.5 mm
RIGLER’S MEASUREMENT
48. When LV enlarges,
Posterior cardiac border gets displaced
posteriorly & IVC shadow gets included in
cardiac shadow, without getting displaced
posteriorly
Rigler’s measurement A >17 mm in lt.
ventricular enlargement
RIGLER’S MEASUREMENT
49. EYELER’S RATIO
To differentiate lt. & rt. Ventricular
enlargement
Valid when IVC shadow is absent or cannot
be visualised
Mark the point of jn. where postero inferior
cardiac border meets the dome as B
From this point B draw a horizontal line to
the posterior border of sternum-AB
50. From pt.B - draw another horizontal line
posteriorly to the inner border of the rib-
BC
Ratio of AB/BC is Eyeler’s ratio < 0.42
EYELER’S RATIO
51. LA Oblique view
There is a retrocardiac space( prevertebral)
(a)Mild lt. Ventricular enlargement-obliteration
of retrocardiac space
(b) mod. Lt.ventricular enlargement-cardiac
shadow overlaps vertebral column
(c)Marked Lt.ventricular enlargement-cardiac
shadow overshoots vertebral column
52. Chest X ray shows left ventricular
enlargement.
Left heart border is displaced
leftward, inferior and posteriorly.
Rounding of the cardiac apex.
53. RV ENLARGEMENT
PA VIEW
Cardiophrenic angle is acute
Clockwise rotation of heart causes RV to form
the middle portion of the left heart border.
RIGHT LATERAL VIEW
Obliteration of retrosternal spac
54. RV ENLARGEMENT
LEFT LATERAL VIEW
Rigler’s measurement will be17mm or less
Rigler’s measurement will be 7.5mm or more
Eyeler’s ratio is 0.42 or less
55. PERICARDIAL EFFUSION
Narrow vascular pedicle
Cardiomegaly directly proportional to severity of pericardial
effusion
This shadow has a rounded, globular appearance with no
particular chamber enlargement
Cardiophrenic angle become more and more acute
Oligaemic pulmonary vascular markings
Marked change in cardiac silhouette in decubitus posture
‘Epicardial fat pad sign’- anterior pericardial strip bordered
by epicardial fat post. and mediastinal fat ant.>2mm
57. DILATED CARDIOMYOPATHY VS
PERICARDIAL EFFUSION
Chambers can be identified
Cardiophrenic angle is obtuse
Increased pulmonary venous hypertension
No change in cardiac silhouette in decubitus
Vascular pedicle is dilated or normal
Fluoro shows cardiac pulsation
58. CONSTRICTIVE PERICARDITIS
1.Straightening of the right
border
2.Pericardial thickening > 4
mm
3.Pericardial calcification (50%
cases)
4.Dilatation of SVC and
azygous vein
Pericardial calcification
59. CONGENITAL ABSENCE OF PERICARDIUM
Focal bulge in area of main pulmonary
artery
Sharply marginated
Absent right cardiac border
Increased distance between sternum
and heart due to absence of sterno
pericardial ligament
63. PULMONARY VENOUS HYPERTENSION
LARRY ELLIOT’S CLASSIFICATION OF PVH
RADIOGRAPHIC
GRADE OF PVH
ACUTE DISEASE
PCWP
CHRONIC DISEASE
PCWP
1 13-17 MMHG 13-17 MMHG
2 18-25 MMHG 18-30 MMHG
3 >25 MMHG >30 MM HG
4 HEMOSIDEROSIS
AND OSSIFICATION
LONG STANDING
PVH
64. GRADE 0 -PCWP< 12 MM HG
Upper lobe pulmonary veins are less prominent than lower lobe veins
GRADE 1- PCWP 13-17MMHG
Redistribution of blood flow with cephalization-’ANTLER SIGN’
1) increased resistance to flow due to interstitial odema
2) alveolar hypoxia in lower lobes causes reflex vasoconstriction
3) vasoconstriction of the arterioles due to LA or pulmonary vein reflex
PULMONARY VENOUS HYPERTENSION
66. KERLEY A LINES
Distended lymphatic channels within
edematous septa coursing from
peripheral lymphatics to central hilar
nodes
Towards the hilum
Less specific for Pulmonary venous
hypertension
KERLEY A LINES
67. KERLEY B LINES
Horizontal lines
1-3 mm thick
Perpendicular to pleural surface
Towards the costophrenic angle
Accumulation of fluid in interlobular
septa and lymphatics
Highly specific for PVH
KERLEY B
68. Crisscross lines seen between A &B
GRADE 3 – pcwp > 25mm hg
Alveolar odema
Bilateral diffuse patchy
cotton wool opacities
KERLEY C LINES
69.
70. Pulmonary circulation
Pulmonary plethora – features
Enlargement of central pulmonary artery , lobar and segmental
artery
Prominent nodular vascular shadows in frontal CXR- shunt vessels
that course ventral to dorsal
Upper & lower lobe vessels prominent
RPDA > 17mm
Right descending pulmonary artery> tracheal diameter Ratio of
RPDA to diameter of trachea > 1
Plethora seen if shunt size >2:1
72. Decreased flow proximal to orgin of main pulmonary artery
Small pulmonary artery
Empty pulmonary bay
Pulmonary vessels small
Lung hypertranslucent
Lateral view shows diminution of hilar vessels
Pulmonary oligaemia
74. High pressure left to right shunts are associated with
obliterative changes in the smaller pulmonary arteries &
arterioles
Large main & large central pulmonary arteries taper down
rapidly to very small vessels
Seen in Eisenmenger’s syndrome
Precapillary PAH
Pruning
86. Linear or railroad track
calcification at site of ductus may
be seen in adults with PDA
PROMINENT
MPA
LV APEX
PLETHORA
AORTIC KNOB
PDA
87. • “FIGURE OF 3” in CXR
• “REVERSE 3” or “E sign” in Barium
meal
COARCTATION OF AORTA
88. DD OF INFERIOR RIB NOTCHING
1)Aortic obstruction- Takayasu arteritis
Coarctation of aorta
2) Subclavian artery obstruction –Classic BT shunt
Takayasu arteritis
3)Chronic Svc obstruction
4)Intercostal Av fistula
5)Neurofibromatosis
89. Cyanosis With Decreased
Vascularity
Tetralogy of Fallot
Truncus-type IV
Tricuspid atresia
Transposition of great arteries
Ebstein’s anomaly
Cyanosis With Increased
Vascularity
Truncus types I, II, III
TAPVC
Tricuspid atresia
Transposition
Single ventricle
Cyanotic Congenital Heart Disease
92. ‘figure of 8’ “snowman”
Rt border-SVC
Upper border-left innominate
Left border-left vertical vein
Body of snowman-RA
CYANOTIC CHD—TAPVC (supracardiac)
93. The scimitar sign is produced
by an anomalous pulmonary
vein that drains any or all of
the lobes of the right lung.
Scimitar vein empties into the
inferior vena cava
CYANOTIC CHD—PAPVC(Scimitar sign)
95. LV apex
Rt pulmonary artery has a superior
orgin (20%)
‘waterfall sign’
‘Hilar comma sign’
Associated right aortic arch (33%)
Concave PA segment
ELEVATED
RIGHT HILUM
CYANOTIC CHD—TRUNCUS ARTERIOSUS
96. CYANOTIC CHD
Eisenmenger’s syndrome
• Chest xray show dilation of central
pulmonary arteries and pruning of peripheral
pulmonary arteries, right ventricular and
atrial enlargement. Left heart would return
to normal size.
• Left to right shunts such as atrial septal
defect, ventricular septal defect and patent
ductus arteriosus, cause increased
pulmonary blood flow. With time, high
pulmonary vascular resistance will
develop, ultimately causing right to left
shunt.
106. PERICARDIAL VS MYOCARDIAL CALCIFICATION
PERICARDIAL
SEEN IN BOTH SIDES OF HEART MOST
COMMONLY IN AV GROOVE
DIFFUSE CALCIFICATION AROUND THE
HEART
CALCIFICATION IS CHUNKY & UGLY
MYOCARDIAL
SEEN IN ONLY LEFT SIDE
MOST COMMON SITE IS ANT.
WALL
LOCALIZED TO THE LEFT
CALCIFICATION IS FINE &
CURVILINEAR
115. MISCELLENOUS X-RAYS
LEFT SVC
Occurs in less than 0.5% of people
Failure of regression of L common
and Ant. Cardinal veins
Drains left jugular and left subclavian
vein
Most patients also have right sided
SVC
Drains into dilated coronary sinus
LEFT SVC
116. RIGHT AORTIC ARCH
Leftward displacement of barium filled
esophagus
Rt. Indentation of trachea
Aortic knob is absent from left side
Aorta descends on right
Associated with TOF
Truncus arteriosus
117. AORTIC NIPPLE
Left superior intercostal vein
Seen in 5% of cases
To be differentiated from a mass
Also called pseudo dissection
It drains into hemiazygous vein
Hartman T .Pearls & Pitfalls in Thoracic imaging,Variants and other difficult diagnosis
118. CERVICAL AORTIC ARCH
Left sided cervical aortic arch
Aortic knob at apex of lung
Descend on the left
CERVICAL AORTIC ARCH
123. BIBLIOGRAPHY
(1)Jefferson K, Rees S. Clinical cardiac radiology, 2nd edition Butterworths; 1980.
(2) Lipton MJ. Plain film diagnosis of heart disease: cardiac enlargement. Contemporary Diagnostic Radiology 1988;11:1-6.
(3) Boxt LM, Reagon K, Katz J. Normal plain film examination of the heart and great arteries in the adult. J Thorac Imaging
1994;9:208-18.
(4)Murray G. Baron,Wendy M. Book .Congenital heart disease in the adult.North American Clinics of Radiology 2004;3
(5) Ramesh M. Gowda,Lawrence M. Boxt. Calcifications of the heart.North American Clinics of Radiology 2004;4
(6) Martin J. Lipton, Lawrence M. Boxt. How to approach cardiac diagnosis from the chest radiograph.North American Clinics
Of Radiology 2004;5
(7) Murray G. Baron .PLAIN FILM DIAGNOSIS OF COMMON CARDIAC ANOMALIES IN THE ADULT.North American Clinics Of
Radiology 2004;6
(8) Radiology imaging – sutton 6th edition
(9) Pediatric cardiology- Perloff’s clinical recognition of congenital heart disease
(10)Radiology of congenital heart disease-Amplatz
(11)Grainger & Allisons- diagnostic radiology vol1 , 4th edition
(12)Cardiac Xrays- v.Chockalingam
(13)Braunwald heart diseases 9th edition
(14) Emma C. Ferguson,Rajesh Krishnamurthy,Sandra A. A.Oldham. Classic Imaging Signs
of Congenital Cardiovascular Abnormalities; RadioGraphics 2007; 27:1323–1334
(15)www.learningradiology.com