Radiology

 Pearls  
101  
 Radiographic Densities

SOFT
BONE WATER FAT AIR
TISSUES
Radiographic Anatomy
 Xray Projections
•  Posterioranterior
•  Anteriorposterior
•  Lateral
•  Oblique
•  Decubitus
•  Supine
•  Upright
 
NORMAL  CHEST  X-­‐RAY  
 Assessment  of  Technical  Factors  
Projec+on    
Criteria PA AP
Direc+on  of  Beam X-­‐ray  beam  from  behind,   X-­‐ray  beam  from  the  front  to  
plate  in  front  of  the  paGent posterior,  plate  behind  the  
paGent
Pa+ent  Posi+on Upright Supine

Distance:  6ft  
 
 Assessment  of  Technical  Factors  
Projec+on    
Criteria PA AP
 
Mongolian  Hat  Sign Present Absent;  vertebral  bodies  are  
  rectangular
 Assessment  of  Technical  Factors  
Projec+on    
Criteria PA AP
Ribs Angulated Straighter
Clavicle V-­‐shaped More  horizontal
 Assessment  of  Technical  Factors  
Projec+on    
Criteria PA AP
Scapula Winging No  winging  
Heart  magnifica+on Heart  not  magnified Heart  and  other  structures  
more  magnified
 Assessment  of  Technical  Factors  
Projec+on    

Radiolucent  
Radiolucent    –  black    –  black    –  air    –  air  
Radioopaque
Radioopaque  –  white  –  white  –  bone/+ssue/liquid  
 –  bone/+ssue/liquid  
   
Overlap  
Overlap  shadow   shadow  
-­‐  -­‐  TThe  
he  shadow  
shadow  cast  
cast  bby  y  aa  t  hick  
thick  mmass  ass  oof  f  fat,  
fat,  skin  
skin  aand  
nd  
muscle  
muscle  that  
that  aapproach  
pproach  that   that  oof  f  aa  b  bone  
one      
   
 Posi+on  
Lateral  Posi+on  
Indica'ons  
¡  Assess  mediasGnal  structures:  
heart,  sternum,  retrocardiac  
space,  lung  
¡  ConfirmaGon  of  findings  in  PA/
AP  views  
¡  used  to  evaluate  blunGng  of  
posterior  guTer  in  pleural  
effusion  

*usually  leW  lateral  is  made  because  the  heart  is  

closer  to  the  film  and  is  less  magnified  
 
 Posi+on    
Lateral  Posi+on  
 
Image  criteria  
a)  Ribs  posterior  to  vertebrae  
should  be  superimposed  
b)  CP  angles  and  lung  apices  
included  
c)  Hilar  region  should  be  at  center  
d)  Circular  structures  on  this  view  
may  represent  blood  vessels  
 Posi+on    
Apicolordo+c  View  
 
•  Lung  apices  viewed  
beTer    
•  Leaning  backward  in  
exaggerated  lordosis  
•  the  anterior  and  
posterior  segments  of  
the  same  ribs  are  
superimposed  
 Posi+on    
Lateral  Decubitus  View  
 
•  PaGent  lying  on  his  side  
for  10-­‐15  minutes  
•  Can  detect  the  
following:  
–  Pleural  Effusions:  
mobile  vs  loculated  
–  Small  pneumothorax  
 
 Lungs    
 
Hilar  height  ra+o  
(HHR)  
•  R  hilum  lower  than  
the  leW  
•  Height  above:  height  
below  hilum  
•  R  HHR  is  approx  ½:½  
•  L  HHR  is  approx.  ⅓:⅔   Bronchovascular ratio
• Diameter of bronchus and artery that
accompanies it
• Should be 1:1
 Lungs    

Bronchovascular  
ra+o  
• Diameter  of  
bronchus  and  
artery  that  
accompanies  it  
• Should  be  1:1    
¡  Cardiothoracic  
ra+o  
§  Adults:  
 <0.50  –  0.52  
§  Children:  
<0.56  
 Medias+num    
¡  the  space  between  the  
two  pleural  sacs  which  
contains  all  the  
structures  in  the  
thorax  except  the  
lungs  and  the  pleura  
 
¡  MediasGnal  width  
§  Upright:  8  cm  
§  Supine:  10  cm    
 Costophrenic  Sulci  

*Check  if  it  is  sharp/

blunted  
 
*blunted  may  denote  
presence  of  pleural  
effusion  
 
 
 Costophrenic  Sulci  

*Check  if  it  is  sharp/

blunted  
 
*blunted  may  denote  
presence  of  pleural  
effusion  
 
 
 Hemi-­‐diaphragms  

 
R  hemidiaphragm  is  higher  
than  the  L,  lies  at  5th  ICS  on  
moderately  deep  
inspiraGon  
 
 
 
Hypertensive  bleed        Brain  tumor  
 Neuroimaging  

•  MRI  
– Hyperacute  infarcts  
– White  maTer  pathologies  
– Pathologies  in  the  posterior  fossa  
 
 NEUROIMAGING  
•  CT  SCAN       •  MRI  
–  Stroke   –  Hyperacute  Stroke  
–  Trauma   –  Perfusion  Studies  
–  Minimal  subarachnoid   –  Neoplasm  vs  abscess  
hemorrhage   –  White  MaTer  Diseases  
–  Hemorrhage   –  Hemorrhage    
–  CTA   –  InfecGon    
–  MRA  
THORACIC  IMAGING  
 SilhoueTe  sign  
•  An  interface  is  not  
visible  when  two  areas  
of  similar  density  
overlap  
 Asthma  
•  HPE  
–  Cough,  dyspnea,  
wheezing  
•  Imaging  
–  Normal—MC  
–  Hyperinflated  lungs  
–  Atelectasis  
 Pneumonia  
•  Alveolar  infiltrates
—"fluffy"  
•  (+)  air  bronchogram  
sign  
 PNEUMATOCOELES  
Staphylococcal  pneumonia  
HONEYCOMB  LUNG  
HONEYCOMB  LUNG  
DeflecGon  of  the  mediasGnum  (Clinical  
correlate_  
•  Atelectasis  
–  Towards  the  affected  
side  
•  Pleural  effusion  
–  Towards  the  unaffected  
side  
•  Pneumothorax  
–  Towards  the  unaffected  
side  
 Cardiomegaly  
•  Ischemic  
cardiomyopathy  is  the  
most  common  cause  
•  Imaging  
–  Cardiothoracic  raGo  
•  Most  lateral  borders  of  
the  heart:inner  border  of  
the  widest  part  of  the  rib  
•  Normal—<0.5  
•  PA  view  only!  
 Pleural  effusion  
•  Chest  PA  
–  BlunGng  of  the  lateral  
costophrenic  sulcus—
300  mL  
•  Lateral  
–  BlunGng  of  the  posterior  
costophrenic  sulcus—75  
mL  
 Pneumothorax  
•  Imaging  
–  (+)  visceral  pleural  line  
with  no  lung  markings  
beyond  
–  Confirmatory  views  
•  Expiratory  view  
•  Lateral  decubitus  view  
–  Right  or  leW?  
APICAL  LUNG  INFILTRATES  
PTB  
 Endotracheal  tube  
•  Tip  2-­‐6  cm  above  the  
carina  
NEUROLOGIC  IMAGING  
 Epidural  hematoma  
•  HPE  
–  blunt  trauma  
–  "lucid  interval"  
•  Anatomy?  
•  Imaging  
–  CT  with  or  without  
contrast?  
–  Biconvex  appearance  
–  Do  not  cross  suture  line  
–  May  cross  midline  
–  Skull  fracture?