PTCUT

IMAGING

LECTURE 5 - RADIOLOGICAL SIGNS (CON.)

By :

ed
Adham Moham
 Radiological signs

Cardiothoracic ratio : CTR

It is the ratio between heart width to thoracic cavity width normally
it is smaller than or equal 50%
( transverse cardiac diameter / transverse thoracic diameter x 100
). if it bigger than this percentage, it is often an indication for
cardiomegaly BUT it may be due to pericardial effusion or excessive
epicardial fat.
Causes of cardiomegaly;
Congestive heart failure.
Pericardial effusion.
Fallout's tetralogy.
Left ventricular hypertrophy.
Right ventricular hypertrophy.

Cardiothoracic ratio

Right atrium increase in Straightened left heart border /

convexity / right atrium left atrium hypertrophy
hypertrophy
 right atrium increase in convexity Apex is directed downward / left
with straightened left heart ventricle enlargement
border / bilateral atrial
enlargement

Apex is directed upward / right

ventricle enlargement

Chest wall deformities :

Normal chest diameter AP : Transverse = 5 : 7
Chest diameters :
A-P : the distance between the vertebrae posteriorly to Cardiac
diameter Thoracic diameter 64 the sternum anteriorly.
Transverse : the distance between the widest area of the ribs
Laterally.
Compressible : it is the lung expansion area from sternum
anteriorly to ant. vertebral body posteriorly.
Incompressible : s the distance between the anterior body of
thoracic vertebrae to the its posterior body.
incompressible diameter ‫المنطقة اللي مش بتتضغط و انا بتنفس هي‬
 CT scan showing normal chest
diameters

Haller index : it is an diagnostic index for chest diameters (

Transverse diameter / AP diameter ). normally about 2.5
transverse ‫ في نفس مستوي‬AP ‫ عشان يطلع مظبوط بحيث يطلع‬CT ‫بنستخدمه في‬
‫ مش هعرف اظبط‬X-ray ‫و بالتالي النسبة هتكون مظبوطة اما لو جيت اطبقه في‬
.‫الخطين انهم يكونوا علي نفس المستوي فهيطلع مش مظبوط‬
Values of Haller index :
Normal chest < 2
Mild excavatum : 2.0-3.2
Moderate excavatum : 3.2-3.5
Severe excavatum >3.5

Chest deformities :
A. Symmetrical deformities :
Barrel chest : AP diameter = Transverse diameter, ribs are
bulged and intercostal spaces are wide. this found in patients
with emphysema

Barrel chest CT
( Haller index = 1 )
 Lateral barrel CXR showing :
Flattened diaphragm.
Hyperlucent lungs
Ribs are horizontal ( seen
better in P-A view )
No difference between
inspiration and expiration
Loss of height of convexity of
the hemidiaphragm (Less
than 1.5cm).
More than 6-10 ribs above
the diaphragm

‫ و اصوره و اكررها تاني‬expiration ‫عشان اتأكد من ان الهواء محبوس هخلي العيان ياخد‬
‫ في الصورتين لو لقيت التغيير في‬diaphragm ‫ و اقارن بين‬inspiration ‫و هو عامل‬
. air trapped in the lungs ‫ سم يبقا عنده‬3 ‫ارتفاعه اقل من‬

Funnel chest ( pectus excavatum ) : The lower part of the

sternum is indented inwards .e.g. Shoemakers. it is associated
with : - Mitral valve prolapse.
- Pulmonary functions abnormalities.
- Cardiac functions abnormalities.
- Sunken spot in anterior aspect of the chest.

funnel CXR showing : Lateral funnel CXR showing :

Displacement of the heart towards Concave depression of the sternum.
the left. Cosmetic and radiological alterations.
Vertical anterior ribs.
Horizontal posterior ribs
Blurring of the right border of the
heart.
 CT scan of a funnel chest showing :
Unequal lung portions
Haller index (HI) > 3.5

Sunken spot on the anterior chest of the

infant which indicates funnel chest
deformity

Pigeon chest ( pectus carinatum ) : AP > Transverse diameter

CT scan of a pigeon chest showing : CXR for pigeon chest

Unequal lung portions
Haller index (HI) < 2.5
Protrusion of the sternum
lateral view showing :
marked protrusion of the
upper third of sternum.
(Normal structures in P-A
view)
B. Asymmetrical deformities :
Retraction : occurs due to Fibrosis, Collapse, kyphoscoliosis &
Thoracoplasty.
Bulging : Subcutaneous emphysema, Tumours , Tense pleural
effusion, Empyema , Tension pneumothorax , Pleural tumours ,
Apical bronchial carcinoma & Obstructive emphysema
‫ و اي حاجة هتزود حجمها‬retraction ‫ هتبان‬lung ‫من االخر اي حاجة هتقلل حجم ال‬
.bulge ‫هتبان‬

Dorsal spine deformities :

Kyphosis : It is an increase in anterior curvature of the thoracic
spine.
X ‫ برسم الشكل اللي تحت ده بحيث يكون الخط‬kyphosis ‫عشان اقيس زاوية ال‬
‫ اما بقا سيتا فهي زاوية ال‬B\X ‫ و بروح جايب النسبة بين‬T12 ‫ و‬C7 ‫يوصل بين‬
‫ درجة‬50 ‫ ل‬20 ‫ بتاعها من‬normal value ‫ و اللي ال‬kyphosis

X-ray of a kyphotic dorsal spine Flexicurve kyphosis index

 Scoliosis : Presence of abnormal curvature of the spine with
either C- Shaped or Sshaped in A-P view.
Signs of scoliosis :
Uneven musculature.
Slow nerve action in some cases.
Protruded scapula in one side due to thoracic rotation.
Uneven legs, arms length or hip level.

‫ و هي الزاوية اللي‬Cobb's angle ‫ بنقيس زاوية اسمها‬scoliosis ‫علشان نحدد درجة ال‬
‫ كله ب‬spine ‫بين اول فقرة بدأ فيها الميل لحد اخر فقرة طبعا الزم نكون مصورين ال‬
‫ شهر و اقيس‬12 ‫ ل‬3 ‫ و عشان اشوف مدي التطور اللي بيحصل فيه بصوره كل‬Xray
‫ في الحاالت اللي الميل فيها شديد عشان اتطمن علي‬MRI ‫الزاوية و ساعات ممكن احتاج‬
.Spinal cord
Grades of scoliosis :
-Mild ( 10-30 degrees )
-Moderate ( 30-45 degrees )
-Severe ( >45 degrees )

X-ray of a severe scoliotic spine

shows large Cobb;s angle
 Kyphoscoliosis : abnormal curvature of the vertebral column in
two planes coronal and Sagittal It is a combination between
kyphosis and scoliosis.

Kyphoscoliosis

Cervical rib : : it is abnormal elongation of the transverse

processes of the 7th vertebrae that limits shoulder shrugging.
inferior trunk of brachial plexus ‫ فممكن يعملي مشاكل في‬C7 ‫عشان طالع من‬
) which is consisting of C8 and T1 ( Ulnar nerve injury

X-ray of cervical rib

Air bronchogram :
branching radiolucent columns of air corresponding to bronchi is
seen, It indicates that the pathology is of pulmonary disease,
Alveolar pathology & consolidation . Air is replaced by Blood, pus ,
cells, mucus or proteins.
‫ بتدل ان في مشكلة فيها و‬bronchi ‫ مكان ال‬xray ‫هي خطوط سوداء بتظهر في ال‬
alveoli ‫ و سببه جاي من‬parenchymal lesion ‫االكيد انها‬
for more info. click the link https://youtu.be/2OV1Iq8SlbQ

Focal lesions and diffused lesions :

Nodule; well defined lesion less Mass; well defined lesion bigger
than 3 cm than 3 cm

Patch; ill defined opacity in the lung Cavity ; a ball with air / with air &
fluid '' blood,pus,...etc.'' .
 Smooth (solitary) single nodule Multiple nodules that indicates mostly
(benign) with calcification inside it metastasis (Cannon balls metastasis )
may be ( hamartoma if it in middle
or lower zone and tuberculoma if it
in the apical or upper zones )

Speculated bronchogenic
carcinoma shows corona radiata of
the margins

N.B.
Metastases may be of one mass or number of masses. (miliary
(Tiny size)- Nodules ( small size)-Cannon balls deposits ( Big in size).
Opacities :
Homogenous opacity : clear white shadow in the lung as in
cases of pleural effusion
Heterogenous opacity : white spots and lines of irregular shape
( Black and white) as in cases of : sever chronic bronchitis the
lung field appear to show a feathery like appearance that
indicate the sclerosis of the bronchial tree.

Types of opacities :
Reticular ( crisscrossing lines ).
Dots and nodules
Cysts or rings.
Consolidation ( diffuse opacity with air bronchogram sign )
Ground glass.
Companion shadow ( lines parallel to bony landmarks )

Gohn's focus : in cases of tuberculosis always present in the upper

lobe.
‫ اللي بتسبب‬mycobacterium bacilli ‫غالبا بتكون في االطفال نتيجة اصابتهم ب‬
.TB

Gohn's focus
 Pleural effusion extended into fissures

Cotton-like appearance indicates for Honey-comb appearance indicates for

pneumonia bronchiectasis (a long-term condition
where the airways of the lungs
become widened, leading to a build-
up of excess mucus that can make the
lungs more vulnerable to infection)
 Infant Vs adult
Imagin views

Children over 5 years are imaged by P-A view, but below 3-4 years
are imaged by A-P view as its easier to hold the child.

In infants, chest is cartilaginous and horizontal till 10 yrs then it

starts to descend down (Oblique), be less compliant and less
movement occurs.
The chest is less efficient and dome of diaphragm is higher
that's explain the higher breathing rate in children (>2yrs) than
adult.
Thoracic diameter :
At birth, transverse and A-P diameters are equal so the ratio
between A-P diameter to transverse diameter (Thoracic index) is 1
so the chest is circular in shape. Then, the transverse diameter
grows more rapidly than A-P till the chest become elliptical so
thoracic index (TI) become close to ZERO.

Infant CXR A-P view ( Arrow points Adult CXR

to thymus gland as it is prominent
in infants )
Trachea :
Normally, tracheal length is 11cm with 2-2.5 cm variations
in children the trachea is shorter and the angel of the right
bronchus at the site of bifurcation is more acute (50-60 degrees)
than in adult (70 degrees ). Bifurcation of the bronchus in children
at T3 level while its at T6 level in adults. air way diameter is 4mm in
infants while it's 20 mm in adults
Heart :
At birth the heart lies centrally behind sternum and it is directed
horizontally at 4th intercostal space with apex lateral to mid
clavicular line till 4 yrs. then, it moves downwards due to
elongation of thorax so the apex became at midclavicular line at 5th
intercostal space. Until the 1st year the width of the heart is no more
than 55% of chest width taken at the xiphoid process. After that.
heart width is slightly less than 50% of the chest width due to
increase in transverse diameter of the thoracic cage.

Radiological Findings in different age groups

Change in rib inclination.
Change in spine curvature.
Change in position of sternum.

Sternum :
Sternum is 17cm in length in adult male and less in female
consisting of prosternum (manubrium), mesosternum (Body),
metasternum (xiphoid process), and it is 4 parts in infants.
Infants ; consists of 4 sternebrae (2-3 yrs). first and second parts
are in the same plane while third ans forth angulated inwards
giving the convex shape of sternum which commonly mis-
diagnosed by pectus carinatum
At puberty ; the union between the sternal centres begins and
proceeds from below upwards, by 25 yrs all are united. With this
fusion the convexity of the body of sternum reduces and the
chest wall appears more flattened in antero-posterior aspect.
With aging ; the lower end of sternum curves inwards making
the upper part of the body and manubrium protrude anteriorly.

N.B. carinatum occurs in boys more than girls till 10yrs

Spine :
At 7th week ossification of the vertebrae occurs.
In infants ; Wide vertebral spaces cause shallow kyphotic
curvature
In old age ; Degenerative changes occur in the spine ( e.g. :
Lipping and osteophyte formation , Reduced height of vertebral
bodies, Degenerating intervertebral disc, Reduced intervertebral
spaces & Adaptive posture) cause exaggerated kyphotic
curvature

CT scan bone window lateral view for the chest shows changes in
sternum and spine with age as (A)infant (B) Adult male (C) Old age

Ribs :
In infants ; Shorter ribs due to incomplete ossification and rib
angle is less prominent.
Adult ; become more oblique due to growth and increase in
vertebral height.
Old age ; become horizontal due to decreased intervertebral
disc spaces and rigid due to calcification of costal cartilage.
 Male
Sternal length is 17cm.
Narrower pubic angle.
Iliac fossa is tall and narrow.
Pelvic inlet is heart-shaped
and narrow.
Obturator foramen in
rounded.
True pelvic border is
narrower.
The ischial tuberosities are
narrower.
Female
Sternal length is 15cm.
Wider pubic angle.
Iliac fossa is more flared.
Pelvic inlet is circular and
wide.
Obturator foramen is oval
True pelvic border is greater.
The bones are more slender.
The ischial tuberosities are
wider.
X-ray of pelvis in male and
female showing wider true
pelvis and greater pubic angle
in female than male
CXR of a female with left
mastectomy