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!IvIng Annfomy of fho Chosf


for l
sf
yonr ModIcnI Sfudonfs
OrIgInnI vorsIon comIIod by r. CIIIInn !Iobormnn for
fho Hnrvnrd ModIcnI SchooI Humnn Iody !ocfuro SorIos.
Adnfod horo for Indoondonf Sfudy.
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!IvIng Annfomy
Radiology is ideally suited to image anatomy in the living patient.
Labeled plain Iilm Chest X-Rays (CXR), Angiograms, Bronchograms,
Computed Tomography (CT) and Magnetic Resonance Images (MRI) Iollow,
accompanied by anatomic diagrams to help Iamiliarize you with chest
anatomy.
Areas covered include:
The Heart: Chambers, valves, great vessels, coronary arteries
The Lungs: Lobes, pulmonary arteries, bronchial tree
The Pleura
The Azygos-Hemiazygos venous system
Basic Radiologic principles are outlined to Iacilitate plain Iilm interpretation.

Annfomy on
ormnI Chosf
X!ny
CXR-PA
Key:
1. Right 1
st
rib
2. Right 2
nd
rib
. Scapula
4. Trachea
5. Carina
6. Bronchus seen end on
7. Bilateral hila
8. Branch oI right main descending
pulmonary artery
9. Right minor (horizontal Iissure)
10. Right hemi diaphragm
11. LeIt hemi diaphragm
12. Gastric air bubble
1. LeIt clavicle
2
1
2
4
5
7
9
6
12
7
13
8
3
11
10
4
Annfomy on
ormnI Chosf
X!ny
CXR-LeIt LAT
Key:
1a. Manubrium sternum
1b. Body oI sternum
2. Right hemi diaphragm
. LeIt hemi diaphragm
4a. Right scapula
4b. LeIt scapula
5. Trachea
6. SoIt tissue oI the arms
7. Major Iissure
8. Minor Iissure-little higher in this
patient than the usual
9a. 9
th
leIt rib
9b. 9
th
right rib
T2-11 Thoracic vertebrae
6
1a
6
1b
8
5
4a 4b
9a
9b
3
2
T11
T10
T9
T8
T7
T6
T5
T3
T2
5
This Iilm is helpIul to demonstrate some
basic radiologic principles which are
essential to understanding x-ray
interpretation.
Key:
1. Denser and smaller right upper lobe due
to pneumonia
2. Elevated minor Iissure
. Top surIace oI liver
4. UndersurIace oI diaphragm
5. Top surIace oI diaphragm
6. Top surIace oI spleen
7. Free air in the abdominal cavity
pneumoperitoneum
Right Upper Lobe Pneumonia with
Partial Volume Loss Pneumoperitoneum
!ndIoIogIc IrIncIIos I
1
2
3
5
4
7
4
6 7
5
6
The plain Iilms are made up oI Iour densities-
Black Air e.g. in lungs,stomach
Fat
Soft tissue which include muscle,
organs e.g. liver, Iluid
e.g. blood
White Bone heavy metal e.g. calcium,
iron
A line or border is seen only when there is an
interIace between two oI these densities. E.g.
The right heart outline is usually seen because
soIt tissue density oI the heart is next to air
density oI the right middle lobe oI the lung.
Air
Fat
Bone
Soft Tissue
!ndIoIogIc IrIncIIos II
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!ndIoIogIc IrIncIIos III
Pneumoperitoneum
Free air in the abdomen (always abnormal)
(pneumoperitoneum) rises to a position under the
diaphragm when the patient is upright. It
thereIore outlines the top oI the liver on the right,
the top oI the spleen on the leIt, and
undersurIaces on both hemi diaphragms. These
are usually hot seen because liver, spleen and
diaphragm are all soIt tissue and thereIore no
interIace is present. The upper border oI the
diaphragms are usually seen because air in the
lower lung lobes abut the soIt tissues oI the
diaphragm.
Pneumonia
In pneumonia, the air in the lung gets
replaced with Iluid which shows up
soIt tissue density on x-ray. The lung
lobe oIten also gets smaller or
consolidated so the Iissures move.
Bacterial inIection commonly respects
the lobar boundaries as in this case.
!neumonia
!neumoperitoneum
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!obos of fho !ung
IMPORTANT FACTS:
The right lung has lobes (separated
by the major Oblique Iissure &
minor Horizontal Iissure)
-Right upper lobe
-Right middle lobe
-Right lower lobe
The leIt lung has 2 lobes separated
by major (oblique) Iissure
-LeIt upper lobe
(medial portion is called the lingula)
-LeIt lower lobe
Lobes and Fissures oI the Lung (Irom the Iront)
'Man`s Anatomy by Tobias & Arnold
9
The pleura is the lining oI the lungs.
There are 2 layers -1. The visceral pleura hugs the lung lobes
-2. The parietal pleura hugs the chest wall
The pleural space is a potential space between the two.
Apneumothorax is the presence oI air (always abnormal) in the pleural space.
A pleural eIIusion is the presence oI detectable Iluid (always abnormal) in the pleural space.
A hydropneumothorax is air and Iluid in the pleural space.
Coronal Section oI Pleural Sacs
(schematic)
%ho IIourn
'Man`s Anatomy
by Tobias &
Arnold
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!obos of fho
!ung
This Iilm is included because it helps demonstrate
the lobes oI the right lung, the pleura and the
pleural space.
Key:
1. Normal pointy leIt costophrenic angle
2. Blunted denser right costophrenic angle
due to Iluid in pleural space pleural
eIIusion
. Air in pleural space pneumothorax
4. . partially collapsed right upper lobe
5. ---partially collapsed right middle lobe
6. -.-partially collapsed right lower lobe
7. Visceral pleura oI right middle lobe
8. (Position oI parietal pleura not seen)
9. LeIt breast shadow. (Notice the right breast
has been removed right mastectomy)
Pneumothorax and pleural eIIusion
hydropneumothorax
Common causes Ior hydropneumothorax include rib Iractures
penetrating chest wounds e.g. stab or bullet wounds and
iatrogenic causes e.g. lung biopsies or eIIusion drainages.
Right Tension Pneumothorax
1 9
2
2
6
7
4
5
3
11
Annfomy on ormnI Chosf X!ny
Heart borders and chambers oI the heart on PA and lateral views.
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Honrf Chnmbors nnd VnIvos
The heart is made up oI 4 chambers. The right side which handles deoxygenated blood is
separated Irom the leIt side which handles oxygenated blood by septa, the top is separated
Irom the bottom by valves.
Simplistic view: 1
1
Vonous !ofurn fo fho Honrf
The atria receives blood Irom the body and lungs.
The SVC and IVC bring deoxygenated (blue) blood to the right atrium Irom the
body. The pulmonary veins bring oxygenated (red) blood to the leIt atrium Irom
the lungs.
Simplistic view: 2
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ArforInI Oufuf from fho Honrf
The ventricles receive blood Irom their respective atria.
The right ventricle pumps deoxygenated blood via the pulmonary
artery to the lungs.
The leIt ventricle pumps oxygenated blood via the aorta to the body.
The entrance to the aorta and the pulmonary artery have aortic and
pulmonary valves respectively.
Simplistic view:
!ulmonary valve Aortic valve
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Honrf VnIvos
This patient had a malIunctioning mitral valve (between leIt atrium and leIt ventricle) and aortic valve
(between leIt ventricle and aorta) and prosthetic valves were inserted (better seen on lateral)
Frontal CXR LAT CXR
ey:
1. Suture material
used for repair
of vertical
incision thru
sternum
(median
sternotomy)
2. Aortic valve
prosthesis
3. Mitral valve
prosthesis
4. Left hemi
diaphragm
5. Right hemi
diaphragm
1
2
3
4
5
2
1
3
4
5
16
The pulmonary artery and aorta cross one another in the mediastinum.
Schomn of gronf vossoIs
connocfod fo fho honrf
'Man`s Anatomy by Tobias & Arnold
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%ho AorfIc nrch
'Man`s Anatomy by Tobias & Arnold
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Cronf ock VossoIs
'Man`s Anatomy by Tobias & Arnold
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AngIogrnmsAorfIc nrch nngIogrnm
An angiogram is an x-ray examination oI blood
vessels Iollowing contrast administration.
Arteriogram Arterial Study
Venogram Venous Study
7
4
9
6
5
2
8
1
3
10
20
Pulmonary Art #1
Key:
1. Right main pulmonary artery branch
2. Right upper lobe pulmonary artery branch
. Right middle lobe pulmonary artery branch
4. Right lower lobe pulmonary artery branch
5. LeIt main pulmonary artery
6. LeIt upper lobe pulmonary artery branch
7. LeIt lower lobe pulmonary artery branch
8. Pulmonary veins
9. LeIt atrium
10. LeIt ventricle
11. Ascending aorta
12. Descending aorta
2
AngIogrnmsIuImonnry nrforIogrnm
IA grnm
2
1
3
5
7
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AngIogrnmsIuImonnry
nrforIogrnm IA grnm
Pulmonary Art #2
Key:
1. Right main pulmonary artery branch
2. Right upper lobe pulmonary artery branch
. Right middle lobe pulmonary artery branch
4. Right lower lobe pulmonary artery branch
5. LeIt main pulmonary artery
6. LeIt upper lobe pulmonary artery branch
7. LeIt lower lobe pulmonary artery branch
8. Pulmonary veins
9. LeIt atrium
10. LeIt ventricle
11. Ascending aorta
12. Descending aorta
12
11
9
10
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AngIogrnmsIuImonnry
nrforIogrnm IA grnm
Pulmonary Art #
Key:
1. Right main pulmonary artery branch
2. Right upper lobe pulmonary artery branch
. Right middle lobe pulmonary artery branch
4. Right lower lobe pulmonary artery branch
5. LeIt main pulmonary artery
6. LeIt upper lobe pulmonary artery branch
7. LeIt lower lobe pulmonary artery branch
8. Pulmonary veins
9. LeIt atrium
10. LeIt ventricle
11. Ascending aorta
12. Descending aorta
11
12
10
2
Cardiomegaly plus early Congestive Heart Failure (CHF)
Key:
1. InIerior vena cava (IVC)
2. Superior vena cava (SVC)
*. Azygos vein
4. Carina
5. Trachea
6. Right main stem bronchus
7. Prominent pulmonary vessels
Honrf nnd VossoIs
Any and or all heart chambers may enlarge when the
heart becomes diseased. Cardiomegaly a big heart.
A patient`s heart enlarges due to a number oI diseases
e.g. valve disease, high blood pressure, congestive
heart Iailure.
II the heart Iails, the lung oIten become congested.
Early on the pulmonary vessels appear more
prominent as in this case. More advanced Iailure can
result in a condition oI pulmonary edema which is
Iluid Ilooding into the alveoli oI the lungs causing
the patient marked shortness oI breath.
2
7
7
7 7 5
4
3
1
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Azygos-Hemiazygos venous system
The Azygos vein receives
tributaries Irom intercostal
veins as outlined. It is seen
as an oval density to the
right oI the trachea just
above the right main stem
bronchus on all chest x-rays
(* on the earlier Iilm)
This is the portion that
travels Iorward to join the
SVC.
In CHF, the Azygos vein
dilates and this density
becomes prominent as seen
on the previous patient`s
CXR.
'Man`s Anatomy by Tobias & Arnold
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Coronnry nrforIos
'Man`s Anatomy by Tobias & Arnold
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Coronnry nrfory nnnfomy
LCX)
'Man`s Anatomy by Tobias & Arnold
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Coronary Angiograms
LT Coronary Art LAO
btuse
Marginal
Artery
Left circumflex
artery
Left main
coronary
artery
LA
iagonal
artery
The coronary arteries can be
outlined in the living patient by
injecting contrast into them. A
catheter (tube) is threaded
through the Patients vessels to the
heart, to gain access- called
'cardiac catheterization
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Coronnry AngIogrnms
LT Coronary Art LAO
Left main coronary
artery
LA
iagonal
artery
Sinus Node Artery
AV
Groove
Left
circumflex
artery
btuse
marginal
artery
Septal
perforator
IV Groove
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Coronnry AngIogrnms
RT Coronary Art LAO
Acute
marginal
artery
AV Node A
Crux
!osterior LV
Bronch
Conus
Bronch
RCA
AV
Groove
0
Coronnry AngIogrnms
RT Coronary Art RAO
Acute
Marginal
Arteries
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IronchInI sogmonfnI nnnfomy
'Man`s Anatomy by
Tobias & Arnold
2
ormnI Ironchogrnm
Contrast agent can be instilled or inhaled into the bronchial tree
outlining the walls oI the trachea, main stem bronchi, segmental and
even subsegmental bronchi
Frontal CXR Lateral CXR

Bronchiectasis localized irreversible dilatation oI the bronchial tree


Contrast agent can be instilled or
inhaled into the bronchial tree
outlining the walls oI the
trachea, main stem bronchi,
segmental and even
subsegmental bronchi
AbnormnI Ironchogrnm IronchIocfnsIs
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Comufod %omogrnhy
Computer tomography (CT) scanning obtains multiple cross sectional images through a patient
using x-rays and computer enhancement. (Imagine slicing a sausage crosswise into many round
equal thickness slices and then looking at these to see what`s in the sausage)
CT, ultrasound and magnetic resonance imaging (MRI) all allow imaging oI the body in diIIerent
planes.
TERMINLGY:
The Iollowing description considers the body in the anatomical position
Axial plane (cross section) a plane oI the body parallel to the horizon
Median/Midline Sagittal plane the vertical plane which passes through the sagittal suture oI
the skull and through the midline oI the body dividing the body into right and leIt halves.
!araSagittal plane any vertical plane parallel to the median sagittal plane.
Coronal plane any vertical plane perpendicular to the median sagittal plane and parallel to the
vertical plane through the coronal suture oI the skull.
With CT scanning, Iactors can be altered Ior better resolution oI diIIerent body parts.
e.g. ReIerring to the images enclosed, the scanner was set to optimally visualize mediastinal
structures (1-4A), and lung parenchyma in (1-4B)
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ormnI Chosf nnnfomy on
AxInI Comufod %omogrnhy
Key:
1. Pectoralis major muscle
2. Pectoralis minor muscle
. Sternum
4. Clavicle
5. Rib
6. Humeral head
7. Scapula
8. Vertebral body
9. Thyroid gland
10. Trachea
11. Esophagus
12. Subclavian artery
1. Carotid artery
14. Innominate (brachialcephalic)
artery
15. Innominate vein
16. Superior vena cava (SVC
Aortic arch
Ascending aorta
Descending aorta
Azygos vein
* Carina (tracheal biIurcation)
21. Pulmonary artery
22. Main stem bronchus
2. Right ventricular outIlow tract
24. LeIt atrium
25. Right atrium
26. LeIt ventricle
27. Right ventricle
28A. Pulmonary veins
28B. InIerior vena cava (IVC)
29. Diaphragm
Liver
1. Spleen
2. Stomach
. Kidney
4. Lung upper lobe
5. Lung right middle lobe
6. Lung lower lobe
7. Major (oblique) Iissure
8. Minor (horizontal) Iissure
9. Segmental bronchus
6
Comufod %omogrnhy
1A
Key:
1. Pectoralis major muscle
2. Pectoralis minor muscle
. Sternum
4. Clavicle
5. Rib
6. Humeral head
7. Scapula
8. Vertebral body
9. Thyroid gland
10. Trachea
11. Esophagus
12. Subclavian artery
1. Carotid artery
14. Innominate (brachialcephalic) artery
15. Innominate vein
1
2 2
1
11
13
13
12
12
7
Comufod %omogrnhy
1B
10 10
Key:
10. Trachea
11. Esophagus
11 11
8
Comufod %omogrnhy
Key:
1. Pectoralis major muscle
2. Pectoralis minor muscle
. Sternum
4. Clavicle
5. Rib
6. Humeral head
7. Scapula
8. Vertebral body
9. Thyroid gland
10. Trachea
11. Esophagus
12. Subclavian artery
1. Carotid artery
14. Innominate (brachialcephalic) artery
15. Innominate vein
16. Superior vena cava (SVC)
17. Aortic arch
2A
7 7
5
1
2
13
15
3
9
Comufod %omogrnhy
2A
Key:
1. Pectoralis major muscle
2. Pectoralis minor muscle
. Sternum
5. Rib
11. Esophagus
16. Superior vena cava (SVC)
17. Aortic arch
18. Ascending aorta
19. Descending aorta
20. Azygos vein
21. Pulmonary artery
20
11
5 11
40
Comufod %omogrnhy
Key:
10. Trachea
11. Esophagus
4. Lung-upper lobe
6. Lung-lower lobe
7. Major (oblique) Iissure
2B
37
34
11
11
10
10
34
36
36
37
41
Comufod %omogrnhy
2B

37
39
39
37
22 22
Key:
* Carina (tracheal biIurcation)
22. Main stem bronchus
7. Major (oblique) Iissure
9. Segmental bronchus
42
Comufod %omogrnhy
Key:
. Sternum
5. Rib
7. Scapula
8. Vertebral body
11. Esophagus
16. Superior vena cava (SVC)
19. Descending aorta
20. Azygos vein
21. Pulmonary artery
2. Right ventricular outIlow tract
24. LeIt atrium
7
7
5
5
3
11
23
4
Comufod %omogrnhy
A
Key:
. Sternum
5. Rib
7. Scapula
16. Superior vena cava (SVC)
18. Ascending aorta
19. Descending aorta
2. Right ventricular outIlow
tract
24. LeIt atrium
28A. Pulmonary veins
3
23
28
7 5
28
44
Comufod %omogrnhy
38
37
37
36 36
35
34
34
11
Key:
11. Esophagus
4. Lung upper lobe
5. Lung right middle lobe
6. Lung lower lobe
7. Major (oblique) Iissure
8. Minor (horizontal) Iissure
45
Comufod %omogrnhy
B
Key:
4. Lung upper lobe
5. Lung right middle lobe
6. Lung lower lobe
7. Major (oblique) Iissure
8. Minor (horizontal) Iissure
37
37
36
36
35
34
46
Comufod %omogrnhy
Key:
. Sternum
5. Rib
8. Vertebral body
11. Esophagus
19. Descending aorta
24. LeIt atrium
25. Right atrium
26. LeIt ventricle
27. Right ventricle
28A. Pulmonary veins
28B. InIerior vena cava (IVC)
29. Diaphragm
11
25
3
47
Comufod %omogrnhy
4A
Key:
19. Descending aorta
26. LeIt ventricle
28A. Pulmonary veins
28B. InIerior vena cava (IVC)
29. Diaphragm
0. Liver
1. Spleen
. Kidney
29
26
48
Comufod %omogrnhy
Key:
11. Esophagus
29. Diaphragm
5. Lung- right middle lobe
6. Lung- lower lobe
7. Major (oblique) Iissure
11
37
36
35
37
36
49
Comufod %omogrnhy
4B
32
Key:
2. Stomach
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ormnI M!I Chosf
Magnetic Resonance Imaging (MRI) utilizes changing magnetic and
electrical Iields to obtain images oI a patient. Factors can be altered to
enhance resolution oI diIIerent structures thus blood Ior example can look
bright white or dark black.
Among the advantages oI MRI are:
1. X-rays and the attendant hazards oI ionizing radiation are not present.
2. Scans in multiple diIIerent projections e.g. oblique, sagittal, coronal, axial
can be obtained with ease.
ReIer to Iilms:
Film 1 -Sagittal oblique MRI angiogram chosen to best demonstrate the aortic arch.
Film 2& -Axial sections
Film 4&5 -Sagittal oblique MRI angiogram chosen to best demonstrate the coronary arteries
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MRI 1
3
ormnI SngIffnI M!I Chosf
52
ormnI AxInI M!I Chosf
MRI 2a
5
ormnI M!I Chosf
MRI 2b
54
ormnI M!I Chosf
15
16
MRI a
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ormnI M!I Chosf
MRI b
56
ormnI InrnsngIffnI M!I Chosf
MRI 4
12
6
57
ormnI M!I Chosf
MRI 4
58
ormnI M!I Chosf
MRI 4
12
13
11
59
ormnI M!I Chosf
MRI 5
12
11
60
ormnI M!I Chosf
61
ormnI M!I Chosf
MRI 5
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ConcIusIon of
!IvIng nnnfomy of fho chosf
Congratulations! You have completed this module.
You worked through many anatomic diagrams and labeled
chest x-rays, bronchograms, angiograms, CT scans & MRI
images. You saw the normal and also some Abnormal images to
peak your interest. Radiology is ideally suited to image not only
normal anatomy, but more importantly Irom a clinical diagnostic
standpoint, abnormal anatomy & pathology.
Wishing you a joy-Iilled career and
liIe long love oI learning. Gill
With grateIul thanks to Pamela Lepkowski, Education Coordinator, Harvard
Medical School & Assistant extraordinaire Ior her outstanding work on this
Independent study module.