Thoracic & Cardiovascular Radiology

Thoracic Imaging 00:23

• Bone density – Very White – Cortical bone/ calculus/ Ca2+

• Soft tissue density – Everything else – water/ pus/ blood/ tumor/ muscle/ liver/
heart/ spleen
• Air density – Very Black – Only air
• Fat density
• Metal density

Chest X- Ray: PA view

Inspiratory
Erect
Erect X ray: Fundic Bubble

Inspiration – In MCL more than 5th rib crosses the diaphragm

Expiration – In MCL less than 5th rib crosses the diaphragm

PA AP
Clavicle Oblique Horizontal
Stapula Outside the lung field Overlap the lung field
Ribs Oblique Horizontal

@ T1 Vertebral body: Spinolaminar line forms an inverted V

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Rotation of film:

• Spinoclavicular distance are equal – No rotation

• If spinoclavicular distance, one distance is more – Film is rotated

Assess Cardiomegaly on Chest X- Ray

• Assessed always in PA view and non rotated

# Apparent cardiomegaly – AP view

CT Ratio:
!
× 100 < 50% = N
"

>50% ® Cardiomegaly

U.Z – Upper Zone

M.Z – Middle Zone

L.Z – Lower Zone

Chest X Ray – PA view, inspiratory erect Chest X Ray – AP view, expiratory supine

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Cardiac Silhouette:

• R heart border ® SVC

RA
IVC
• L heart border ® Aortic knuckle
Pulmonary trunk
Left atrial appendage
Left ventricle
• Base
# Base is opposite to apex
It is posterior
Formed by RA + LA
• Inferior border ® RV and LV
• Apex ® LV: Point down and out
RV apex: Up and out ® TOF apex formed by RV

TERMINOLOGY IN CHEST XRAY 05:09

• Luscent ® Black
• Opaque ® White

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 Opacity

↓ Air ­ Soft tissue

Air is lost Air is replaced Pleura

Collapse Consolidation Volume Gain

Collapse Consolidation
Volume: Replacement/ Same
Loss
• Crowding of ribs
• Elevation of
hemidiaphragm
• I/L Mediastinal • Identified margins
shift • Air bronchongram sign – Alveolar opacity
• Sharp margins
• Displacement of Visualization of air in bronchi surrounded by
inter labor fissure is alveolar opacity
the most reliable Eg:
direct sign of • Exudates – Pneumonia (alvular)
collapse Not interstitial pneumonia – Mycoplasma
viral
• Fluid – Pulmonary oedema
ARDS
Hyaline membrane disease
• Blood – Alveolar Hemorrhage
Good Pastuer syndrome
• Cells – Benign -Macrophage – PAP
Malignant – Bronchoalveolar Carcinoma

CXR IN COVID 08:33

1. Grand Glass Appearance – Haziness – Earliest feature

2. Consolidation – Advanced cases

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Volume gain:

Features:

i. Widening of I/C space

ii. Depression of diaphragm
iii. C/L Mediastinal shift

MASSIVE PLEURAL EFFUSION

• Complete left opaque hemithorax
• Trachea slightly shifted to opposite side ® Volume gain ® Pleural pathology

COLLAPSE
• Complete left opaque hemithorax
• Trachea shifts to same side ® Volume less

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CONSOLIDATION

• Air bronchogram sign

• Trachea in midline
• Opacity on left side

COLLAPSE

Reverse ‘Sign’/ Golden ‘S’ Sign Collapse

R Upper lobe collapse 2° to a

Bronchogenic cancer

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• Frontal radiograph – cannot differ
• Anterior or posterior

Silhouette Sign:
If two structures of same density are in anatomical continuity with each other their
interface is lost, however they overlaying their interface is seen.

Opacity is in continuity with

left heart border.

Opacity lies anteriorly

towards heart – it is at
linguila.

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Silhouette sign 12:34

• Obscuration of a part of Heart border, diaphragm and aorta by any intrathoracic

opacity of same density when it is in anatomical contact with that structure.

Opacity lie posteriorly

Opacity lies in anterior aspect – Middle lobe

Silhouette/ Structure Contact with Lung

Upper right heart border/ ascending Anterior segment of RUL
aorta
Right heart border AML (medial)
Upper left heart border Anterior segment of LUL
Left heart border Lingual (anterior)
Aortic knob Apical portion of LUL (posterior)
Anterior hemidiaphragms Lower lobes (anterior)

PLEURAL EFFUSION
• Blunting of CP angle
• At least 150-200 ml of pleural effusion required in an erect PA view CXRay – for
blunting of CP angle

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• Supine view blunting of CP angle to be view, fluid of 500 ml required

Lateral X Ray

Blunting of posterior CP angle

>75 ml of fluid required

L Plueral effusion

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L Pleural effusion:

L Lateral decubitus view ® 10-15 ml of fluid can be seen

Left Pleural Effusion

Left lateral decubitus view

Pneumothorax

R Side

• Area of hyperlucency along the lateral aspect devoid of any vascular marking

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HYDROPNEUMOTHORAX
• Fluid level present

TENSION PNEUOMOTHORAX
• Trachea shifted opposite side
Air under pressure
• Diaphragm shifted down

PNEUMOTHORAX
• Supine X ray
• All air collected anteriorly - CP angle
• Deep sulcus sign – sign of pneumothorax in supine view
# Best X ray to diagnose pneumothorax

Chest X ray PA, in expiration

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Normal lungs on usg 17:44

Seeshore Sign ® M mode ultrasound

Pneumothorax on usg 18:37

M mode USG B Scan

Stratosphere sign/ Barcode Loss of sliding pleura
sign sign

CT SCAN – CHEST 19:12

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ABNORMALITIES IN CT CHEST 19:40

Right Sided Pneumothorax

Hydropneumothorax

Left Sided Pneumothorax

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Mediastinal lesions 20:12

Felsons Radiological Division of Mediastinum

Draw a line from the anterior tracheal margin

to the posterior pericardium
Draw 2nd line 1 cm behind the anterior
vertebral
Divided in three spaces:
i. Anterior
ii. Middle
iii. Posterior

Anterior Mediastinal Mass:

4 Ts –

1. Thymoma
2. Teratoma
3. Thyroid masses
4. Terrible lymphoma

Middle Mediastinal Mass:

1. Lymph node
2. Vascular
3. Pleuro pericardial cyst

Posterior: Neurogenic

• As per anatomy ® Heart is a part of middle mediastinum

• As per radiology ® Heart is a part of anterior mediastinum
• InxOC of mediastinal mass ® CECT
• InxOC for posterior mediastinal mass ® MRI because they are neurogenic in nature

Chest X-Ray: Mediastinal lesions have very sharp margins

Convex borders/ Margin

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Interparenchymal lesion ®

Q. Most common anterior mediastinal mass ® Thymoma

Q. Most common mediastinal mass

Adults ® Thymoma
Children ® Neurogenic
Overall ® Thymoma

Virtual Bronchoscopy 22:42

Patient with collapse left lung. Virtual bronchoscopy showed mass at the origin of the
left main bronchus

VB in combination with axial CT images and coronal or sagittal reconstruction can be

useful in determining the best location for transbronchial biopsy.

Virtual bronchoscopy

CT Scan

MDCT
• Virtual bronchoscopy can view distal to the mass
Endoluminal view: Non invasive • But biopsy cannot be taken

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Uses:

1. Virtual bronchoscopy
2. Virtual gastroscopy
3. Virtual colonoscopy

Pulmonary INFECTIONS 22:23

TB:

TB
â
Chest X Ray

1° Post 1° Hematogenous Endobronchial

Latent Infection â route
1. Ghon’s complex Reactivation
à Hilar • Cavitation
• “Tree in Bud” –
Lymphodenopathy • Fibrosis – Miliary nodules Sign of
â septal
bronchiolitis
Mediastinal thickening < 5 mm • S/I HRCT
enlargement • Apical
Also seen in RSV
à Lymphatics predominance 1° / Post 1° Both
à Sub Pleural focus

Causes of miliary nodules:

i. TB (MCC)
ii. Fungal infection ® Histoplasmosis/ Coccidioidomycosis
iii. Silicosis
iv. Sarcoidosis
v. Metastasis –
• Kidney
• Thyroid
• Melanoma
vi. Hemosiderosis – M.S

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Complications in TB:

1. Cavitation

• Most Common vessel involved in TB – Bronchial Artery

Rasmussen’s aneurysm:

i. From pulmonary artery

ii. Involved in TB
iii. Rare aneurysm
iv. Life threatening hemoptysis

2. Fibrosis – Bronchiectasis – MCC:TB

InxOC: HRCT

Tram track sign (loss of tapering of bronchus)

Signet Ring Sign

Bronchus dilatation Pulmonary artery

“Cluster of grape appearance”

Cystic bronchus

Honey combing – ILD (UIP variant)

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Periphery: white area
Necrotic mediastinal Lymphoadenpathy – Diagnostic for TB
Center: Necrosis

• Cavities
• Consolidation Diagnostic for TB
• Tree in bud pattern

Abscess:

• Air fluid level within lung parenchyma

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PERICARDITIS
Effusion

Pericardial Effusion

Pleural Effusion

• Meningeal
• Pleural
Normally too thin to be visible ® Seen on thickened ® Sign of infection/Inflammation
• Pericardial
• Peritoneal

PERICARDIAL EFFUSION

SPLIT PLEURA SIGN

Pleural layers thickened

Infected

Empyema

Split Pleural Sign

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Hydatid cyst 21:09

Air crescent sign ® Cyst

membrane rupture

• Most common site is Liver

• 2nd most common site is lung
• Hydatid cyst is known to calcify at all the parts of the body except lung

Floating water lilly sign

Pneumatocoel formation

Staphylococcal Pneumonia

S. Aureus

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Klebsiella pneumonia: • “Halo sign”

• Lobar pneumonia
• Excess mucous production – Fills the alveoli ® Distends the alveoli ® Volume gain
® Horizontal fissure bulging
↓
“Bulging Fissure Sign”

ASPERGILLOMA
Fungal ball in TB cavity with air crescent sign

Angioinvasive
Aspergillosis

“HALO SIGN”

Manifestations:

ABPA: Allergic Broncho Pulmonary Aspergillosis

• Hypersensitivity reaction
• Central bronchiectasis

• High density mucous filling the bronchus ® “Finger in Gloves”

• Central bronchiectasis ® s/i Cystic fibrosis

Invasive Aspergillosis

• Seen in immune compromised patient

• Well defined nodular lesion with ground glassing due to infiltrating nature of this
lesion

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Haemoptysis 33:20

• Check Pulse/ BP

Thready Low
Massive blood loss
â
Stop the bleeding
â
MC vessel involved Bronchial artery
â
Bronchial Artery embolization

Polivinyl alcohol particles

(PVA)

Non massive blood loss

â
CX Ray

Normal Abnormal
â
Bronchoscopy Mass Some other disease
â
Biopsy
â
Staging
PET CT/CECT
MRI – Pancoast Tumor
CECT – Adrenal gland should always be included in the imaging because it is the
most common site of metastasis form CA. LUNG

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SUDDEN ONSET DYSPNOEA 35:23

Sudden Onset Dyspnoea

CX Ray ® To rule out pneumothorax

Normal

Low probability (-) High probability (+)

Rule out screening InxOC Confirm

D- Dimer CTPA

­­

r/o P.E

Named signs IN Chest X-Ray:

1. Westermark sign ® Focal oligemia

2. Palla’s sign
3. Hampton’s hump
ECG ® Most Common Sinus tachycardia

Most characteristic ® S1Q3T3

PULMONARY EDEMA 36:16

• Severe manifestation of PVH ®­ PCWP

• Normal PCWP = 9-12 mm Hg
• Most Common Cause = ­ left atrial pressure ® Mitral stenosis ® RHD

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• Chest X-Ray:
­ PCWP = 12-20 mm Hg ® GdI PVH

• Upper lobe diversion of blood

• Cephalization of blood vessels
Earliest sign
• Reverse moustache sign
• Antler sign
• PCWP = 20-25 mm of Hg ® Gd II PVH ® Interstitial edema
• Thickened lymphatics at base lungs ® Kerly B lines

Kerley B Lines

• Always perpendicular to pleural

• Sign of PVH
• Not the earliest feature of PVH

• PCWP > 25 mm Hg ® Alveolar edema

Batwing appearance
# Batwing appearance on MRI Brain – Joubert syndrome

BRONCHIECTASIS

Cystic Bronchiectasis

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Grade 1 PVH Bat Wing Appearance

Bat Wing Appearance

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 Contrast Enhanced CT Scan

Pulmonary Embolism

Filling defect within pulmonary artery

• M.C.C – Rupture of Emphysematous bullae

• Best imaging Investigation: CT
• On Radiography ®
• Air encircle thymus ®Spinnaker Sail Sign
• Pulmonary artery ® Ring around artery
sign
• V sign of naclerio
• Continuous diaphragm sign

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Pneumopericardium ® Air in pericardium

X -Ray i. Continous ddiaphragm sign

Pulmonary alveolar proteinosis 39:37

“Crazy Paving Pattern”

2° in Lung
• Cannon ball metastasis/ Coin shape
• Suggestive of 2°

Pneumo Pericardium

Air

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PERICARDIAL EFFUSION

• Money bag appearance

Named signs 40:00

Shapes of Heart:

1. ® “Figure of 8”: Supracardiac TAPV “Total Anomalous Pulmonary Venous

Connection”

2. ® Ebsteins anomaly – Box shaped heart

3. Boot shaped heart ® TOF

4. Egg on string ® TGV
5. Sitting duck heart ® Persistent truncus arteriosus
6. Egg in a cup ® Constrictive pericarditis
7. Jug handle ® Primary pulmonary hypertension

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Cardiac imaging 41:20

Coronary Angio:

• Blood to heart is via coronaries ® Best way ® Catheter angiography

• Radial route

CT Angio:

• Dual source CT
• Mid diastolic phase

NCCT:

• Calcium in coronary vessel

• Coronary calcium score
• “AGATSTON SCORE”

Ventricular function:

• Most practical test to see this is echo (not accurate test)

• Accurate test ® MUGA
• Most accurate test ® Cardiac MRI

RWMA: Nonfunctioning myocardium

Dead Unconscious

Non viable Hibernating myocardium

Viable

• Thallium test
• Sestamibi
• MRI
• FDG PET (Best) ® MC source of metabolism of myocardium ® Fatty acids
MC source of metabolism of Hibernating myocardium ® Glucose

Shows activity on FDG PET

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IMAGES 43:32

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SIGNS OF LEFT ATRIAL ENLARGEMENT 4:05

LA:

• Enlargement of the LA appendage

• “Splaying” of the carina
• Elevation of the LMB
• “Double density” projecting over the central portions of the heart
• Displacement of descending aorta to the left (Bedford sign)
• Always check left heart border for straightening.

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