Imaging of the Mediastinum

The mediastinum is the central part of the chest cavity containing many vital structures, such
as the heart, great vessels, trachea, thoracic esophagus, lymph nodes, multiple nerves,
sympathetic chains, and thoracic spine. Mediastinal pathology (e.g., masses) can be noted on
conventional radiographs as part of evaluating chest-related symptoms, or it can be
incidentally detected. To elucidate the characteristics of the mediastinal abnormality, further
imaging studies are warranted. Common additional modalities are CT and MRI.

Last updated: February 21, 2023

CONTENTS

Introduction
Chest Radiograph
Computed Tomography
Magnetic resonance imaging
Abnormal Findings
References

Introduction
Mediastinum
The middle of the thoracic cavity, located between the lungs
Subdivided into the:
Superior mediastinum
Inferior mediastinum:
Anterior: from the sternum anteriorly to the anterior surface of the pericardium
posteriorly
Middle: between the anterior and posterior surfaces of the pericardium
Posterior: between the posterior surface of the pericardium and T4–T12
The mediastinum:
subdivided into the superior and inferior mediastinum, which is further divided into anterior, middle, and
posterior thirds.
Image by Lecturio.

Imaging modalities
The common radiologic modalities used to evaluate the mediastinum:
Chest X-ray
CT
MRI
Additional details covering the radiologic modalities for chest evaluation are summarized
in Pulmonary Radiology.

Chest Radiograph
Overview
 Chest X-ray is the initial modality of choice in evaluating mediastinal structures.
Positioning:
Rotation:
There should be no rotation.
Spinous processes midway between medial ends of clavicles
Visualization:
Lungs should be fully visible from apices, above clavicles, to bases.
Performed in inspiration: 7–10 posterior ribs visualized above diaphragm
No superimposition of chin over neck or arms over peripheral chest
Positioning for specific views:
Posteroanterior (PA):
The board is against the anterior chest.
X-ray beams posterior → anterior direction through patient
Anteroposterior (AP):
The board is against back.
X-ray beams anterior → posterior direction through the patient
Lateral (from side):
The patient is upright.
The board is against the side (left or right).
Lateral decubitus (from side, lying down):
The patient is supine.
The board is against the side.
Usually left side down on table

PA view
The trachea is midline.
The shadow of the superior vena cava (SVC) is immediately to the right of the
mediastinum.
The right and left hila are seen.
The right (right atrium) and left (left ventricle) heart borders are clearly visible.
Portions of ascending and descending aorta are visible.
Posteroanterior (PA) view on chest X-ray showing normal findings:
The trachea is midline. The shadow of the superior vena cava (SVC) is immediately to the right of the
mediastinum. Right and left hila are seen. The right (right atrium) and left (left ventricle) heart borders are
clearly visible. Portions of ascending and descending aorta are visible.
Image by Hetal Verma.

Lateral view
The retrosternal space is clear.
The anterior (right ventricle) and posterior (right atrium) heart borders are visible.
The right hemidiaphragm is slightly higher.
The hila overlap each other in this view.
Lateral view on chest X-ray showing normal findings:
The retrosternal space is clear. The anterior (right ventricle) and posterior (right atrium) heart borders are
clearly visible.
Image by Hetal Verma.

Compartments of the mediastinum

Anterior mediastinum (prevascular):
Area between the sternum to the anterior heart border (essentially anterior to the
pericardium)
Contents:
Thymus
Fat
Lymph nodes
Internal mammary arteries
In adults, most common area of mediastinal masses
Mediastinal masses typically found here (“Terrible Ts”):
Thymoma
Teratoma/germ cell tumor (GCT)
(Terrible) lymphoma
Thyroid tissue
Middle mediastinum (visceral):
Area extending from the anterior to posterior margins of the heart
Lies between the anterior and posterior mediastinum
Contents:
Pericardium
Heart
Aorta and its branches
Vena cava
Trachea
Esophagus
Masses typically found:
Lymphadenopathy (LAD)
Cystic masses
Vascular aneurysms
Esophageal tumors
Posterior mediastinum (paravertebral):
Area extending from the posterior wall of the pericardium to the spinous processes
(includes the vertebral column)
Contents:
Spinal cord (SC)
Thoracic spine
Neurovascular bundle
Sympathetic chain
Masses typically found here:
Neurogenic tumors
Thoracic spine lesions
Meningocele
Extramedullary hematopoiesis (can present as a soft-tissue mass)
Computed Tomography
Overview
CT identifies the location of the pathology accurately and is thus the modality of choice in
evaluating the mediastinum.
Contrast helps define structures (e.g., vasculature, lymph nodes, mass).
The degree and variability of attenuation of a mass or structure depends on its
content.
Hounsfield units (HUs) measure the density of the structures:
Air (seen in pneumomediastinum): lowest HU
Fat
Water
Soft tissue
Ca/calcification
Bone: highest HU
Window levels: digital manipulation of the images to accentuate structures (e.g., in
soft-tissue window, soft tissues such as muscles are seen well)

Normal findings
 The trachea is visible as a black air-filled space.
Heart:
4 chambers are visible.
The pericardium (made of 2 layers) is seen as a linear line (upper limit is 2 mm thick)
enclosing the heart and great vessels.
Blood vessels:
Blood-filled structures appear brighter in CT with contrast.
Major vessels (pulmonary arteries and veins, aorta, and SVC) are continuous with the
heart.
Each smaller (black) bronchus is paired with a blood vessel (white).
Bony structures: ribs, vertebrae, scapulae, and humeri should be visible and lightest in
color (the most dense structures).

Axial mediastinal anatomy on CT (post-contrast):

the blood vessels (SVC: superior vena cava; PA: pulmonary artery, AO: aorta) are filled with contrast. The
bronchi are air-filled. Bone structures are noted to be bright on CT.
Image by Hetal Verma.

Magnetic resonance imaging

Overview
MRI
 Usually used to study mediastinal masses, specifically to:
Determine precise location
Assess invasion and staging (subcarinal and aorticopulmonary lymph node masses
are well visualized in coronal and sagittal sections)
Evaluate for mass contents (due to excellent resolution of soft-tissue structures)
Also indicated for those with contrast allergy and/or renal failure
Not associated with ionizing radiation
Among the disadvantages:
High cost
Longer scan time

Normal Findings
Views:
T1-weighted image (T1):
Tissues with high fat content appear bright/white.
Compartments filled with water appear dark/black.
T2-weighted image (T2):
Compartments filled with water appear bright/white.
Tissues with high fat content appear dark/black.
Structures:
Thymus:
Soft-tissue lobulation
Convex, straight, or concave edges based on patient age
Largest ages 12–19, then involutes (7 mm after age 19)
MRI demonstrates heart:
Muscle thickness
Ventricular size
End diastolic volume
Soft-tissue structures:
SC
Pulmonary parenchyma
Diaphragm
Top of liver
Vasculature

Abnormal Findings
Overview
 Abnormalities include:
Pneumomediastinum
Vascular abnormalities
Masses (e.g., tumors, cysts)
These conditions can produce widened mediastinum, but there are normal variants to
consider that can also produce the same effect:
AP projection (instead of PA projection)
Mediastinal fat (in the obese or those on steroid therapy)
Vascular tortuosity (noted in the elderly)
Low inspiratory supine position

Pneumomediastinum
Extraluminal gas (which may be from the lungs, trachea, esophagus, peritoneal cavity)
found in the mediastinum
Radiographic findings:
Linear lucencies outlining mediastinal structures:
Bronchi or trachea
Major blood vessels
Pericardium and heart
Findings are consistent with air surrounding the structure(s):
Thymic sail sign: upward shift of thymic lobes, forming a triangular inferior
thymic border (found in neonates)
"Ring around the artery" sign: gas around major aortic branches
Double bronchial wall sign: gas surrounding the bronchial wall
Continuous diaphragm sign: air between the diaphragm and the pericardium
SC emphysema is also seen.
CT findings:
Provides more details regarding coexisting illness or injuries (involving the
aerodigestive tract)
Also detects small air accumulations not seen on chest radiograph
Thyroid-related masses
Can be:
An enlarged thyroid gland (goiter) or thyroid mass (benign nodule or malignant
tumor) extending (from the neck) into the intrathoracic area
An ectopic thyroid
The majority of goiters found in the mediastinum are anterior to the brachiocephalic
vessels.
Radiographic findings:
Opacification in the anterior mediastinum
Widened mediastinum
+/- Mass effect: tracheal deviation to the opposite side
CT findings:
Anterior mediastinal mass
Goiters:
Heterogeneous density
Marked contrast enhancement
Thyroid nodules:
Common incidental findings on CT
American College of Radiology suggests follow-up ultrasound for incidental
nodules: if > 1 cm in those aged < 35 years, or > 1.5 cm in those aged > 35
years
Features suggestive of malignancy: ill-defined or irregular margins, tissue
invasion, and/or LAD
Teratoma
 GCT that typically presents as a large mass
20% are malignant.
The anterior mediastinum is the most common extragonadal site.
Variable contents:
Fat or fat-fluid levels
Cysts
Calcification
Soft tissue
Radiographic findings:
Opacification in the anterior mediastinum
Widened mediastinum
+/- Mass effect (e.g., tracheal deviation to the opposite side)
+/- Calcification and/or fat
In some, teeth or bone is seen.
CT findings:
CT scan is the radiologic exam of choice.
Anterior mediastinal mass with mixed density components related to the multiplicity
of contents
Fat-fluid level in the mass: pathognomonic
+/- Mass effect
Benign (mature) teratomas are well defined.
Features of malignancy:
Ill defined
Invasion
MRI findings:
Anterior mediastinal mass
Fat-fluid level is diagnostic.
MRI detects macroscopic fat (like CT) but also determines microscopic
intracellular fat (not detected by CT).
T1-/T2-hyperintensity and saturation on fat-saturated MRI pulse sequences
confirm macroscopic fat.
Calcification can be:
Rim-like
Focal
+/- Mass effect
+/- Septation

Thymoma and thymic carcinoma

 Tumors:
Thymoma:
Most common primary tumor in the anterior mediastinum
20% of mediastinal tumors
Thymic carcinomas: aggressive malignancy, often presenting with invasion of
structures in the mediastinum
Radiographic findings:
Well-defined anterior mediastinal mass, seen as a lobulated soft-tissue density
Typically slightly more protruding on 1 side
Lateral view: The retrosternal space is opacified.
+/- Calcification
CT findings:
Thymoma:
Sharply demarcated, encapsulated mass
Often with smooth contour
Round- or oval-shaped
Enhances with contrast
Often homogeneous but can have focal areas of hemorrhage, necrosis, or cyst
formation
+/- Calcification
Thymic carcinoma:
Anterior mediastinal mass
Irregular borders
Often heterogenous, with necrotic, cystic, or hemorrhagic components
Heterogeneous enhancement
+/- Calcifications
+/- Local invasion or LAD
+/- Extrathoracic metastases
MRI findings:
Thymoma:
Well-defined mass in the anterior mediastinum
Oval-/round-shaped
Usually homogeneous
Isointense to slightly hyperintense to muscle on T1 images
Typically slightly hyperintense to muscle on T2 images
Thymic carcinoma:
Anterior mediastinal mass
Irregular borders
Hypo- to isointense on T1-weighted images
Hyperintense on T2-weighted images
Heterogenous
+/- Local invasion or LAD

Lymphoma
 Types commonly found in the mediastinum:
Nodular sclerosing Hodgkin lymphoma (NSHL)
Primary mediastinal B cell lymphoma
Radiographic findings:
Anterior mediastinum location
Widened mediastinum
Retrosternal space obscured
CT findings:
Anterior mediastinum (although can be seen in the other mediastinal compartments)
Irregular contours (often with areas of conglomeration appearing as a large mass)
Homogeneous, with soft-tissue attenuation (but can be heterogeneous if with
necrosis or hemorrhage)
Mild-to-moderate enhancement
MRI findings: vary with the type of lymphoma

Bronchogenic cyst
Anomalous congenital outpouching of the foregut
The middle mediastinum is the most common location.
Radiographic findings:
Soft-tissue density, round or ovoid mass(es)
+/- Air-fluid level
+/- Calcification
CT findings:
Well-defined oval-/round-shaped mass(es)
Smooth borders
Varying attenuation due to different contents
Homogeneous
No enhancement
No invasion
MRI findings:
Rarely needed for evaluation
Homogeneous
Variable T1, dependent on cyst contents (low intensity in fluid, high intensity in
protein content)
Hyperintense on T2
No enhancement
No invasion

LAD
 LAD is the most common mass in the middle mediastinum.
Middle mediastinal lymph nodes:
Paratracheal
Subcarinal: below the tracheal bifurcation
Subaortic
Tracheobronchial (pulmonary root, hilar)
Causes include lymphoma, lung cancer, and sarcoidosis.
Radiographic findings:
Middle mediastinal mass(es)
Smooth borders
May be bilateral
+/- Splaying of the carina in subcarinal LAD
CT findings: The abnormal lymph node has a short-axis diameter >1 cm.

Aortic aneurysm
A thoracic aortic aneurysm is the abnormal dilation of a segment of the thoracic aorta with
the majority affecting the ascending aorta.
Radiographic findings:
Widened mediastinum
Smooth borders
Large aortic knob
+/- Calcifications
Deviation or compression of trachea or left mainstem bronchus
Note: cannot distinguish a thoracic aortic aneurysm from a tortuous aorta
CT findings:
CTA is the best modality (MRA is an option but is not readily available in many
centers).
Detects aortic diameter, vessel anatomy, dissection, rupture, thrombus
Shows a dilated aorta
+/- Filling defect (representing a thrombus or dissection)

Schwannoma
 Most common neurogenic mediastinal tumor
Often arising posteriorly, in the neural foramina
CT findings:
Located in the posterior mediastinum
“Dumbbell” configuration (demonstrating the tumor being “squeezed” through a
neural foramen)
Heterogeneous
Cystic changes
Hemorrhage
+/- Calcifications
Enhances with contrast
MRI findings: hyperintensity on T2

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