Imaging chest pain

Dr. Haveen Azo 

lecturer/college of medicine/HMU
Miscellaneous notes
The standard positions are erect PA and lateral (left
lateral, i.e., the left side of the patient is against the
image receptor, so there’s minimum magnification of
the heart)
Three borders should be assessed in the silhouette
sign: diaphragm, cardiac, mediastinum.
Background
5 million patients/ year present to the ED with chest
pain
1.5 million patients/ year are admitted for workup of
acute coronary syndrome (ACS)
3-10 billion dollars/ year are spent USA to evaluate
complaints to chest pain
Immediate life-threatening causes of CP:
Acute myocardial infarction (AMI) / Acute Coronary
Syndrome (ACS)
Pulmonary embolism (PE)
Aortic dissection
Tension Pneumothorax
Esophageal rupture (appears as pneumomediastinum)
Pericardial tamponade
46 y/o male with PMH of GERD and
tobacco use c/o left-sided, sharp CP that
radiates to his back and down his left arm.
ACUTE MYOCARDIAL INFARCTION (AMI) and ACUTE CORONARY SYNDROME (ACS)

Erect PA CXR. Non-homogenous

opacification in both lung fields, not
limited by a fissure, ill-defined (maybe
also air bronchogram?), perihilar and
goes outwards (bat wing appearance).
This is alveolar pulmonary edema
(transudate filling of alveoli).

Note – CXR and AMI: Useful in

excluding other causes of chest pain, e.g.
pneumonia. Less useful in the direct
diagnosis of myocardial infarction. The
cardiomediastinal contours are usually
normal. One may occasionally see signs
of heart failure.
Axial, contrast-enhanced computed tomography (CT) scan
shows alveolar and interstitial pulmonary edema.
CT shows cotton wool perihilar opacification (alveolar edema)
and peripherally the lung is more clear.
Note: the main cause of pulmonary edema is congestive heart failure

Note: In interstitial edema, there’s reticular opacification (Kerley A, B, C). Kerley

B is the most easily seen. Kerley-B lines are seen as peripheral short 1-2 cm
horizontal lines near the costophrenic angles and they run perpendicular to the
pleura (The outer third of the lung is devoid of vascular markings, so seeing these
Kerley B lines is easier?). If interstitial not treated it’ll progress to alveolar
Cephalization

Note: in normal patients, due to gravity, the lower pulmonary vessels are
more prominent
The initial phase of cardiogenic pulmonary edema is manifested as
redistribution of the pulmonary veins.
This is know as cephalization because the pulmonary veins of the upper
zone dilate due to increased pressure.
This diagnosis is made when the upper lobe vessels are equal to or
larger in diameter than the lower lobe vessels.
The diagnosis of cephalization is more difficult in the supine patient
due to gravitational effects.
Note: vessels in the 2nd intercostal space shouldn’t be > 3 mm??
Note: At the level of the hilum, the blood vessels are the same size as end on
bronchi. In the lower zones, they are larger??
cephalization
normal
Normal(A) and cephalization (B)

A
B
Cardiothoracic ratio
A:cardiac diameter
B:interthoracic diameter

It is the ratio between the

maximum transverse diameter of
the heart and the maximum
width of thorax above the
costophrenic angles
Notes
One of the features of heart failure on CXR is
Enlargement of cardiac shadow (not cardiomegaly;
remember that this cant be determined by CXR alone, and
CT or echocardiography is needed to find cardiomegaly)
Before checking for an enlarged cardiac shadow you
should check technical factors, most importantly rotation
(distance from medial end of the clavicles to the spinous
processes should be equal) and inspiration (6 ribs
anteriorly, 10 ribs posteriorly should be above dome of
diaphragm on the right side). The film should also be
erect and PA.
Note: Kerley A lines are 2-6 cm long oblique lines that are <1 mm thick and course
towards the hila. 
Note: Kerley B lines ae
produced by lymphatic
engorgement of the
interstitium. They may be seen
in any zone but are most
frequently observed at the lung
bases at the lateral costophrenic
angles on the PA radiograph,
and in the substernal region on
lateral radiographs. These lines
are parallel to each other and
perpendicular to the surface of
the parietal pleura.
PA erect CXR. There’s a homogenous opacity over the left lung field, and the left
hemidiaphragm and left cardiac border obliterated. The costophrenic angle is blunted.
The opacity extends upward laterally (meniscus sign) (the typical configuration of the
upper border of the opacity in pleural effusion is a meniscus extending up the lateral
chest wall). This is pleural effusion.
note: In a lateral decubitus film, the fluid will be distributed on the dependent part (on
the lateral chest wall)
Note: in hydropneumothorax,, an air-fluid level is seen instead at the upper margin of
the opacity
Pleural effusion extending into the fissures
Pleural effusion

Obliteration of
costophrenic
angle and
meniscus sign.
Notes on previous slide
Bilateral pleural effusion seen (blunting of costophrenic angles)
Normal azygos vein anatomy: the vein ascends in the posterior mediastinum before
arching over the right main bronchus posteriorly at the root of the right lung where it
joins the superior vena cava.
Arrow: An azygos fissure is present in 1 in 200 subjects, defining the presence of an azygos
lobe. An azygos lobe represents parts of the apical or posterior segments of the right upper
lobe. An azygos fissure and azygos lobe are formed when the azygos vein invaginates the
right upper lobe during gestation. The azygos fissure consists of four layers of pleura (two
parietal and two visceral) and contains the arch of the azygos vein. On the frontal
radiograph, the azygos fissure has a characteristic curvilinear appearance adjacent to the
right mediastinum, convex laterally; the azygos vein itself (curving forwards as it enters
the superior vena cava) has a teardrop appearance at the inferior extent of the fissure
Side-note: The aortic knob or knuckle refers to the frontal chest x-ray appearance of the
distal aortic arch as it curves posterolaterally to continue as the descending thoracic aorta. It
appears as a laterally-projecting bulge, as the medial aspect of the aorta cannot be seen
separate from the mediastinum. It forms the superior border of the left cardiomediastinal
contour.
Bat Wing Edema
Bat wing edema refers to a central, nongravitational
distribution of alveolar edema.
 It is seen in less than 10% of cases of pulmonary
edema and generally occurs with rapidly developing
severe cardiac failure
Congestive Heart Failure
Common features observed on the chest radiograph of a
CHF patient include:
Cardiomegaly (cardiothoracic ratio > 50%)
Cephalization of the pulmonary veins
Appearance of Kerley B lines
Alveolar edema often present in a classis perihilar bat
wing pattern of density
Pleural effusion
Note: Summary of CXR features
Enlarged cardiac shadow
Cephalization
Peribronchial cuffing
Kerley B lines
The kerley B lines can then progress to interstitial edema (in bat’s wing
pattern – perihilar and expanding peripherally)
After interstitial edema is alveolar edema.
Cardiogenic alveolar edema is different from pneumonic consolidation in that it’s
not lobar, perihilar, not limited by fissures and ill-defined
If the condition progresses further, pleural effusion occurs.
Cardiogenic pleural effusion should be accompanied by pulmonary edema?? (Dr.
Salah)
Cardiogenic pleural effusion is usually bilateral, but it's occasionally unilateral (in
which case it's usually on the right)
Treating the condition at any phase resolves it and doesn’t let it progress
further.
Pulmonary embolism (PE) refers to embolic occlusion of the pulmonary arterial system. The
majority of cases result from thrombotic occlusion and therefore the condition is frequently
termed pulmonary thrombo-embolism, which is what this article mainly covers.

Other embolic sources include:

air embolism
fat embolism
tumour embolism: comprised of tumour thrombus
hydatid pulmonary embolism 
talc pulmonary embolism
Iodinated oil pulmonary embolism
metallic Mercury pulmonary embolism
amniotic fluid embolism
cement embolism
catheter embolism
septic pulmonary embolism
Risk factors
primary hypercoagulable states
protein C deficiency
antithrombin III
lupus anticoagulant
recent surgery
pregnancy
prolonged bed rest/immobility
malignancy
oral contraceptive use
A case presented to ER with sever chest
pain, cough, and dyspnea

Overexposed CXR (note With adequate

exposure, you don’t see the bifurcation of
the trachea so clearly)

Erect PA CXR. There is a wedge shaped

opacity in the middle zone of the right lung
field, with the apex pointed towards the
hilum and the base located peripherally.
This is Hampton’s sign. The right
costophrenic angle is blunted (pleural
effusion). This is pulmonary embolism.
A case presented to ER with sever chest
pain, cough, and dyspnea

PT (no filling defect)

AA
SVC

DA
Notes on previous slide
Chest CT, IV contrast, axial view, mediastinal window
(lungs are completely dark, no details of parenchyma are
visible like they would be in the pulmonary window).
Low attenuation filling defect seen in the right
pulmonary artery and a smaller one also in the left
pulmonary artery (arrows). This is a pulmonary
embolism
A small pleural effusion can be seen (arrow head)
DA, descending aorta; AA, ascending aorta; PT,
pulmonary trunk; SVC, superior vena cava
Saddle pulmonary
embolism (severe
type); filling defect
extending into
both right and left
pulmonary arteries
Radiographic features
Depends to some extent on whether it is acute or chronic. Overall has a
predilection for the lower lobes.
Plain film: Most CXRs in patients with a PE are normal (90%?) (Contrast CT
should be done if embolism is suspected). 
Described chest radiographic signs include:
Fleishner sign: enlarged pulmonary artery (20%)
Hampton hump: peripheral wedge of airspace opacity and implies lung infarction
(20%)
(extra) While a pulmonary embolism is expected to result in a wedge-shaped
infarction, the expected apex of this infarction may be spared because of collateral
supply from the bronchial arterial circulation, leading to the characteristic rounded
appearance of a Hampton hump. Opacification occurs secondary to hemorrhage due
to the dual blood supply from the bronchial arteries
Westermark's sign: regional oligaemia and highest positive predictive value (10%)
pleural effusion (35%) (on the same side)
Note: elevation of diaphragm
Note 2: dilation and abrupt termination of pulmonary artery (Chang sign)
Note (extra): side of pleural effusion in
pulmonary embolism
Though pleural effusions are typically present on the
same side as the lung affected by pulmonary
embolism, they may be unilateral despite bilateral
embolic disease or bilateral when the pulmonary
embolism is unilateral.
Surprisingly, the effusion is also present unilaterally
and contralateral to the embolism in ∼7.5% of
patients with effusions due to pulmonary embolism
Diagnosis of pulmonary embolism is done by CT of
chest with contrast
Note: CT pulmonary angiography is the imaging investigation of choice for PE. The
pulmonary arteries are first evaluated to detect embolism during the pulmonary
arterial phase of the injection (contrast is in the pulmonary arteries).
 the CT should not be taken when contrast is in the pulmonary vein.

 Extra: the same bolus of contrast then enhances the deep lower extremity veins, which
are imaged with a delayed scan without injection of additional contrast for the
detection of DVT.
Note: CT can only detect emboli in the main arteries and proximal branches; this test is
generally unable to detect smaller emboli in the distal branches of the pulmonary arteries [1].
However, embolization of more distal branches is thankfully not life threatening (Dr. Salah,
[1])
A 27-year-old previously healthy woman presented to the emergency room
after the sudden onset of severe chest pain and shortness of breath during
the 37th week of pregnancy. Her examination was remarkable for a blood
pressure of 118/70 mm Hg, heart rate of 100 bpm, and respiratory rate of 24
breaths per minute. The cardiovascular examination was notable for a soft
systolic ejection murmur, and the pulmonary and general examinations were
unremarkable. ECG demonstrated sinus tachycardia,

and her chest x-ray was

normal.
 CT of chest, axial view, IV contrast, mediastinal window. A low attenuation line seen in
the lumen of the ascending and descending aorta (intimal flap). A Double lumen can
be seen (the smaller one is the true lumen, and the larger one is the false lumen; The
true lumen is often smaller due to compression by the false lumen). This is dissecting
aortic aneurysm . (note: an aneurysm increases the risk of aortic dissection)

Contrast computed tomography scan demonstrating acute type A aortic dissection with
enlargement of the ascending aorta and intimal flap (arrow) in the ascending and
descending aorta. Both the true lumen (TL) and false lumen are opacified with contrast in
this example.
Note: true vs false lumen
 The true lumen is often compressed by the higher pressure false lumen
and the smaller of the two
 If one lumen wraps around another in the aortic arch, the inner lumen
is the true lumen.
  The presence of an acute angle between the flap and the outer wall
(the “beak” sign) is seen only in the false lumen.
 Slender lines of low attenuation can be seen in the false lumen (the
“cobweb” sign), which represent residual strands of the media
 Outer wall calcification always indicates the true lumen in an acute
dissection.
 The false lumen is often of lower contrast density due to delayed
opacification
Note: aortic dissection, classification
 Aortic dissection occurs when blood enters the medial layer of the aortic wall through a tear or
penetrating ulcer in the intima and tracks longitudinally along with the media, forming a
second blood-filled channel (false lumen) within the vessel wall.
 Stanford classification: The Stanford classification divides dissections by the most proximal
involvement: type A involves any part of the aorta proximal to the origin of the left subclavian
artery, whereas type B arises distal to this vessel origin.
 type A: A affects ascending aorta
 type B: B begins beyond brachiocephalic vessels

 The DeBakey classification divides dissections into:

 type I: involves ascending and descending aorta (= Stanford A)
 type II: involves ascending aorta only (= Stanford A)
 type III: involves descending aorta only, commencing after the origin of the left subclavian artery (=
Stanford B)
 The classification of aortic dissection affects management. Type A dissections need surgical
management, while type B dissections need medical management with blood pressure control.
CT of chest, axial view, IV contrast, mediastinal window. A low attenuation line seen
in the lumen of the ascending aorta (intimal flap). Double lumen can be seen.
30 yrs old man presented with severe chest
pain

CXR shows widened mediastinum

Magnetic resonance images showing
separation of the dissected membrane. AA:
ascending aorta; F: false lumen; I: intimal
flap; P: pulmonary artery; S: subclavian
artery; T: true lumen.
Hypertension
Genetically triggered thoracic
aortic disease  
Marfan syndrome
Bicuspid aortic valve
Loeys-Dietz syndrome
Hereditary TAA/D
Vascular Ehlers-Danlos syndrome Motor vehicle accident
Congenital diseases/syndromes
Coarctation of the aorta
Turner syndrome
Tetralogy of Fallot
Aortitis
Syphilis
Pregnancy
Atherosclerosis
Penetrating atherosclerotic ulcer
Trauma, blunt, or iatrogenic
Catheter/stent     
Intraaortic balloon pump
Aortic/vascular surgery
Coronary artery bypass
surgery/aortic valve replacement
Cocaine use Inflammatory/infectious
diseases
Giant cell arteritis
Takayasu arteritis
Behet disease
Aortic angiography
Chest x-ray
Chest MRI
CT scan of chest with dye
Doppler ultrasonography (occasionally performed)
Most classic aortic dissections begin at 3
distinct anatomic locations:
the aortic root; 2 cm above the aortic root;
and just distal to the left subclavian artery
Plain film features of aortic dissection
Chest radiography may be normal, or demonstrate a number of
suggestive findings, including:
widened mediastinum (> 8.0-8.8 cm at the level of the aortic knob)
double aortic contour
irregular aortic contour
inward displacement of atherosclerotic calcification
Note: Calcification of the aortic knob is a common finding on chest X-
rays of elderly individuals and is probably the result of local stress and
strain
Note: CXR is not conclusive; diagnosis is made by contrast-enhanced
CT
Post contrast CT (CTA preferably) gives excellent detail.
Findings include:
intimal flap
double lumen
dilatation of aorta
complications
 Aneurysmal dilatation is considered when the ascending aortic diameter
reaches or exceeds 1.5 times the expected normal diameter (equal to or
greater than 5 cm).

Note: the risks of dissection

and rupture increase with
the diameter of the
aneurysm[1]
18 y old man admitted to ER with sharp, severe CP giving history
of blunt trauma to chest

Erect PA CXR. There’s a translucency occupying the left

hemithorax without any lung markings and increased
translucency compared to the right side and the lung is
collapsed (arrow). The heart is a bit shifted to the
contralateral side (remember that 2/3 of the heart should
be to the left of the midline normally). This is tension
pneumothorax
Note:
A tension pneumothorax will have the same features
as a simple pneumothorax with a number of additional
features, helpful in identifying tension.
These additional signs indicate hyper expansion of the
hemithorax: ipsilateral increased intercostal spaces,
contralateral shift of the mediastinum, depression of
the hemidiaphragm
Tension pneumothorax has a history of severe
dyspnea.
Inspiratory/expiratory projections are one technique that can be used to make a
pneumothorax more obvious. Expiration results in the lung reducing in volume,
becoming more dense and making the pneumothorax easier to identify (pnth and small
pl effusion) (the Blue and yellow arrows point to the visceral pleura line)
Underexposed film (dorsal spine not seen
through heart shadow)

There’s translucency occupying the left

hemithorax with no lung markings and the
lung is collapsed. The mediastinum is
shifted contralaterally and the diaphragm is
also compressed/flattened. This is tension
pneumothorax.
There’s translucency occupying the left hemithorax with no lung
markings and the lung is collapsed. The mediastinum is shifted
contralaterally. This is tension pneumothorax
Tension pneumothoraces occur when intrapleural
air accumulates progressively in such a way as to exert
positive pressure on mediastinal and intrathoracic
structures. It is a life-threatening occurrence requiring
both rapid recognition and prompt treatment to avoid
a cardiorespiratory arrest.
Cardiac tamponade
is the result of an accumulation of fluid, pus, blood,
gas, or benign or malignant neoplastic tissue within
the pericardial cavity, which can occur either rapidly or
gradually over time, but eventually, results in impaired
cardiac output.
Abnormal amount of fluid in the pericardial space,
defined as the space between the visceral and parietal
layers of the pericardium
Normally contains about 20-50 cc of fluid
Fat covers outside of heart and outside of pericardium
sandwiching pericardial space between the two layers
32 patient with history of malignancy presented to ER with retrosternal and
left precordial Sharp, stabbing, pleuritic last hours to days Worse with deep
breaths or supine position; better by upright and forward position)

Front chest x-ray demonstrates

marked enlargement of the
cardiac outline. This was due to
pericardial effusion and is a good
example of the water bottle sign.
This refers to the shape of the
cardiac silhouette on erect frontal
chest x-rays in patients who have a
very large pericardial effusion. The
fluid, often measuring a litre or
more, causes the pericardium to
sag mimicking an old-fashioned
water bottle sitting on a
bench. Typically the effusion has
accumulated over many and the
pericardium has gradually
stretched
Note: enlarged cardiac shadow
Enlarged cardiac silhouette could be pericardial
effusion or cardiac enlargement. 
An enlarged cardiac shadow with normal cardiac
contour is likely cardiomegaly.
A large cardiac shadow with water bottle appearance is
indicative of pericardial effusion.
The shape of the heart is not a certain thing for
differentiating pericardial effusion and cardiomegaly. CT
and echocardiography should be used to differentiate
the two. (Dr. Salah)
A 32-year-old man with acquired immunodeficiency syndrome and developing
tuberculosis presented to ER with retrosternal Sharp, stabbing, pleuritic CP

a b

(a) Chest radiograph shows significant enlargement of the cardiac silhouette with
the characteristic “water bottle” appearance. (b) Axial nonenhanced CT image of the
chest shows a large pericardial effusion flattening the anterior cardiac contour.
Note: those black spots in the CT may be fat or air (measuring attenuation can help
differentiate the two)
52 year old male presented with fevers,chest pain, shoulder tip pain, and recent travel in
South-East Asia.
Dx was pericarditis

Hypodense (fluid
density) area
around the heart

Pericardial effusion and enhancing

pericardium. There is also a left pleural
effusion.(diamond shape)
 There’s a translucency
surrounding the heart
shadow.

Cardiac tamponade in a newborn with respiratory distress

syndrome who developed pneumopericardium associated
with barotrauma from mechanical ventilation. Chest
radiograph shows pneumopericardium with cardiac
tamponade.
Pneumomediastinum is defined as small amounts of gas appear as linear or curvilinear
lucencies outlining mediastinal contours such as:
1. subcutaneous emphysema
2. gas anterior to pericardium: pneumopericardium
3. Curvilinear lucencies lines around superior mediastinal major vessels
extending to neck
4. continuous diaphragm sign: due to gas trapped posterior to pericardium.
The continuous diaphragm sign is a chest radiograph sign of 
pneumomediastinum or pneumopericardium if lucency is above the
diaphragm, or of pneumoperitoneum if lucency is below the diaphragm.
Normally the central portion of the diaphragm is not discretely visualized on
chest radiographs as it merges with the cardiac silhouette. If the diaphragm
can be seen continuously across the midline then this is highly suggestive of
free gas within the mediastinum, pericardium or peritoneal cavity. 
5. Naclerios V sign
Subcutaneous emphysema (or less
correctly surgical emphysema), strictly
speaking, refers to gas in the subcutaneous
tissues. (Normally, translucency is not seen
within the subcutaneous tissue.)
Curvilinear lucencies lines around superior mediastinal major vessels extending
to neck

There’s also
subcutaneous
emphysema (red
arrow) along the chest
wall, more prominent
along the right than
left. Continuous
diaphragm sign also
seen.

Note: this is more

easily seen with CT (?)
There is air in the mediastinum surrounding the aorta and trachea. The patient was
an asthmatic who presumably ruptured a bleb with air dissecting back along the
bronchovascular bundles of the lung to the mediastinum
Pneumopericardium
Naclerio V sign

The Naclerio V sign is a sign described on the plain film in patients with

a pneumomediastinum occurring often secondary to an 
esophageal rupture. 
It is seen as a V-shaped air collection. One limb of the V is produced by
mediastinal gas outlining the left lower lateral mediastinal border (left
arrow). The other limb is produced by gas between the parietal pleura
and medial left hemidiaphragm (right arrow). 
 MRI if available is usually best for
imaging ascending aorta
 Contrast-enhanced CT can image arch
and descending aorta.
 Transesophageal ultrasound, if
available, especially for root and
ascending aorta
 Angiography

-A normal chest X-ray does not exclude

dissection. Abnormal widening of mediastinum,
widened mediastinum: >8.0-8.8 cm at the abnormal aortic contour, dissection
level of the aortic knob on portable AP suspected.
chest x-ray
Dissection seen
in arch of aorta
A case presented with severe chest pain,cough,and
dyspnea
Frontal CXR: Arrow indicates:

Wedge shaped infarct abrupt cut off in pulmonary vasculature

Another cause of acute chest pain

A patient presented with severe shortness of breath and left-sided chest pain that
started 30 minutes ago and he is hypotensive, tachycardiac and in obvious stress.
What is your diagnosis?
The arrows point to what structure?
Normal
 What is abnormal?

Continuous diaphragm sign. The right picture also shows subcutaneous emphysema
• Curvilinear
translucent lines
around the major
vessels can be seen
• A translucency can
be seen around the
heart shadow
• Note the
subcutaneous
emphysema and
continuous
diaphragm sign
• There’s lung collapse
in the lower right
zone