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137 Cards in this Set

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  • Back
What is the name of the fissure sometimes seen which divides the superior segment of the upper lobe from the rest of the upper lobe?
Superior accessory fissure
What percentage of patients have one?
Different on left and right
What percent have one on the left?
What percent have one on the right?
Why is it important to know about this fissure's existance?
Because consolidation in the superior segment of the upper lobe demarcated by this fissure can appear as upper lobe disease, and below the fissure can mimic lower lobe disease.
How can disease confined to the superior lobe by a superior accessory fissure be delineated from upper lobe disease?
1) If involvement occurs on the right, the superior vena caval margin will be visible because it is anterior while the process is posterior, in the superior segment of the upper lobe.

2) The lateral view will quickly clarify any confusion
In a patient with cardiomegaly, what is the first question you must ask?
Is there pulmonary vascular engorgement
What is the differential diagnosis for cardiomegaly without pulm vascular engorgement?
Pericardial effusion

Fluid overload (acute)

Compensated left ventricular failure
What entity falls under compensated LV failure?
Aortic regurgitation
How can the lesions in this differential be differentiated by plain film?
Can't be
What suggests aortic regurgitation as the cause?
Prematurely tortuous aorta
Where can lesions that cause aortic regurgitation be?
Aortic valve or aortic root
What suggests the lesion is at the aortic root?
Prominence of the ascending aorta
If this finding is not present, what are the likely causes?
Aortic valvular disease, which is typically caused by

1) Bicuspid aortic valve

2) Endocarditis

3) Rheumatic heart disease
In what setting is aortic regurgitation impossible to diagnose on plain film?
In the setting of mitral heart disease
Because the dilated left atrium due to the mitral stenosis laterally deviates the descending aorta, making it look tortuous.
What is the most common radiologic finding in patients with sequelae of rheumatic heart disease?
Mitral stenosis causing mitral configuration heart
What percent of rheumatic heart patients have involvement of the mitral valve?
What is the most common finding in sarcoidosis?
Bilateral symmetric hilar lymphadenopathy, with right mediastinal lymphadenopathy possibly evident
What is the most common parenchymal appearance in sarcoidosis?
Nodular or reticulonodular disease
What part of lung are findings predominant?
Upper lungs
Why does that make sense?
Because you know that sarcoid can cause cicatricial changes of the upper lobes just like Tb in end stage
What do the nodules represent?
Noncaseating granulomas, 2-3 mm large.
Where are they seen on HRCT?
Lymphatic distribution. SO they follow the peribronchovascular lymphatics, the interlobular septae, and the subpleural lymphatics.
Where is lung contusion seen?
Adjacent to area of direct blunt or penetrating trauma (so look for rib fractures or bullet fragments when you are suspecting lung contusion)
When should contusion have completely cleared?
1 week
What is the other type of parenchymal lung injury that occurs in trauma?
Pulmonary laceration (laceration, just like in liver)
What does laceration look like?
Usually small ovoid lucency within the area of clearing contusion.
How else may it look?
If may fill with blood, forming a hematoma, which can take weeks to clear
What is pulmonary contusion?
Hemorrhage into alveoli
What is the most common cause of pneumomediastinum?
Alveolar rupture into the mediastinum.
What are the other causes of pneumomediastinum?
Tracheal rupture

Esophageal rupture

Via neck or retroperitoneum
What are causes of alveolar rupture?
Either elevated intraalveolar pressure or damage to alveolar walls.
What are causes of elevated intraalveolar pressure?
Airway obstruction, such as from asthma or foreign body

Mechanical ventilation

Blunt thoracic trauma

What are the causes of alveolar wall damage that can promote pneumomediastinum?



Interstitial fibrosis
How do you determine pneumomediastinum from pneumopericardium?
Pneumopericardium will not extend superior to the great vessels, where the pericardium ends. Pneumomediastinum will often extend much further, into the neck.
Will pneumopericardium shift in position in lateral decubitus view?

Will pneumomediastinum?
Pneumopericardium -- yes

Pneumomediastinum -- no
What are 4 features of malignant pleural thickening?
1) Greater than 1 cm thick

2) Circumferential (versus focal plaques)

3) Nodular/irregular

4) Involves mediastinal pleura as well
What is the differential for malignant pleural thickening?
1) Malignant mesothelioma

2) Pleural metastases
Which is more common?
Pleural metastases
In what percent of malignant mesothelioma cases is pleural calcification seen on CT?
only 20%
How is it treated?
Can be treated surgically only in limited cases: When there has been NO

Transdiaphragmatic extension

Diffuse invasion of chest wall

Invasion of vital mediastinal structures

Vertebral body invasion

Direct extension to contralateral pleura

Distant mets
What is the most sensitive view to see pleural effusion?
Lateral decub view
How much fluid needed to blunt costophrenic angle on frontal view?
200 ml
How much needed on lateral view?
75 ml
How much needed on lateral decubitus view?
5 ml
What do you see?
Lung floating on top of effusion, which is seen against chest wall as a dense meniscus.

Also see hyperinflation of the up lung.
What does subpulmonic effusion do on frontal view?
Collects in the most dependent area of the lung, so first in posterior costophrenic angle, then causes the lung to float up on top of it, just like what happens on lateral decub view.

So you see instead of the hemidiaphragm on that side the subpulmonic fluid collection, which extends out flatter more laterally than the lung actually does.
How do you verify whether there is a subpulmonic effusion or not?
Just get a lateral decub view, and it will all spill out.
What are the most common locations for PTX on supine radiograph?
1) Anteromedial -- makes sense, as this would be highest point in chest

2) Subpulmonic -- deep sulcus sign
What are the signs of a subpulmonic pneumothorax?
Helpful to think where this air is loculated: Same place that fluid is when it is subpulmonic, except that it will tend to float anteriorly vs posteriorly in supine patients.


1) Deep sulcus sign

2) Hyperlucent upper abdomen (area just below hemidiaphragm) on that side

3) Double diaphragm sign

4) Sharp margination of the hemidiaphragm
What is double diaphragm sign?
Visualization of both anterior and posterior diaphragmatic surfaces
What is radiographic evidence of anteromedial PTX?
Sharp outline of the cardiac and mediastinal contours on that side
What is the most helpful differentiating feature between pleural and extrapleural (chest wall) masses?
Presence of rib destruction or remodeling. Suggests extrapleural (chest wall) disease.
What are the two most common causes of extrapleural mass with associated rib destruction in an adult?

What are two hypervascular mets to the chest wall that will show intense enhancement?
Renal cell carcinoma

What are the two important descriptors for both pleural based and extrapleural chest wall masses on CXR?
The lesions are broad-based, forming obtuse margins with the chest wall.

The lesions have incomplete borders.
What are 3 entities that present with peripheral consolidation?
Eosinophilic pneumonia

Loffler's syndrome


Pulm infarcts

Where does chronic eosinophilic pneumonia most prominently affect?
Lung apices. Lung bases are less frequently involved.
What is the differential diagnosis for a well-marginated cystic structure adjacent to the trachea near the lung apex?
1) Paratracheal air cyst

2) Apical bullea

3) Apical lung hernia
What is a paratracheal air cyst?
A tracheal diverticulum
Where do these diverticulae occur most often?
At the right posterolateral tracheal wall, at the level of the thoracic inlet.
What is the finding that should make you immediately suspicious of tracheoesophageal malformation?
Gasless abdomen
How do you make the diagnosis?
Put a feeding tube in and inject AIR to diagnose the esophageal atresia. Don't inject contrast unless necessary, and then only a tiny bit of BARIUM as kid can easily aspirate.
Why is it so easy to aspirate?
Because most esophageal atresias have associated tracheal involvement.
What is the level of esophageal atresia usually?
Lower cervical or upper thoracic.
What is the level of the tracheoesophageal fistula usually?
Usually level of carina = T4
What are tracheoesophageal malformations associated with?

What is the differential diagnosis for apical pleural density?
Apical pleural cap


Pancoast tumor
What is apical pleural cap due to?
Old age, related to apical pleural ischemia
When is the diagnosis of tumor suspected?
When there is more than 5 mm asymmetry between the thickness of the caps between each side
Where must you never forget to look on a CXR ever again?
Look to see the normal vessels coursing through the retrocardiac shadow on ALL CASES!
Where is intralobar sequestration usually located?
Posterobasal segment of a lower lobe
What is the treatment?
Surgical excision
What does congenital lobar emphysema do?
Causes mass effect
On what?
1) mediastinum

2) Rest of ipsilateral lung, compressing it, making it look consolidated
What lobe is most commonly involved in CLE?
Left upper lobe
What lobe is second most common?
Right middle lobe
What is the third most common lobe?
Right upper
What is NOT involved
lower lobes are not
What is the most common cause?
Bronchial cartilage deficiency resulting in airway collapse
When does it present?
1) First few days of life: CXR does not clear in that lobe, due to bronchial blockage

2) Presents symptomatically usually after neonatal period
How do you make the final diagnosis if CXR is not enough (should be, though)?
To differentiate from bronchial obstruction with a check valve mechanism
Where should tip of intraaortic balloon pump be?
2-4 cm below SUPERIOR margin of aortic nob. Anatomically, you want it just distal to takeoff of the final branch of the arch (L subclavian usually)
Is it OK for pacing wire to be in the coronary sinus?
Yes. Put here for atrial pacing.
What is the 4 chamber view of the heart an example of?
An apical view, with transducer cutting coronally through the heart, apex first.
So what does this mean?
Means ventricles are always closest to transducer.
What is the overall incidence of congenital heart disease?
What are the two most common congenital heart abnormalities?
Bicuspid aortic valve

Mitral valve prolapse
What is true about these lesions clinically?
Usually asymptomatic
What are the three most common symptomatic congenital heart abnormalities?
Atrial septal defect


Tetralogy of Fallot
What are the next three most common symptomatic ones?


When do most congenital heart lesions clinically present?
After first month
What is the most common lesion to present in the first month?
Hypoplastic left heart
What is the second most common in first month?
What is the third most common to present in the first month?
Coarctation (severe)
What is the 4th most common in 1st month?
Severe tetralogy, or severe isolated pulm atresia
How many things must you evaluate on the CXR for cardiac disease?
What 5 things; First?
Pulmonary vascularity
Side of aortic arch
Chamber enlargement
Bone and soft tissue changes
At what pressure does venous redistribution occur?
about 15-18 mmHg
Interstitial edema?
18-25 mmHg
What is a rule of thumb about the appearance of the cardiac silhouettte in cyanotic cong heart dz?
PA segment small, concave, or not visible

Small pulmonary arteries
How many and what are the segments (moguls) of the right side of the heart?
There are 3:


Right atrium

How many and what are the segments of the left side of the cardiac silhouette?
Aortic arch

Pulm artery

Left atrial appendage

Left ventricle
Which of those 4 may not be visible in a normal patient?
Left atrial appendage
What are the segments of the anterior heart on the lateral view?
Right ventricle

Main PA (short segment)

Ascending aorta
What are the segments of the posterior heart shadow?
Left ventricle

Left atrium
What is the location of the right pulmonary artery on the lateral view?
Anterior to carina
What proportion of the sternum is occupied by contact with the right ventricle?
1/3. If more than that, there is RV enlargement
What are radiographic signs of left atrial enlargement?
Posterior displacement of the left mainstem bronchus

Posterior displacement of esophagus during barium swallow
Which is more superior: Right upper lobe bronchus or left upper lobe bronchus?
How do you determine situs?
1) Look for IVC = position of right atrium

2) Look at bronchi -- look for right mainstem bronchus

3) Gastric air bubble

4) Usually just obvious
What is incidence of congenital heart disease in situs inversus?
What is the first step in evaluation of congenital heart disease radiographically?
Clinical information: Is the patient cyanotic?
What if the patient is not cyanotic. What is the first step?
Evaluate pulmonary vascularity
What are the options for vascularity in an acyanotic patient with suspected congenital heart disease?
Normal or increased
What is the reason for this?
All acyanotic lesions are either the result of intact vascular circuitry with stenosis/interruption, OR of left to right shunting of bloodflow, back through the pulmonary circuit. The first situation results in normal vascularity. The second situation results in increased pulmonary vascularity.
What is the pulmonary to systemic flow ratio at which a CXR will demonstrate increased pulmonary vascularity?
What is the next step in patient with normal vascularity?
Render a differential.
What is the differential?
1) Aortic stenosis

2) Pulmonic stenosis (without intracardiac shunt)

3) Coarctation

4) Interruption of aortic arch
What if the acyanotic patient has increased pulmonary vascularity. What is next step?
Evaluate for presence of left atrial enlargement.
Why is this the next step?
By demonstrating increased pulmonary vascular flow, you are suspicious of a shunt. Most left to right shunts cause enlargement of the left atrium, as the blood all comes back to the LA again after being shunted back through the lungs.
What is the next step if there is no enlargement of the left atrium?
Render a differential
What is the differential?
Atrial septal defect
Why is there no left atrial dilatation?
Because the left atrium is able to decompress through the septal defect into the right ventricle.
What is the next step if there is left atrial enlargement?
Look for aortic enlargement
What is the differential if there is no aortic enlargement?
ventricular septal defect
Because the aorta is not seeing increased bloodflow. The shunt is occurring into the right ventricle
What is the differential if there is aortic enlargement?
Patent ductus arteriosus
What if there is cyanosis, what is the initial step?
Same thing. Evaluate the pulmonary vascularity.
What are the choices for pulmonary vascularity if there is cyanosis?
Normal or decreased