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48 Cards in this Set

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Four basic x-ray densities
Air
Fat
Water
Metal (calcium)

Dense objects as white, more easily penetrated as gray/black.
Basic x-ray density descriptions
Radiopaque
Radiodense
Radiolucent
Opacity - white
Lucency - black
Penetration
Faint visualization of the intervertebral disc spaces of the thoracic spine

Discrete branching vessels can be identified through the cardiac shadow

Images can be under or over penetrated.

Shown: underpenetration
Faint visualization of the intervertebral disc spaces of the thoracic spine

Discrete branching vessels can be identified through the cardiac shadow

Images can be under or over penetrated.

Shown: underpenetration
Rotation
There should be equal distance between clavicular heads and spinous processes.

If wider on one side, patient is rotated.

Anterior structures move in the same direction as the patient is rotated and posterior structures move in the opposite direction.
Inspiration
An appropriate deep inspiration in a normal individual is present when the apex of the right hemidiaphragm is visible below the 10th posterior rib.
- Count 8-10 ribs

Poor inspiration can mimic infiltrates on lungs and be confused for pneumonia.
Motion
The cardiac margin, diaphragms and pulmonary vessels should be sharply marginated in a completely still patient who has suspended respiration.
Where are the most commonly missed pathologies located?
Right upper lobe

Other areas include retrocardiac, peripheral lung margins and posterior costophrenic sulci.
Right upper lobe

Other areas include retrocardiac, peripheral lung margins and posterior costophrenic sulci.

Rib fractures - pleuritic pain
PE - increased D dimer
What is the best approach to take when reading an image?
A systematic approach

Look at various structures in a deliberate order, concentrating on the anatomy of each while excluding the superimposed shadows of other structures
Lobes of the lungs
Right lung - 3 lobes
- RUL - 3 segments
- RML - 2 segments
- RLL - 5 segments

Left lung - 2 lobes
- LUL - 4 segments
- LLL - 4 segments
Right lung - 3 lobes
- RUL - 3 segments
- RML - 2 segments
- RLL - 5 segments

Left lung - 2 lobes
- LUL - 4 segments
- LLL - 4 segments

Lingula of left lung is analogous to RML.
Lung fissures
Fissures - best visualized on lateral
- Major separates upper from lower lobes
- Minor separates RUL from RML
- Azygos (0.5%), accessory
Fissures - best visualized on lateral
- Major separates upper from lower lobes
- Minor separates RUL from RML
- Azygos (0.5%), accessory
Azygos fissure
An anomaly sometimes seen
Normal variant

Can resemble right apical mass
Pseudotumors
Fluid in fissures that can be mistaken for tumors.
Fluid in fissures that can be mistaken for tumors.
Frontal cardiac view
Right cardiac border - right atrium 

Left cardiac border - left ventricle  

The SVC forms a right paramedian border
Right cardiac border - right atrium

Left cardiac border - left ventricle

The SVC forms a right paramedian border
Lateral cardiac view
Anterior cardiac border - right ventricle

Posterior cardiac border -  LV and LA  

The IVC is seen best on lateral projection.  The posterior border is evident in contrast to the air-filled lungs.
Anterior cardiac border - right ventricle

Posterior cardiac border - LV and LA

The IVC is seen best on lateral projection. The posterior border is evident in contrast to the air-filled lungs.

Left ventricular hypertrophy can be seen as enlargement on lateral view.
Hila
Pulmonary arteries, veins & airways
- Airways do not produce significant shadows therefore the majority of detectable structures are vascular.

Left Pulmonary Artery
- Courses over left upper lobe bronchus
- Directed posterolaterally 
- On l...
Pulmonary arteries, veins & airways
- Airways do not produce significant shadows therefore the majority of detectable structures are vascular.

Left Pulmonary Artery
- Courses over left upper lobe bronchus
- Directed posterolaterally
- On lateral, behind tracheal air column

Right Pulmonary Artery
- Courses beneath right upper lobe bronchus
- Directed horizontally
- On lateral, anterior to tracheal air column
Hilar relationship
70% left hilum higher than right

30% hila equal

Right NEVER higher than left
70% left hilum higher than right

30% hila equal

Right NEVER higher than left
Pulmonary veins
More horizontal

Best seen on lateral

Don’t confuse with retrocardiac infiltrate
More horizontal

Best seen on lateral

Don’t confuse with retrocardiac space or infiltrate
Aortopulmonary window
A “space” located below the aortic arch and above the left pulmonary artery

Normally contains fat

An opacified window  is a “red flag”
A “space” located below the aortic arch and above the left pulmonary artery, bordered by aortic valve.

Normally contains fat

An opacified window is a “red flag”

If window not present, could indicate an aortic dissection or MI.
Hilar lymphadenopathy
If right is higher than left, it can indicate a mediastinal lymphadenopathy.
Mediastinum anterior
4 Ts
- terrible lymph nodes
- thymus (thyoma)
- thyroid (substernal goiter)
- teratoma (shown)
4 Ts
- terrible lymph nodes
- thymus (thyoma)
- thyroid (substernal goiter)
- teratoma (shown)
Mediastinum middle
Heart, vessels, lung root
- lymph nodes
- congenital cysts
- diaphragmatic hernias
- vascular lesions
Thymus
Sail sign may be present in pediatric patients.
Medistinum posterior
Esophagus, aorta
- neurogenic tumors
- esophageal lesions
- vertebral lesions
- congenital cysts
Diaphragm
Sharply marginated domes with the apex approximately mid-clavicular

Peripheral margins define the costophrenic sulci

Right diaphragm higher than left due to position of the liver

Always look below the diaphragm
Sharply marginated domes with the apex approximately mid-clavicular

Peripheral margins define the costophrenic sulci

Right diaphragm higher than left due to position of the liver

Always look below the diaphragm
Costophrenic sulci
Sharp, costophrenic angles
- Rounded angles could indicate pleural effusion.
Laterally dispaced diaphragm
Apex of diaphragm laterally displaced due to subpulmonic effusion.
Apex of diaphragm laterally displaced due to subpulmonic effusion.
Air under diaphragm
Air under the diaphragm is an ominous sign that should not be overlooked.
Air under the diaphragm is an ominous sign that should not be overlooked.

Any gas should have an outline of visceral structure.

Chilidi's sign - colonic interposition
Diaphragmatic rupture
Traumatic diaphragmatic rupture (mimics a pleural effusion).
Traumatic diaphragmatic rupture (mimics a pleural effusion).
Trachea
Look for deviations, may indicate pneumothorax.
Look for deviations, may indicate pneumothorax.
Osseous structures
Bony structures
Bony structures
Metastatic disease
Ivory vertebral body
Ivory vertebral body
How to distinguish skin folds from abnormalities
Pneumothorax or skin fold?
- Second view – inspiratory/expiratory views
- Hyperlucent lung – mastectomy may appear this way
Pneumothorax or skin fold?
- Second view – inspiratory/expiratory views
- Hyperlucent lung – mastectomy may appear this way
Silhouette sign
When two structures of similar density abut one another, anatomical margins are lost.
When two structures (opacities) of similar density abut one another, anatomical margins are lost.
Air bronchogram
Indicates air space disease with fluid density outlining the air-filled bronchi.

Shown: right middle lobe pneumonia
Indicates air space disease with fluid density outlining the air-filled bronchi.

Shown: right middle lobe pneumonia
Extrapleural sign
A mass outside the pleural space has characteristic, smoothly sloped margins.
A mass outside the pleural space has characteristic, smoothly sloped margins.
What should you examine when looking at lungs on an image?
Are they expanded to the periphery?

Symmetry

Status

Patterns of parenchymal opacity
- air space (alveolar)
- interstitial
- atelectasis
- nodule/mass
Are they expanded to the periphery?

Symmetry

Status

Patterns of parenchymal opacity
- air space (alveolar)
- interstitial
- atelectasis
- nodule/mass
Air space disease
Produced when air in terminal air spaces is replaced with “stuff”

Radiographic characteristics
- lobar or segmental distribution
- fluffy margins
- tendency to coalesce
- air bronchograms
- rapidly changing over time
- “bat wing” ...
Produced when air in terminal air spaces is replaced with “stuff”

Radiographic characteristics
- lobar or segmental distribution
- fluffy margins
- tendency to coalesce
- air bronchograms
- rapidly changing over time
- “bat wing” distribution

Acute
- blood
- pus
- fluid

Chronic
- lymphoma
- TB
- proteinosis
Interstitial disease
Produced by processes that thicken the interstitial compartments
- water, blood, tumor, cells, infection, fibrosis

Radiographic patterns
- linear
- reticular 
- reticulonodular
- nodular 
- “ground glass”

Acute - interstitial edema...
Produced by processes that thicken the interstitial compartments
- water, blood, tumor, cells, infection, fibrosis

Radiographic patterns
- linear
- reticular
- reticulonodular
- nodular
- “ground glass”
- curly B lines

Acute - interstitial edema, viral/atypical

Chronic - multitude (CHF)
Atelectasis
Obstructive
- oxygen reabsorbed
- mucus plug / F.B. / tumor

Passive
- mass effect / pleural
- pleural effusion

Compressive
- mass effect / lung
- bulla, tumor, abscess

Cicatricial
- scarring & retraction
- TB, fibrosis

Adhesive
- surfactant deficiency
- R.D.S. of Newborn
Signs of volume loss
- movement of lobar fissures
- crowding of the lung markings
- ribs more closely spaced
- elevation of the hemidiaphragm
- mediastinal shift
- tracheal shift
- consolidation
- movement of lobar fissures
- crowding of the lung markings
- ribs more closely spaced
- elevation of the hemidiaphragm
- mediastinal shift
- tracheal shift
- consolidation
Projectional phenomenom
Anterior objects appear larger

Can mimic congestive heart failure

When you lie down, vessels compressed
Pleural effusion
Fluid layering on film
Sulpulmonic effusion/mass
Diaphragm raised on one side
- Rule out phrenic nerve paralysis
- Can be normal variant
Consolidation
Very dense, masslike
Acute
- Pneumonia
- Blood
- Atelactesis 

Chronic
- Lymphoma 
- BAC (bronchioloalveolar carcinoma cell)

Order follow up x-ray to see if consolidation has cleared
Very dense, masslike
Acute
- Pneumonia
- Blood
- Atelactesis

Chronic
- Lymphoma
- BAC (bronchioloalveolar carcinoma cell)

Order follow up x-ray to see if consolidation has cleared
Pulmonary edema
Hilum thickening
Interstitial thickening
- Perpendicular lines can be seen – curly B lines
- Also seen in CHF
Fluid spills over and can be seen on periphery
Can then develop a pleural effusion
Cardiogenic – enlarged heart – CHF
How do you distinguish between an atelectasis and pneumothorax?
Volume loss results from atelectasis
Subsegmental atelectasis
- non-pathological

How do you discern between atelectasis and another problem?
- Volume loss
- Trachea, mediastinum displace towards opacity
Medistinal widening
With pain – CT to rule out aortic dissection
Use contrast to light up vessels
- Pulmonary embolism
- Any traumatic setting
- Unless contraindicated
Deep sulcus sign
Secondary sign of pneumothorax