CARDIAC XRAY 1. BASICS OF CXR 2.STRUCTURES IN ANTERIOR VIEW 3.STRUCTURES IN LATERAL VIEW 4.CHAMBER ENLARGEMENT 5.PULMONARY CIRCULATION 6.CONGENITAL HEART DISEASE 7.PERICARDIAL DISEASE 8.PACEMAKER & ICD 9.CARDIAC CALCIFICATION 10.PROSTHETIC.
Download ReportTranscript CARDIAC XRAY 1. BASICS OF CXR 2.STRUCTURES IN ANTERIOR VIEW 3.STRUCTURES IN LATERAL VIEW 4.CHAMBER ENLARGEMENT 5.PULMONARY CIRCULATION 6.CONGENITAL HEART DISEASE 7.PERICARDIAL DISEASE 8.PACEMAKER & ICD 9.CARDIAC CALCIFICATION 10.PROSTHETIC.
CARDIAC XRAY
1. BASICS OF CXR 2.STRUCTURES IN ANTERIOR VIEW 3.STRUCTURES IN LATERAL VIEW 4.CHAMBER ENLARGEMENT 5.PULMONARY CIRCULATION 6.CONGENITAL HEART DISEASE 7.PERICARDIAL DISEASE 8.PACEMAKER & ICD 9.CARDIAC CALCIFICATION 10.PROSTHETIC HEART VALVE 11.DISEASES OF AORTA 12. MISCELLENOUS
R – ROTATION
I -- INSPIRATION
P -- PROJECTION
E -- EXPOSURE
The medial ends of both clavicles should be equidistant from the spinous process of the vertebral body projected between the clavicles
The increase in blackness of one hemithorax is always on the side to which the patient is rotated, irrespective of whether the CXR has been taken PA or AP
It is ascertained by counting either the number of visible anterior or posterior ribs Adequate inspiratory effort - six complete anterior or ten posterior ribs are visible Poor inspiratory effort - fewer than six anterior ribs Hyperinflated lung-more than six anterior ribs
POOR INSPIRATORY FILM 1 3 2 NORMAL INSPIRATORY FILM 1.MEDIASTINAL WIDENING 2.CMGLY 3.LOWER LOBE PATCHY OPACIFICN
Projection is defined as the direction of x-ray with relation to the patient
If the direction of x-ray projection is from front – AP projection
If the direction of x-ray projection is from behind –PA projection
In erect patients Vertebral spines more prominent Scapulae clear of lungs Clavicles are horizontal In supine patients Vertebral bodies clear Apparent cardiomegaly Scapulae overlap Clavicles are oblique
Gas bubble in fundus with a clear air fluid level Gas bubble in antrum Apparent cardiomegaly
Normal exposure - the vertebral bodies should just be visible at the lower part of cardiac shadow Underexposed -If the vertebral bodies are not visible , insufficient number of x-ray photons have passed through the patient to reach the x ray film Similarly, if the film appears too ‘black’, then too many photons have resulted in overexposure of the x-ray film.
UNDERPENETRATION NORMAL OVERPENETRATION
1. BASICS OF CXR
2 . S T R U C T U R E S I N A N T E R I O R V I E W
3.STRUCTURES IN LATERAL VIEW 4.CHAMBER ENLARGEMENT 5.PULMONARY CIRCULATION 6.CONGENITAL HEART DISEASE 7.PERICARDIAL DISEASE 8.PACEMAKER & ICD 9.CARDIAC CALCIFICATION 10.PROSTHETIC HEART VALVE 11.DISEASES OF AORTA 12. MISCELLENOUS
Technical factors Skeletal abnormalities and hardware Situs: gastric air bubble, cardiac apex, and aortic knob Heart: position, size, and shape Great vessels: position, size, and shape Lung fields and vascularity by zone Search for calcifications
PT AA RV LV LA
Brachiocephalic vessels Trachea RV LV RPA Pulmonary outflow tract Aorta LPA Right upper lobe bronchus Left upper lobe bronchus IVC LA Confluence of pulmonary veins Right hemidiaphragm Gastric air bubble Left hemidiaphragm
Aortic knob is the junction formed by the arch and descending aorta
LPA
If we draw a tangent line from the apex of the left ventricle to the aortic knob(red line) and measure along a perpendicular to that tangent line (yellow line) The distance between the tangent and the main pulmonary artery (between two small green arrows) falls in a range between 0 mm (touching the tangent line) to as much as 15 mm away from the tangent line
Main pulmonary artery projects more than the tangent
Causes:
1.
2.
Increased pressure Increased flow
MPA > 15 mm from the tangent
Concave PA segment
Causes:
1.
TOF 2. TRUNCUS ARTERIOSUS
L LA ENLARGEMENT HYPERTROPHIED LA APPENDAGE
A B C The cardiothoracic ratio should be less than 0.5. i.e. A+B/C<0.5
A cardiothoracic ratio > 0.5 suggests cardiomegaly in adults A cardiothoracic ratio > 0.6 suggests cardiomegaly in newborn
CTR is more than 50% but heart is normal Extracardiac causes of cardiac enlargement Portable AP films Obesity Pregnant Ascites Straight back syndrome Pectus excavatum
CTR is less than 50% but heart is abnormal Obstruction to outflow of the ventricles Ventricular hypertrophy Must look at cardiac contours < 50% ASCENDING AORTA DILATED LV CONTOUR
Cardiothoracic ratio >0.5 in adults Cardiothoracic ratio >0.6 in newborn Any increase in transcardiac diameter > 2 cm compared to old x-ray In old age and emphysema a transcardiac diameter more than 15.5 cm in males &>12.5 cm in females
RA enlargement
LA enlargement
RV enlargement
LV enlargement
Rt. Cardiac border becomes more convex > 50% of right border Rt. Atrial border extends >3 intercostal spaces Measurement from mid vertical line to max. convexity in rt. Border>5 cm in adult & >4cm in children Lateral view – fullness in space between sternum and front of upper part of cardiac silhouette
a Ab > 5cm b
Widening of carina( normal 45-75 degree) Elevation of left bronchus Straightening of left border Double atrial shadow( shadow within shadow) Grade 1 –double cardiac contour Grade2 - LA touches RA border Grade 3 – LA overshoots the Rt. Cardiac border Displaces the descending aorta to the left and esophagus to right seen in barium swallow
HYPERTROPHIED LA APPENDAGE
WIDENING OF CARINA ELEVATION OF LEFT BRONCHUS LAA enlargement DOUBLE ATRIAL SHADOW
Widening of carina Aneurysmal LA Elevation of lt. bronchus Aneurysmal LA – When La enlarges to left and right and approaches within an inch of lateral chest wall
LA pushing the Esophagus posterior
PA view
(
a)Left cardiac border gets enlarged and becomes more convex resulting in cardiomegaly (b)Lt. cardiac border dips into lt. dome of diaphragm (c) rounded apical segment (d) cardiophrenic angle is obtuse
Lateral view
(a) Left ventricle enlarges inferiorly and posteriorly (b)Rigler’s measurement A is >17 mm (c)Rigler,s measurement B is< 7.5 mm (d) Eyeler’s ratio becomes > 0.42
Rigler’s A & B used to differentiate left ventricular and right ventricular enlargement Possible only when IVC shadow is present Jn. Of IVC with Lt. Atrium – J point Rigler’s A- from J point along line of IVC draw a line of 2 cm above and mark the point X.
Draw a horizontal line from pt. A to posterior Cardiac border and mark that pt. y Distance between points x & y is Rigler’s measurement A NORMAL<17 mm Rigler’s B-from the pt. J drop a perpendicular line to the dome and this distance is Rigler’s measurement B NORMAL>7.5 mm
When LV enlarges, Posterior cardiac border gets displaced posteriorly & IVC shadow gets included in cardiac shadow, without getting displaced posteriorly Rigler’s measurement A >17 mm in lt. ventricular enlargement
To differentiate lt. & rt. Ventricular enlargement Valid when IVC shadow is absent or cannot be visualised Mark the pt. of jn. where postero inferior cardiac border meets the dome as B From this pt. B draw a horizontal line to the posterior border of sternum-AB
From pt.B - draw another horizontal line posteriorly to the inner border of the rib-BC Ratio of AB/BC is Eyeler’s ratio < 0.42
LA Oblique view
There is a retrocardiac space( prevertebral) (a)Mild lt. Ventricular enlargement-obliteration of retrocardiac space (b) mod. Lt.ventricular
enlargement-cardiac shadow overlaps vertebral column (c)Marked Lt.ventricular
enlargement-cardiac shadow overshoots vertebral column
Chest X ray shows left ventricular enlargement.
Left heart border is displaced leftward, inferior and posteriorly.
Rounding of the cardiac apex.
PA VIEW
Cardiophrenic angle is acute Clockwise rotation of heart causes RV to form the middle portion of the left heart border
.
RIGHT LATERAL VIEW
Obliteration of retrosternal space
LEFT LATERAL VIEW
Rigler’s measurement will be17mm or less Rigler’s measurement will be 7.5mm or more Eyeler’s ratio is 0.42 or less
Narrow vascular pedicle Cardiomegaly directly proportional to severity of pericardial effusion This shadow has a rounded, globular appearance with no particular chamber enlargement Cardiophrenic angle become more and more acute Oligaemic pulmonary vascular markings Marked change in cardiac silhouette in decubitus posture ‘Epicardial fat pad sign’- anterior pericardial strip bordered by epicardial fat post. and mediastinal fat ant.>2mm
Pulmonary oligaemia ‘Water bottle’ appearence
Acute cardiophrenic angle
Narrow vascular pedicle
Chambers can be identified Cardiophrenic angle is obtuse Increased pulmonary venous hypertension No change in cardiac silhouette in decubitus Vascular pedicle is dilated or normal Fluoro shows cardiac pulsation
1.Straightening of the right border 2.Pericardial thickening > 4 mm 3.Pericardial calcification (50% cases) 4.Dilatation of SVC and azygous vein
Pericardial calcification
Focal bulge in area of main pulmonary artery Sharply marginated Absent right cardiac border Increased distance between sternum and heart due to absence of sterno pericardial ligament
NORMAL PULMONARY CIRCULATION – 3 FEATURES 1.RDPA<17MM
LARRY ELLIOT’S CLASSIFICATION OF PVH
RADIOGRAPHIC GRADE OF PVH
1 2 3 4
ACUTE DISEASE PCWP
13-17 MMHG 18-25 MMHG >25 MMHG
CHRONIC DISEASE PCWP
13-17 18-30 >30 MMHG MMHG MM HG HEMOSIDEROSIS AND OSSIFICATION LONG STANDING PVH
GRADE 0 -PCWP< 12 MM HG Upper lobe pulmonary veins are less prominent than lower lobe veins GRADE 1- PCWP 13-17MMHG Redistribution of blood flow with cephalization-’ANTLER SIGN’ 1) increased resistance to flow due to interstitial odema 2) alveolar hypoxia in lower lobes causes reflex vasoconstriction 3) vasoconstriction of the arterioles due to LA or pulmonary vein reflex
GRADE 2- PCWP 18-25mm hg Interstitial edema Peribronchial cuffing Kerley A,B,C lines Interlobular effusion Pleural effusion Hilar haze Peribronchial cuffing
Distended lymphatic channels within edematous septa coursing from peripheral lymphatics to central hilar nodes Towards the hilum Less specific for Pulmonary venous hypertension KERLEY A LINES
KERLEY B Horizontal lines 1-3 mm thick Perpendicular to pleural surface Towards the costophrenic angle Accumulation of fluid in interlobular septa and lymphatics Highly specific for PVH
KERLEY C LINES
Crisscross lines seen between A &B GRADE 3 – pcwp > 25mm hg Alveolar odema B/l diffuse patchy cotton wool opacities
Pulmonary plethora – features Enlargement of central pulmonary artery , lobar and segmental artery Prominent nodular vascular shadows in frontal CXR- shunt vessels that course ventral to dorsal Upper & lower lobe vessels prominent RPDA > 17mm Right descending pulmonary artery> tracheal diameter Ratio of RPDA to diameter of trachea > 1 Plethora seen if shunt size >2:1
Pulmonary oligaemia
Decreased flow proximal to orgin of main pulmonary artery Small pulmonary artery Empty pulmonary bay Pulmonary vessels small Lung hypertranslucent Lateral view shows diminution of hilar vessels
Empty pulmonary bay
Pruning High pressure left to right shunts are associated with obliterative changes in the smaller pulmonary arteries & arterioles Large main & large central pulmonary arteries taper down rapidly to very small vessels Seen in Eisenmenger’s syndrome Precapillary PAH
Hamptons hump Wedge opacity Westermark sign Hampton’s hump Fleischner’s sign- prominent central pulmonary artery Palla’s sign-dilated rt. Descending pulmonary artery Chang’s sign – dilatation and abrupt change in calibre of the rt. Descending PA
MITRAL STENOSIS Small aortic knob from decreased cardiac output Features of left atrial enlargement Right atrial enlargement from tricuspid insufficiency Pulmonary venous hypertension Enlarged MPA Calcified mitral valve
Mitral regurgitation
LA enlargement LV enlargement Pulmonary venous hypertension
AORTIC STENOSIS Ascending aorta dilated Left ventricular hypertrophy Aortic valve calcification
AORTIC REGURGITATION Dilated ascending aorta LV enlargement
VALVULAR PS No obvious cardiomegaly Enlarged PA Dilated left pulmonary artery Normal to decreased pulmonary vasculature
INFUNDIBULAR PS
Concave PA segment
RVH
ASD
PULMONARY PLETHORA MPA DILATED RPA DILATED RV APEX
DISEASE
ASD VSD PDA
LEFT ATRIUM AORTA
VSD
PLETHORA MPA DILATED RPA DILATED LV APEX
PDA
Linear or railroad track calcification at site of ductus may be seen in adults with PDA AORTIC KNOB PROMINENT MPA PLETHORA LV APEX
COARCTATION OF AORTA “FIGURE OF 3” in CXR “REVERSE 3” or “E sign” in Barium meal SUBCLAVIAN ARTERY DILATION COARCTATION POSTSTENOTIC AORTIC DILATION RIB NOTCHING
1)Aortic obstruction- Takayasu arteritis Coarctation of aorta 2) Subclavian artery obstruction –Classic BT shunt Takayasu arteritis 3)Chronic Svc obstruction 4)Intercostal Av fistula 5)Neurofibromatosis
Cyanosis With Decreased Vascularity
Tetralogy of Fallot Truncus-type IV Tricuspid atresia Transposition of great arteries Ebstein’s anomaly
Cyanosis With Increased Vascularity
Truncus types I, II, III TAPVC Tricuspid atresia Transposition Single ventricle
TOF
‘Cour en sabot’ Due to 1)Rv apex 2)Underfilled LV 3)Concave pulmonary artery 4)Pulmonary oligaemia
TGA
‘
Egg on string’ 1)Narrow pedicle 2)Rt. Border RA 3)Lt. border LV 4)Increased vascularity 5)Hypoplastic thymus
TAPVC (supracardiac)
‘figure of 8’ “snowman” Rt border-SVC Upper border-left innominate Left border-left vertical vein Body of snowman-RA
PAPVC(Scimitar sign)
The scimitar sign is produced by an anomalous pulmonary vein that drains any or all of the lobes of the right lung.
Scimitar vein empties into the inferior vena cava
EBSTEIN
‘Box shaped’heart Enlarged RA Hypoplastic pulmonary trunk Decreased vascularity
TRUNCUS ARTERIOSUS
LV apex Rt pulmonary artery has a superior orgin (20%) ‘waterfall sign’ ‘Hilar comma sign’ ELEVATED RIGHT HILUM Associated right aortic arch (33%) Concave PA segment
Eisenmenger’s syndrome
RV LEAD RA LEAD
LEAD FRACTURE DISPLACED RV LEAD DISPLACED RA LEAD
A) Valvular – Mitral , aortic valve B)Pericardial – constrictive pericarditis C) Myocardial – left atrial wall, LV aneurysm D)Endocardial – Endomyocardial fibrosis E) Intraluminal – La thrombus , La myxoma , Lv thrombus F) Vascular – aortic calcification , coronary artery
MITRAL VALVE CALCIFICATION
CALCIFIED LV APICAL ANEURYSM
CALCIFIED PERICARDIUM
PERICARDIAL SEEN IN BOTH SIDES OF HEART MOST COMMONLY IN AV GROOVE MYOCARDIAL SEEN IN ONLY LEFT SIDE MOST COMMON SITE IS ANT. WALL DIFFUSE CALCIFICATION AROUND THE HEART LOCALIZED TO THE LEFT CALCIFICATION IS CHUNKY & UGLY CALCIFICATION IS FINE & CURVILINEAR
GIANT LA CALCIFICATION
TILTING DISK VALVE
MITRAL STAR EDWARD
MITRAL PROSTHESIS
ST.JUDE
MITRAL PROSTHETIC
Aneurysm of ascending & Descending aorta
Egg shell sign
LEFT SVC
LEFT SVC Occurs in less than 0.5% of people Failure of regression of L common and Ant. Cardinal veins Drains left jugular and left subclavian vein Most patients also have right sided SVC Drains into dilated coronary sinus
RT . AORTIC ARCH Leftward displacement of barium filled esophagus Rt. Indentation of trachea Aortic knob is absent from left side Aorta descends on right Associated with TOF Truncus arteriosus
Left superior intercostal vein Seen in 5% of cases To be differentiated from a mass Also called pseudo dissection It drains into hemiazygous vein Hartman T .Pearls & Pitfalls in Thoracic imaging,Variants and other difficult diagnosis
CERVICAL AORTIC ARCH Left sided cervical aortic arch Aortic knob at apex of lung Descend on the left
SITUS INVERSUS WITH DEXTROCARDIA SITUS INVERSUS WITH LEVOCARDIA
DEXTROCARDIA HYDROPNEUMOPERICARDIUM
PDA CLIP
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