Lecture 3 (x-ray-chest), Exam 2

Question 1

Chest

• Plain flim diagnosis of heart disease is limited because why?
• What is the standard set of imaging?
• How should you look at the chest r-xay?

Answer 1

• Plain film diagnosis of heart disease islimited to the determination of cardiacenlargement, pulmonary vascularabnormalities, cardiac calcifications andCHF
• PA and Lateral comprise standard set of imaging
• Start at apices, thencostophrenicangles,cardiophrenicangles, diaphragms, gastric bubbles,pulmvasculature, and then trachea and heart size.

Question 2

Chest PA vs AP

• How is PA chest radiograph obtained?
• What does AP projection result in?
• What is the x-ray for those that cannot stand?

Answer 2

• Posteroanterior (PA) chest radiograph obtained by placing the x-ray source behind the patient.
• Anteroposterior projection (AP)results in apparent enlargementof the heart, a phenomenonknown as magnification.
• AP Chest reserved for those thatcannot stand

Question 3

Which one is AP and PA?

Answer 3

The AP shows magnification of the heart and widening of the mediastinum. Whenever possible the patient should be imaged in an upright PA position. AP views are less useful and should be reserved for very ill patients who cannot stand erect.

Question 4

The Heart – Key Concepts

• Advanced imaging can give detailed information about what?
• Heart size should be no larger than what?
• When can cardiac enlargment be simulated or masked?

Answer 4

• Advanced imaging can give detailedinformation about cardiac thickness andmotion, precise chamber size, the presenceof valvular disease, coronary artery disease,pericardial disease, and cardiac function
• Heart size should be no larger than half ofthe thoracic cage at its widest margin (thisis known as the cardiothoracic ratio)
• Cardiac enlargement may be simulated (ason poor inspiration) or masked (as in apatient with a pleural effusion)

Question 5

• The cardiac silhouette normally occupies what? What happens if it exceeds that?
• What can the exceed space be the result from?
• What are non-cardiac causes of an enlarged silhouette?

Answer 5

• The cardiac silhouette normally occupies less than 50% of the transverse diameter of the chest on a PA radiograph. If this cardio-thoracic ratio exceeds 50%, the cardiac silhouette may be enlarged.
• This can result from enlargement of the heart or from pericardial fluid.
• Non-cardiac causes of an enlarged silhouette include increased mediastinal fat, thoracic cage deformities such as pectus excavatum, and poor inspiration.

Question 6

Lateral views

• How is lateral view obtained?
• What ribs are larger?
• What is usually lower than the right?
• What is easy to see?

Answer 6

• The lateral view is obtained with the left chest against the cassette.
• Right ribs are larger (red arrows)
• Left hemidiaphragm (black arrow) and left costophrenic angle (blue) areusually lower than the right
• easy to see posterior fluid collection

Question 7

On the left lateral chestfilm, the convexposterior heart border does what?

Answer 7

On the left lateral chestfilm, the convexposterior heart border does not extendbeyond the posterior margin of the inferiorvena cava
* (A to B) X2 =C to D

Question 8

Lateral Decubitus Position:
* Could be helpful in what?
* Not a _ view
* What does the this flim show?

Answer 8

• This could be helpful to assess the volume of pleural effusion and demonstrate whether a pleural effusion is mobile or loculated (look at difference).
• Not a standard view
• Decubitus film in this case showing a mobile pleural effusion (arrows).

Nowadays: order CT +percuss on PE

Question 9

What are the factors that alter the cardiothoracic ratiomeasurement?

Answer 9

• Factors that alter the cardiothoracic ratiomeasurement:
• Expiratory films
• Whenever any kind of abdominal distension ispresent (pregnancy, ascites, intestinal obstruction),you will not be able to determine heart size
• AP portable chest film will slightly magnify theheart
• A rotated film will change the size of the heartand shape of themediastinum–cannotdetermineheart size

Question 10

Chest:
* Patient should be examined when? What does this help with?
* What can expiration lead to?
* What level should the diaphragm be found out?

Answer 10

• The patient should be examined in full inspiration. This greatly helps the radiologist to determine if there are intrapulmonary abnormalities.
• Expiration can lead toloss of the right heart border silhouette.
• The diaphragm should be found at about the level of the 8th- 10thposterior rib or 5th- 6thanterior rib on good inspiration.

Question 11

Which one is underpenetrated and overpenetrated?

Answer 11

Question 12

What type of film is this?

Answer 12

Right: rotated film skin folds can be mistaken for a tension pneumothorax.
* Notice the skewed positioning of the heads of the clavicles.

Question 13

Which views comprise a standard CXR series
* AP and lateral
* PA and lateral
* AP and PA
* PA and decubitus

Answer 13

PA and lateral

Question 14

What are the lobes and fissures of the lungs?
* What divides lobes? What does it allow?
* On PA chest x-ray, the minor fissure divides what?
* What is really not seen well?
* If there is fluid in the fissure, it is occasionally manifested as what?

Answer 14

• Fissures divide lobes. Knowing them allows localization of lesion.
• On the PA chest xray, the minor fissure divides the right middle lobe from the right upper lobe and is sometimes not well seen. There is no minor fissure on the left.
• The major fissures are usually not well seen on the PA view because you are looking through them obliquely.
• If there is fluid in the fissure, it is occasionally manifested as a density at the lower lateral margin.

Question 15

What does the x-rays show?

Answer 15

Question 16

Fill in the lung margins

Answer 16

Question 17

Fill in

Answer 17

Question 18

Fill in

Answer 18

Question 19

Fill in

Answer 19

Question 20

Great Vessels

• What is indicated of the right aortic arch?
• Where is the descending aorta?

Answer 20

• Presence of a right aortic arch is indicated by a large bulge on the right side of the trachea (arrows) and leftward deviation of the trachea.
• The descending aorta is just to the left of the spine shadow in patients with a left arch and usually to the right of the spine in those with a right arch.

Depending on age, the ascending aorta may not be visible. The aortic arch is on the left in almost all individuals, but is found on the right in a small number (see figure below). Right aortic arch is occasionally associated with other cardiac anomalies or dysphagia.

Question 21

Great Vessels: what is this?

Answer 21

In the adult, the pulmonary trunk (arrow) is normally concave or straightened.

Question 22

• The main pulmonary artery (pulmonary trunk) is normally where? Why?
• In adults it should be what?
• In children and young adults it will be what?
• Enlargement of the pulmonary trunk suggests what?

Answer 22

• The main pulmonary artery (pulmonary trunk) is normally present just below the aortic arch. Because it is within the pericardium, its shadow is continuous with the left cardiac border.
• In adults it should be either flat or concave (see figure below).
• In children and some young adults it will be convex.
• Enlargement of the pulmonary trunk suggests increased pulmonary blood flow or increased pressure due to pulmonary valvular stenosis.

Question 23

What is this?

Answer 23

Enlargement of the azygous vein (arrow) in a patient with right ventricular failure secondary to left ventricular failure or vena cava obstruction.

Question 24

What is this?

Answer 24

Enlargement of the inferior vena cava is indicated by bulging of the cava at the right cardiophrenic angle (arrow, left) and posteriorly (arrow, right) in this patient with severe tricuspid regurgitation.

Question 25

* The inferior vena cava (IVC) is usually visible where? * What does the SVC usually form? * What may indicate increased right atrial pressure?

Answer 25

* The inferior vena cava (IVC) is usually visible posterior to the posterior border of the heart on the lateral projection. * The superior vena cava (SVC) usually forms the right border of the upper supracardiac mediastinum. * Distension of the SVC or posterior bulging (see figure below) or visibility of the IVC in the right cardiophrenic angle may indicate increased right atrial pressure

Question 26

Pulmonary Vascular Patterns: * A normal pulmonary vascular pattern in the adult is characterized by what? * What tapers laterally * What should happen inferiorly? * Where should there be no markings?

Answer 26

* A normal pulmonary vascular pattern in the adult is characterized by a concave or straight pulmonary trunk and normal gravitational distribution of the blood flow. * Blood vessels taper laterally (bolded medially) * Increase in caliber inferiorly (gravity) * Outer 1cm should have no markings (becasue distal is the most smallest vessel)

Question 27

* What are erect individuals, what will the lobes look like? * What will the lobes look like in a supine patient?

Answer 27

In the erect individual this means that the upper lobe vessels will be smaller than the lower lobe vessels, and that none of the vessels will be enlarged. In the supine patient, the upper and lower lobe vessels will be more equal in size.

Question 28

* What is this? * What is it usually caused by? * >_ mmHg * Redistribution of blood flow to the upper lung zones results in what?

Answer 28

* PVH is usually caused by left atrial hypertension * >12-14mmHg (start seeing cephilization) * Redistribution of blood flow to the upper lung zones results in abnormal enlargement of the upper lobe vessels.  | Normal pressure is under 10 ## Footnote Look at picture and like increase pressure

Question 29

Mild elevation of the PCWP (pulmonary wedge pressure) results in what?

Answer 29

in redistribution of the pulmonary blood flow to the non-dependent lung zones

Question 30

* What is this? * What is present and thickened? * What is the pressure?

Answer 30

* Pulmonary Venous Hypertension * Interstitial edema with indistinct vessels and thickened interlobular septa (Kerley B lines) -> CHF, ARDS and pulm edema * Pressure approaches 20 mmHg

Question 31

What is this? * Pressures in the mid 20s typically cause what? * What do you need to note? * What are common causes?

Answer 31

* Pulmonary Venous hypertension * Pressures in the mid 20s typically cause alveolar edema * Note airspace edema with confluent airspace opacities in both lungs

Question 32

What is this? * What is present?

Answer 32

Question 33

* Pulmonary arterial hypertension results from what? * What is it characterized? This has been referred to as what?

Answer 33

* Pulmonary arterial hypertension results from elevation of the resistance in the pulmonary arterial bed, usually at the arteriolar level. * It is characterized radiographically by enlargement of the pulmonary trunk and right and left main pulmonary arteries with disproportionately small peripheral vessels. This has been referred to as "pruning" of the pulmonary arteries.

Question 34

* What is this? * What happens to vessels?

Answer 34

Mild pulmonary HTN

Question 35

* Pulmonary overcirculation, also referred to as shunt vascularity, results from what? * Radiographically it is characterized by what?

Answer 35

* Pulmonary overcirculation, also referred to as shunt vascularity, results from an absolute increase in blood flow to the lungs and in adults is most often associated with left to right shunts. * Radiographically it is characterized by proportional enlargement of all of the central and peripheral pulmonary vessels

Question 36

* What is this? * Who is this seen in?

Answer 36

Diminished vascularity in a patient with Ebstein's anomaly. Both the central and peripheral vessels are small. There is also massive right heart enlargement owing to severe tricuspid valve regurgitation. | Water bottle heart

Question 37

* Diminished pulmonary vascularity is rare in the adult. the most frequently encountered lesion being what? * What is decreased in size?

Answer 37

Diminished pulmonary vascularity is rare in the adult. the most frequently encountered lesion being Ebstein's anomaly of the tricuspid valve. Both the central and peripheral vessels are decreased in size.

Question 38

What is this?

Answer 38

Tetralogy of Fallot. The pulmonary vascularity is markedly diminished and the heart is not enlarged. ## Footnote PS, VSD, OA, RVH

Question 39

What are these?

Answer 39

Question 40

What is this?

Answer 40

Cardiac Enlargement: * Left atrial enlargement in a patient with chronic mitral regurgitation. * There is a double density behind the right side of the heart (arrows).

Question 41

* What is this? * Who is this seen in?

Answer 41

Right atrial enlargement in a patient with mild Ebstein's anomaly (normal pulmonary vascularity). The right heart border is prominent (arrows, left) and the retrosternal clear space is filled in by the right heart (arrows, right) 

Question 42

What is this?

Answer 42

Pericardial Effusion

Question 43

Pericardial Effusion: * What type of shadow? * What is a fat pad sign? * What is the choice to screen for effusions? * 400-500 ml of fluid must be in the pericardium to lead to what?

Answer 43

* Globular shaped shadow * A "fat pad" sign, a soft tissue stripe wider than 2mm between the epicardial fat and the anterior mediastinal fat can be seen anterior to the heart on a lateral view. * Echo is the modality of choice to screen for effusions * 400-500 ml of fluid must be in the pericardium to lead to a detectable change of increased heart shadow on CXR

Question 44

What is this?

Answer 44

Fat Pad Sign * Indication of percardial effusion so get echo

Question 45

What is this?

Answer 45

Heart lesions: * Calcified myocardium (arrows, left) in a patient with previous myocardial infarction. Calcified aortic valve (arrows, right) in a patient with left ventricular failure secondary to critical aortic stenosis. 

Question 46

What is this?

Answer 46

Heart lesions: * Rheumatic mitral valve stenosis (after strept throat infection without abx). There is enlargement of the left atrium (arrows, left) and left atrial appendage-> cleft formation in a.fib (arrows, right). The latter is relatively specific for rheumatic heart disease and is rarely seen in non-rheumatic mitral disease.

Question 47

How do we read an x-ray?

Answer 47

Notes from under PP: * It is best to do a directed search of the chest film rather than simply gazing at the film.  An abnormality will not likely hit you over the head.  * Remember that detail vision is only permitted at the fovea centralis of your retina.  This area contains only cones and is the part that you use to read.  The remainder of the retina helps you to put this detailed portion in context and helps to determine whether this is a saber tooth tiger sneaking up on you.  Therefore, it is best to look for abnormalities and to have a planned search in mind.  * Your eye gaze should scan all portions of the film, follow lung/mediastinal interfaces and look again carefully in areas where you know that mistakes are easily made, such as over the spine on the lateral view and in the apex on the PA view.

Question 48

What is present?

Answer 48

sharp v

Question 49

Answer 49

Pulmonary arteries and veins

Question 50

* What is this? * What are some causes?

Answer 50

Question 51

What is this? * Loss of lung/soft tissue interface caused by what? * What will obscure the border? * The location of this abnormality can help to determine what?

Answer 51

Silhouette sign * Loss of lung/soft tissue interface caused by a mass or fluid in the normally air-filled lung * If an intrathoracic opacity is in anatomic contact with, for example, the heart border, then the opacity will obscure that border.  * The location of this abnormality can help to determine the location anatomically.

Question 52

What is an air bronchogram?

Answer 52

* An air bronchogram is a tubular outline of an airway made visible by filling of the surrounding alveoli by fluid or inflammatory exudates. In this case patient has bilateral lower lobe pulmonary edema. * Air Bronchograms = Alveolar filling

Question 53

What is this?

Answer 53

Question 54

Atelectasis: * What is it? Common or uncommon? * What is it caused by? * What is an unusual type of atelectasis? * Atelectasis is almost always associated with what? What does the apex tend to be? * The density is associated with what? What are some indirect signs? * What might there be? * Most common in who?

Answer 54

* Atelectasis is collapse or incomplete expansion of the lung or part of the lung. This is one of the most common findings on a chest x-ray. * It is most often caused by an endobronchial lesion, such as mucus plug or tumor. It can also be caused by extrinsic compression centrally by a mass such as lymph nodes or peripheral compression by pleural effusion. * An unusual type of atelectasis is cicatricial and is secondary to scarring, TB, or status post radiation. * Atelectasis is almost always associated with a linear increased density on chest x-ray. The apex tends to be at the hilum. * The density is associated with volume loss. Some indirect signs of volume loss include vascular crowding or fissural, tracheal, or mediastinal shift, towards the collapse. * There may be compensatory hyperinflation of adjacent lobes, or hilar elevation (upper lobe collapse) or depression (lower lobe collapse). Segmental and subsegmental collapse may show linear, curvilinear, wedge shaped opacities. * This is most often associated with post-op patients and those with massive hepatosplenomegaly or ascites .

Question 55

What is this?

Answer 55

Question 56

What is this?

Answer 56

Question 57

What is this?

Answer 57

Question 58

Left Lower Lobe Atelectasis: * What can be seen on the left? * It is important to remember that these findings are all nonspecific, often occuring in cases of what? * A substantially collapsed lower lobe will usually show as what?

Answer 58

* Silhouetting of the corresponding hemidiaphragm, crowding of vessels, and air bronchograms are sometimes seen, and silhouetting of descending aorta is seen on the left. * It is important to remember that these findings are all nonspecific, often occuring in cases of consolidation, as well. * A substantially collapsed lower lobe will usually show as a triangular opacity situated posteromedially against the mediastinum.

Question 59

What is this?

Answer 59

Question 60

What is this?

Answer 60

Question 61

What is this? * What is it a common acuse of? * What can be done to remove it?

Answer 61

Question 62

What is cardogenic and noncardogenic pul edema caused from?

Answer 62

Question 63

What is a helpful mnemonic for noncardiogenic pul edema?

Answer 63

A helpful mnemonic for noncardiogenic pulmonary edema is NOT CARDIAC (near-drowning, oxygen therapy, transfusion or trauma, CNS disorder, ARDS, aspiration, or altitude sickness, renal disorder or resuscitation, drugs, inhaled toxins, allergic alveolitis, contrast or contusion.  

Question 64

* On a CXR, cardiogenic pulmonary edema can show what? * Unilateral, miliary and lobar or lower zone edema are considered what? * A unilateral pattern may be caused by what? * Unusual patterns of edema may be found in patients with what?

Answer 64

* On a CXR, cardiogenic pulmonary edema can show; cephalization of the pulmonary vessels, Kerley B lines or septal lines, peribronchial cuffing, "bat wing" pattern, patchy shadowing with air bronchograms, and increased cardiac size.  * Unilateral, miliary and lobar or lower zone edema are considered atypical patterns of cardiac pulmonary edema.  * A unilateral pattern may be caused by lying preferentially on one side.  * Unusual patterns of edema may be found in patients with COPD who have predominant upper lobe emphysema.

Question 65

What is this?

Answer 65

Question 66

What is cephalization?

Answer 66

Cephalization = Blood vessels are more prominent in the upper lung fields compared to the base (opposite to normal)

Question 67

What does this xray show?

Answer 67

* This is a typical chest x-ray of a patient in severe CHF.   * Note the cardiomegaly, alveolar edema, and haziness of vascular margins.

Question 68

What is this?

Answer 68

Question 69

Cardiogenic Pulmonary Edema: * These are are horizontal lines less than 2cm long, commonly found where? * The lines are what? * What are the causes of kerley b lines? * They can be an evanescent sign of what?

Answer 69

* These are horizontal lines less than 2cm long, commonly found in the lower zone periphery.  * These lines are the thickened, edematous interlobular septa.  * Causes of Kerley B lines include; pulmonary edema, lymphangitis carcinomatosa and malignant lymphoma, viral and mycoplasmal pneumonia, interstital pulmonary fibrosis, pneumoconiosis, sarcoidosis.  * They can be an evanescent sign on the CXR of a patient in and out of heart failure.

Question 70

What are each of these?

Answer 70

Question 71

What is this? * What does it look like? * The xray may be normal in who? * What can be seen? * THe situation may be complicated by what?

Answer 71

Question 72

What is this? * The air spaces are filled with what? * What is it not associated with? * What can help you identify marginal involvement?

Answer 72

Question 73

The type of pneumonia is sometimes characteristic on chest x-ray: * Lobar: * Lobular: * Intersitial: * Aspiration pneumonia: * Diffused pulmonary infection:

Answer 73

* Lobular - often Staphlococcus, multifocal, patchy, sometimes without air bronchograms * Interstitial - Viral or Mycoplasma; latter starts perihilar and can become confluent and/or patchy as disease progresses, no air bronchograms * Aspiration pneumonia - follows gravitational flow of aspirated contents; impaired consciousness, post anesthesia, common in alcoholics, debilitated, demented pts; anaerobic (Bacteroides and Fusobacterium) * Diffuse pulmonary infections - community acquired (Mycoplasma, resolves spontaneoulsy) nosocomial (Pseudomonas, debilitated, mechanical vent pts, high mortality rate, patchy opacities, cavitation, ill-defined nodular) immunocompromised host(bacterial, fungal, PCP) *

Question 74

What is this? * What does it show? * These occur most commonly in what?

Answer 74

Question 75

* Primary tuberculosis (TB) is the initial infection with what? * Post-primary TB is what? * Radiographically, TB is represented by what?

Answer 75

* Primary tuberculosis (TB) is the initial infection with Mycobacterium tuberculosis.  * Post-primary TB is reactivation of a primary focus, or continuation of the initial infection. * Radiographically, TB is represented by consolidation, adenopathy, and pleural effusion.

Question 76

What is this? * What is the study of choice? * Never order what? * What can be seen on cxr? What are the signs?

Answer 76

* Pulmonar embolism * CTA is the study of choice * Never order CXR to diagnose PE * Large PE could be seen on CXR * Westermark's sign (acute)-> dark patch with sharp cut off=occulusion so need CTa * Hamptons Hump (wedge-shaped opacity) (chronic)-> vessel occulusion cause tissue dealth

Question 77

What is the westermark sign?

Answer 77

Westermark sign – Dilation of pulmonary vessels proximal to embolism, collapse of vessels distally with a sharp cutoff, central hyperlucency

Question 78

What is the most likely CXR finding in a PE? * Hamptons Hump * Westermark Sign * Atelectasis * Normal CXR

Answer 78

* Normal CXR

Question 79

What is this? * Where is the fluid? * Typically causes what? * What can a large effusion can lead to? * How much fluid is needed to detect an effusion in frontal film? Lateral?

Answer 79

## Footnote Fluid can be exudative, transudative, blood or pus

Question 80

what is this?

Answer 80

Question 81

What is the sign in pleural effusion?

Answer 81

The Meniscus sign * Signifies presence of effusion

Question 82

Pleural Effusion: * What does decubitus position allow? * Also revels what?

Answer 82

* Decubitus position allows layering of effusion * Also reveals if effusion is mobile in nature, rather than loculated

Question 83

What is this? * best done on what? * Hallmark is what? * Can occur how? * May be treated how?

Answer 83

Question 84

32yo smoker presents to ED for evaluation of sudden onset of Chest Pain and SOB. You obtain following XRay. What is the most likely diagnosis? * Pleural Effusion * Pneumothorax * Pneumonia * Tension Pneumothorax

Answer 84

Question 85

What is this? * What is the cause? * What can you note? * Can be fatal due to what?

Answer 85

Question 86

What is this? * What is the mechanism? * Can be seen in what? * What is it managed by?

Answer 86

Question 87

What is this? * What is absence?

Answer 87

Question 88

What is this? * What do you see? * Trauma leading to what?

Answer 88

Question 89

What is this? * What do you see? * What are some causes? (3)

Answer 89

Question 90

# Interstitial Pulmonary Fibrosis * The six most common causes of diffuse interstitial pulmonary fibrosis are what? * Clinically the patient with IPF will present with what? * IPF carries a poor prognosis with death due to what?

Answer 90

* The six most common causes of diffuse interstitial pulmonary fibrosis are idiopathic (IPF, >50% of cases), collagen vascular disease, cytotoxic agents and nitrofurantoin, pneumoconioses, radiation, and sarcoidosis. * Clinically the patient with IPF will present with progressive exertional dyspnea and a nonproductive cough. * IPF carries a poor prognosis with death due to pulmonary failure usually occurring within 3-6 years of the diagnosis unless lung transplant is performed. 

Question 91

What is this? * What leads to fibrosis? * What is involved bilaterally? * Clinically may present with what?

Answer 91

## Footnote Wide and flat

Question 92

What is this? * What is it caused by? * See what?

Answer 92

Asbestosis/Mesothelimoa * Pleural involvement from asbestos fibers inhalation * See pleural plaques and local fibrosis

Question 93

What is this? * What is it part of? * Multiple what? * Similar appearance to what?

Answer 93

* Part of pneumoconioses * From inhaled mineral dust * Multiple pulmonary nodules bilaterally in "eggshell" pattern (more pronounced than pul fibrosis) * Similar appearance to anthracosis and silicosis

Question 94

What is this? * What is destroyed? * What is it caused by? * See what?

Answer 94

Question 95

* In smokers with known emphysema, what lung zones are more common? * The situation is reversed in patients with what?

Answer 95

* In smokers with known emphysema the upper lung zones are commonly more involved than the lower lobes. * This situation is reversed in patients with alpha-1 anti-trypsin deficiency, where the lower lobes are affected.

Question 96

* What is this? * Copd causes what?

Answer 96

Emphysema: * COPD causes Hyperaeration, which stretches the heart and makes it look smaller than usual. 

Question 97

* What is this? * What are the three types?

Answer 97

Question 98

What is the most common diaphargmatic hernia? Wha t is a bochdalek hernia? Where do morgagni hernias typically occur? What causes it?

Answer 98

* By far the most common is a hiatal hernia - the stomach slips through the esophageal hiatus into the chest.  * A Bochdalek hernia is through a weakness in the diaphragm, and usually occurs on the left side posteriorly (Bochdalek - back and to the left).  * Morgagni hernias typically occur medially.  Weakness of the diaphragm can occur without frank herniation of abdominal contents.  This is termed an eventration, and it usually occurs on the right with a portion of the liver bulging cephalad.

Question 99

What is this? * Seen as what?

Answer 99

Question 100

What is this? * Fracture of the upper three ribs is associated with what? * Fracture of the lower three ribs can be associated with what? * Multiple bilateral rib fractures in various stages of healing are associated with what?

Answer 100

Rib fracture: * Fracture of the upper three ribs is associated with an increased risk of aortic injury because of the excessive force needed to fracture these ribs.  * Fracture of the lower three ribs can be associated with liver or spleen injury.  * Multiple bilateral rib fractures in various stages of healing are associated with child abuse in children or alcohol abuse.

Question 101

What is this? * What is it caused by? What type of appearance? * Clinially have what? * Common in who? * What is ideal to evaluate the bronchi?

Answer 101

Question 102

What is this? * What looks larger and why?

Answer 102

Question 103

Anterior mediastinal mass: * What are the 4 ts? * What can also be seen? * What is needed for deinitive disgnosis?

Answer 103

consist of the 4 "T's" * Terrible lymphadenopathy (T-cell lymphoma) * Thymic tumors * Teratoma * Thyroid mass Can also be seen in  * aortic aneurysm * pericardial cyst * epicardial fat pad CT or fine needle aspiration is needed to make the definitive diagnosis 

Question 104

What is this? * What is it due to? * Can be seen in what?

Answer 104

## Footnote saccular aortic aneurysm

Question 105

What is this? what should the differential include?

Answer 105

Differential should include neoplasm (esophageal), lymphadenopathy, aortic aneurysm, adjacent pleural or lung mass, neuroenteric cyst or lateral meningocele, and extramedullary hematopoiesis.

Question 106

Posterior Mediastinal Mass: * Note that this mass is detected by what? * What is interrupted? * Abteruor mediastinum ends where? * Any abnormality in the apex of the thorax must be what? * What is a benign tumor of the nerve sheath?

Answer 106

* Note that this mass is detected by a pleural margin search as you move your eye along the superomedial part of the right lung.  * The interface is interrupted. Think about the anatomy of the lung in this area. * The anterior mediastinum ends at the level of the clavicles. * Any abnormality in the apex of the thorax must be posterior in the chest.   * It is a schwannoma, a benign tumor of the nerve sheath.

Question 107

What is this? * Can be seen with? * What can be confused with hilar adenopathy?

Answer 107

* Left: bilateral pulmonary artery enlargement.  Note the smooth contours of the arteries. * Right: the lumpy-bumpy opacities characteristic of hilar adenopathy.

Question 108

What is this?

Answer 108

Mass is generally well defined Opacity is generally ill-defined

Question 109

What are these locations of mass?

Answer 109

* A – Intraparenchymal (within lung tissue) * B – Pleural (outside of lung) * C - Extrapleural (outside of pleural)

Question 110

What is this?

Answer 110

* A solitary nodule in the lung can be totally innocuous or potentially a fatal lung cancer. * After detection the initial step in analysis is to compare the film with prior films if available.  * A nodule that is unchanged for two years is almost certainly benign.  * If the nodule is completely calcified or has central or stippled calcium it is benign.  * Nodules with irregular calcifications or those that are off center should be considered suspicious, and need to be worked up further with a PET scan or biopsy.   * Be sure to evaluate for the presence of multiple nodules as this finding would change the differential entirely.  * If the nodule is indeterminate after considering old films and calcification, subsequent steps in the work-up include ordering a CT and a tissue biopsy.  * The patient may choose to have an indeterminate nodule removed if there is no evidence of spread on CT as this would diagnose and treat a cancer if present.

Question 111

Solitary Pulmonary Nodule: * Diagnosed as benign if what? * Follow up what?

Answer 111

Question 112

What is this?

Answer 112

Faint lung cancer

Question 113

Answer 113

1. Left upper lobe

Question 114

What is this? * What is the staging? * What is the most common? * What masses are unresectable?

Answer 114

Question 116

The six cell types of primary lung carcinomas with their typical appearances are as follows:

Answer 116

* Adenocarcinoma – (35-50%) Peripheral, sometimes associated with scars, high incidence of early metastasis * Squamous Cell Carcinoma – (30%) Central, with hilar involvement, cavitation is common, slow growing * Small Cell - (15-20%) Central, cavitation is rare, hilar and mediastinal masses often the dominant feature, rapid growth and early metastases * Large cell – (10-15%) Peripheral, large, cavitation present * Bronchaveolar – (3%) Peripheral, rounded appearance, pneumonia-like infiltrate (air bronchograms), occasionally multifocal * Carcinoid – (less than 1%) Typically a well defined endobronchial lesion; nodal, liver and brain metastases may enhance densely (i.e. They may be hypervascular)

Question 117

What does this show?

Answer 117

* The above image shows a right lower lobe squamous cell cancer. Notice the cavitation, which is found more characteristically in squamous cell than in other bronchogenic carcinomas. * Stages of T4, N3 and M1 make the masses unresectable. 

Question 118

Total lung white out: * What differentials should be included?

Answer 118

* Total lung collapse * Massive pleural effusion * Pneumonia with total consolidation * Large mass * Pneumonectomy * Severe unilateral pulmonary edema * Severe aspiration

Question 119

Which of the following is an indication to order a CXR? * Chest pain * Fever * Trauma * All of the above

Answer 119

All of the above

Question 120

Answer 120

community acquired pneumonia

Question 121

Echocardiogram: * What is it the gold standard of? * What is the modality of choise for imaging of pericardium?

Answer 121

Question 122

Cardiac CT: * In the early years, CT cardiac imaging was not successful because why? * What yields excellent cardiac resolution?

Answer 122

Question 123

What are the newer spiral CT scans?

Answer 123

The newer spiral (also called helical) CT scan takes continuous pictures of the body in a rapid spiral motion, so that there are no gaps in the pictures co

Question 124

Fill in for cardiac ct: * What do you need to do to heart? * What is it slowly replacing?

Answer 124

* Need to slow the HR * Slowly replacing stress test

Question 125

* What is shown well on CT? * Noncontrast cardiac CT can be sued to screen what?

Answer 125

* Coronary artery calcifications are shown well at CT * Noncontrast cardiac CT can be used to screen patients with unexplained chest pain for the presence of coronary artery disease.

Question 126

CT angiogram: * Blood vessels are shown well in what? * A newer technique for displaying blood vessels by CT is what?

Answer 126

* Blood vessels are shown well in cross section by CT, especially when the procedure is performed with IV contrast. * A newer technique for displaying blood vessels by CT is computed tomography angiography, or CTA, which employs the same computer reconstruction principles as MRA. * Although much faster, CTA requires contrast administration

Question 127

CTA: * To perform CTA, the radiologist needs to do what? * The CT computer can then do what?

Answer 127

* To perform CTA, the radiologist rapidly scans a region of anatomy (preferably with a fast spiral/helical or multidetector scanner) to obtain very thin, contiguous CT slices while the patient is injected with IV contrast.  * The CT computer can then reconstruct a 3D CTA model.

Question 128

What are these?

Answer 128

3D CTA: * Left: CTA (3DCT) of the lower legs showing the popliteal arteries behind the knees and their divisions into the anterior tibial, posterior tibial, and peroneal arteries. * Right: CTA of the abdominal aorta.  S, splenic artery; H, common hepatic artery; M, superior mesenteric artery.  The arrows point to the renal arteries.

Question 129

What do these show?

Answer 129

* Left: CT reformation of the coronary arteries.  The arrow indicates a tight stenosis in the left anterior descending branch of the left coronary artery.  * Middle: 3D CT reformation of the heart showing the same stenosis in the left anterior descending branch. * Right: Left coronary arteriogram in same patient showing the same stenosis.

Question 130

Coronary Angiogram: * What is it for? * Dextrocardiogram vs. levocardiogram?

Answer 130

* For determination of ventricular wall motion in the post MI patient * Dextrocardiogram (right) – contrast filling of the right atrium, right ventricle, and pulmonary arteries * Levocardiogram (left) – filling of pulmonary veins, left ventricle, left atrium, and ascending aorta

Question 131

Fill in

Answer 131

Question 132

Coronary Arteriography: * Evaulate before what? * Evaulate after what? * Determination if a patient is a candidate for what? * CORONARY ANGIOGRAPHY IS THE “GOLD STANDARD” FOR what?

Answer 132

* Evaluation before cardiac surgery * Evaluation after coronary artery bypass graft (CABG) surgery * Determination if a patient is a candidate for angioplasty * CORONARY ANGIOGRAPHY IS THE “GOLD STANDARD” FOR EVALUATION OF THE CORONARY ARTERIES

Question 133

Answer 133

Question 134

What is this?

Answer 134

Arteriography | Radiolucencies and lack of vasculature – atherosclerosis in coronaries 

Question 135

Aortogram: * What are the indications? * Most aortic aneurysms involve what? * Usually fusiform, but occasionally can be saccular.  Saccular aneurysms are caused by what?

Answer 135

Question 136

What are these

Answer 136

Question 137

What are these?

Answer 137

Question 138

Aortic dissection: * Separation of what? * A new lumen is formed, blood may do what? * What is most common and why? Increased incidence in patients with what? * Patients present with what?

Answer 138

* Separation of the layers of aortic wall, usually through the medial layer * A new lumen is formed (false lumen); blood may flow though this lumen and thrombose, resulting in a dissecting hematoma * Due to an intimal tear.  Hypertension is the most common cause.  Increased incidence in patients with  Marfan’s,  coarctation  of the aorta , and bicuspid  aortic  valve. * Patients present with the sudden onset “tearing” chest pain, radiating to the back.

Question 139

What is this? * What do you need to be suspicious of in CXR? * What is CT for? * What is the study of choice

Answer 139

Question 140

What is this?

Answer 140

Aortic dissection * Type 1 – includes entire aorta * Type 2 – ascending only * Type 3 – descending aorta only. 

Question 141

What type of dissection is this?

Answer 141

Question 142

What is this?

Answer 142

Question 143

chest trauma evaluation: * On acute basis, what is needed?

Answer 143

On acute basis, CT with IV contrast for both Chest with Abdomen and Pelvis will be necessary.

Question 144

Traumatic Aortic Injuries: * Often result from what? * The injuries typically occur at two sites?

Answer 144

Question 145

What is this? * What is it due to? * usuallly, the tear is located where?

Answer 145

Question 146

What is aortic rupture showing on Cxr? CT?

Answer 146

Question 147

What are the CT findings of aortic rupture?

Answer 147

Question 148

* Aneurism – not ruptured in who? What is it an indication of? * What is an flase aneurism?

Answer 148

* Aneurism – not ruptured – in young healthy patient post MVA. Indication of aortic injury.  * False aneurism –> defect in the aorta = aortic injury. 

Question 149

What is shown on this CT?

Answer 149

* Radiopacity on left lung – blood. Contrast leaking out of aorta with blood. * Also, intraluminal filling defect on descending aorta, both indicating aortic injury

Question 150

Atherosclerotic Arterial  Occlusive Disease: * Atherosclerosis is the primary cause of what? * The two clinical manifestations of occlusive disease in the lower extremity are what? * The area of stenosis can be anywhere from what to what? What is it common for?

Answer 150

* Atherosclerosis is the primary cause of occlusive disease in the arterial system * The two clinical manifestations of occlusive disease in the lower extremity are intermittent claudication and rest pain * The area of stenosis can be anywhere from the aorta to the pedal arteries.  Therefore it is common for a patient to undergo an aortogram with a runoff arteriogram

Question 151

* What is the choice to evaluate PAD? * What could be used?

Answer 151

Question 152

What do these show? What can you do for them?

Answer 152

* Stenosis – can do bypass or angioplasty.  * On right – no BS below knee – cant do bypass – have to amputate.

Question 153

What is this?

Answer 153

PAD * chronic * Most likely diabetes

Question 154

Venography: * For what (2)? * Typically done to screen for what?

Answer 154

* For larger veins; may require catheterization * For extremities involves direct injection into a peripheral vein * Typically done to screen for good vessel prior to surgery or dialysis | Typically setting of CABG (saphenous vein (runes to medial malleoli))

Question 155

Duplex Ultrasonography: * What is used for arterial occlusive disease? * What is used for DVT and venous  valvular incompetence * Color doppler, while not diagnostic in its own right, can provide valuable information of what?

Answer 155

* Arterial duplex (for arterial occlusive disease) * Venous duplex (for DVT and venous valvular incompetence) * Color doppler, while not diagnostic in its own right, can provide valuable information with regard to flow turbulence and variance in anatomic routes

Question 156

Deep Venous Thrombosis: * What are risk factors? * Patients present with what? * Traditionally diagnosed with what? What is done more often today?

Answer 156

* Risk factors: prolonged immobilization, pregnancy, CHF, and neoplastic disease * Patients present with pain and swelling of the affected limb * Traditionally diagnosed with venography, but venous duplex is more often done today to rule out DVT

Question 157

Image Guided Venous Access: * What is it used for? * What is a PICC line? * Where is PICC line inserted?

Answer 157

* Imaging the  subclavian  vein can expedite the placement of Hickman catheters, portacaths, and PICC lines.   * PICC line (Peripherally Inserted Central Catheter). * A PICC is inserted in a peripheral  vein, such as the  cephalic vein,  basilic vein, or  brachial vein and then advanced through  increasingly larger veins, toward the heart until the tip rests in the distal  superior vena  cava or  cavo-atrial junctions

Question 158

IVC Filters: * Are placed in patients with a history of what? * Indicated in patients with documented what? * Usually inserted through what?

Answer 158

* IVC filters are placed in patents with a history of DVT and pulmonary embolism to prevent future pulmonary emboli * Indicated in patients with documented PE or DVT who have contraindications to anticoagulation therapy or who have suffered recurrent PE while being treated optimal levels of anticoagulation * Usually inserted through a femoral vein, but occasionally through a jugular vein in a patient with iliac vein thrombosis

Question 159

IVC Filters: What are they? What is it a replacement for?

Answer 159

Umbrella filter was developed as a replacement for surgical ligation, caval  plication, and caval  clips and partially to interrupt the flow in the IVC and to prevent PE. Since then, several filters have been introduced.

Question 160

Percutaneous Transluminal Angioplasty (PTA): * The reopening of an occluded or stenotic artery by what? * Radiologists use what? * Most successful for the treatment of what? * Less successful in the treatment of what?

Answer 160

* The reopening of an occluded or  stenotic  artery by displacement of the obstructing material within it, usually atherosclerotic  plaque * Radiologists use a  percutaneously  inserted  balloon catheter that is inflated within the stenotic  or occluded artery * Most successful for the treatment of short  single  stenoses  and occlusions * Less successful in the treatment of long segment occlusions and severely calcified stenoses

Question 161

What is the Pre and post PTA?

Answer 161

Question 162

PTA Stents: * Do if what?

Answer 162

* Recurrent stenoses * Angioplasty failure