Imaging Modalities in Diagnostic Radiology

Plain Radiographs
Plain radiographs, also known as x-rays or plain films, produce two-dimensional images. X-
rays are generated by the machine and directed towards the subject (e.g. a wrist or chest). The
detector on the other side of the subject is a piece of film or (more commonly) a digital plate.
This records the magnitude of x-rays that have managed to make it to the detector and we can
thereby infer where x-rays have been attenuated.

X-rays can be used in a wide variety of situations, such as investigating fractures, pneumonia
or confirming nasogastric tube position.

They are quick and relatively simple to perform and compared to other imaging modalities,
relatively inexpensive. The image is available almost immediately. However, they do make use
of ionizing radiation and their use is limited to the situations where there is a clinical need
because of the risk of cancer induction.

The five basic densities

When x-rays meet the detector and create an image, there are five main densities that can be
visualized. They are a direct result of how many x-rays have passed through the subject and
arrived at the detector.

If all of the x-rays continue through (e.g. air), that area of the image has little density and is
black. If the x-rays are blocked (e.g. bones), that area of the image is very dense and is therefore
white. There are five basic densities you should be able to recognize - the differences between
them can be subtle and require experience! Try to identify each of the five densities on the
attached chest x-ray:

 air: the blackest part of the radiograph. May include areas outside the patient or air
within the body (e.g. lungs).
 fat: lighter grey shade compared to air
 soft tissue or fluid: consists of denser organs and fluid within the body. More white than
fatty tissue
 bones or calcium: bones are very dense and allow little x-rays to get through them.
Calcifications elsewhere (e.g. in arteries) will also appear white.
 metal: extremely dense and white that will not allow any x-rays to pass. Not normally
present in the body and may be placed on purpose (e.g. prosthetics, contrast media) or
accidentally (e.g. ingested foreign object).

Dr. Hiranmayee Bagwe (PT). MGMSOPNM Diagnostic Radiology

Computed Tomography (CT)
CT scans also use x-rays to create a picture. The patient lies down on a table that passes into
the CT scanner. A rotating x-ray source and detector spin around the outside of the patient
gathering data similar to the plain radiograph above.

Once all the data has been gathered, a computer can build up the data and present it as a series
of images. These two-dimensional cross-sectional images can be scrolled and viewed in the
axial, sagittal or coronal planes. This also means that overlapping structures are not an issue,
as they are in x-rays. Depending on the type of imaging, 3D reconstructions can be created.

As technology and techniques improve, the dose required to perform the scans is decreasing
and the speed to acquire the images has decreased also.

The benefits of CT scans are their speed, accuracy and quantity of information. A CT can be
taken within minutes of entering an emergency department and can help direct future
management of the patient. Some disadvantages of CTs include their cost to purchase and
maintain, and the high dose of radiation. Due to the potential effects on a fetus, a CT scan of
the body is not usually permitted on pregnant women.

CT Densities
CT images are comprised of pixels or varying density. In the same manner as conventional
radiographs, the density of each pixel corresponds to the type of tissue imaged. High density
substances absorb more x-rays and appear whiter. Low density substances absorb few x-rays
and appear darker.

The density of each pixel is measured in Hounsfield units (HU), where air is assigned -1000
HU, water is 0 HU and bone is around 500 HU. The range of Hounsfield units included in a
study is called the window. Windowing is very important in diagnostic images at it allows
optimization of the CT to identify different types of pathology - all without having to rescan
the patient. A widely used example of this is in chest CTs - where different windows can show
the bones, lung fields and mediastinum in detail. This may reveal fractures, emphysema or
heart disease respectively. By adjusting the window you can highlight certain fields to
maximize the diagnostic power of the CT.

Ultrasonography (US)
Ultrasound probes produce high-frequency sound waves instead of x-rays to create images.
Sound waves travel inside the patient and 'bounce back' off of internal structures such as bone
or organs. The relative density of each substance varies and so does how much of the sound is
reflected. These reflected waves are read by the same probe and are converted to produce a
real-time image on the machine. Tissues are described by their echogenicity, with bone being
hyperechoic and white, while fluid is hypoechoic and dark.

A Doppler ultrasound can interpret if an object is moving towards or away from the probe. This
is especially useful for imaging blood flow and can determine the velocity and direction of

Dr. Hiranmayee Bagwe (PT). MGMSOPNM Diagnostic Radiology

blood in the heart or blood vessels. US can also be applied to increase the accuracy of biopsies
(e.g. breast or thyroid mass) or can be used internally in transvaginal or transesophageal studies.

US is widely available and has advantages of being safe, inexpensive and portable. Since
ionizing radiation is not used, they are harmless in children and during pregnancy. They are
especially good at differentiating between types of soft tissue, such as cystic (fluid-filled) or
solid lesions. The main disadvantages are related to operator error and its inability to see past
air and bone, as the sound waves are all reflected back and deeper structures cannot be
visualized.

Magnetic Resonance Imaging (MRI)

MRI machines look similar to a CT scanner but utilize strong magnetic fields instead of a
rotating x-ray. The physics involved are complicated but in a simplified manner, the magnetic
fields cause certain atoms to release radio waves which can be picked up by the scanner.
Hydrogen nuclei (comprised of one proton) have a positive electrical charge which makes a
very tiny magnetic field. The MRI manipulates these protons to align with its own magnetic
field and release energy that can be collected and turned into an image.

These machines are especially useful for visualizing soft tissue in detail. MRI is applied to
view diseases in muscles, ligaments, brains, livers, masses and more. Another advantage is
their absence of ionizing radiation. Disadvantages of MRI include their cost and safety issues.
Magnetic fields can manipulate ferromagnetic objects within the patient (e.g. shrapnel) or turn
objects outside the patient in the room (e.g. scalpels) into high-velocity projectiles. Many
prosthetic devices such as surgical staples or pacemakers are now made MRI compatible.

Nuclear Medicine
Nuclear medicine uses radiotracers, or small radioactive substances, to diagnose and treat
various diseases. As opposed to conventional X-rays, where the radiation source is external to
the patient, nuclear medicine and imaging uses internal radiation sources to create a picture of
disease. An advantage of this technique is that radiotracers can be used to determine the
function of an organ or bodily system. Combining nuclear medicine and conventional imaging
can show both anatomy and physiology; this is frequently done using PET/CT scans.

Common examples of nuclear medicine and imaging include positron emission tomography
(PET), VQ scans, thyroid scans, bone scans and myocardial perfusion scans.

Dr. Hiranmayee Bagwe (PT). MGMSOPNM Diagnostic Radiology

 Magnetic resonance imaging (MRI)

Introduction
Magnetic resonance imaging (MRI) is a topic that is delivered in a variety of different formats
throughout medical school, therefore students and healthcare professionals alike may receive
different standards of teaching. There are several different types, of viewing planes, and a large
range of associated pathologies to visualize.

Why do we need to use MRIs?

Generally, MRI is used less commonly than plain films and CT scans. They are often reserved
for superior viewing of soft tissues. MRI is particularly helpful in patients with suspected
neurological or musculoskeletal pathology, however, it can be used in many other specialties
too. It takes slightly longer to acquire MR images and they are more expensive. MRI is
contraindicated in patients who have ferromagnetic metal implants or foreign
bodies.1 Consideration should be given to patients who are claustrophobic as well.

How do they work?

MRI machines work by exploiting the interaction of the magnetic field, hydrogen ions, and
radiofrequency (RF) pulse. When you put a patient in a strong magnetic field, their hydrogen
ions align in the direction of the magnetic field. Applying an RF pulse will change the direction
of alignment of these hydrogen ions. When the RF pulse is turned off, these ions will attempt
to realign with the magnetic field again and release a signal. The strength of this signal depends
on the type of tissue (fat, muscle, water) that the hydrogen ion is in.1

Using these principles, you can adjust the machine to detect signals of varying ranges and from
varying planes of magnetisation – this is where the “weighted imaging” comes in. We can also
tell the machine to disregard certain values of signals to “suppress” them when it comes to
viewing the pictures – these are known as “fat suppression” sequences.2

MRI can also be used as a dynamic imaging tool. For example, diffusion of water molecules
can be studied with diffusion-weighted imaging (DWI), or macroscopic movement of blood
can be studied, in the case of MR angiographic techniques.

MRI images and sequences

There are many factors that lead to the production of a final MR image. Different combinations
of these will be useful for different clinical presentations, but here are some examples of
common images and sequences:

 T1-weighted and T2-weighted imaging (T1WI and T2WI)

 DWI and ADC
 FLAIR
 STIR

T1 and T2 weighted images

T1 and T2 images demonstrate different tissues based on the timing of the RF pulses. Between
the two, the key differences you need to be aware of are:

Dr. Hiranmayee Bagwe (PT). MGMSOPNM Diagnostic Radiology

 T1 – ONE tissue is bright: fat
 T2 – TWO tissues are bright: fat and water (WW2 – Water is White in T2)
 T1 is the most ‘anatomical’ image (Figure 1). Conversely, the cerebrospinal fluid (CSF) is
bright in T2 due to its’ water content.
 T2 is generally the more commonly used, but T1 can be used as a reference for anatomical
structures or to distinguish between fat vs. water bright signals.

Figure 1. Normal brain MRI shows differences between T1 and T2 images

Additional features of T1/T2 weighted images

Fat suppressed
The fat signal can be suppressed to enable a better view of pathology in and around anatomical
structures – particularly oedema. This is useful in adrenal tumours or bone marrow pathology,
where the image will appear homogenous with surrounding tissue due to fat content.

Gadolinium-enhanced
Gadolinium enhances vasculature (i.e. arteries) or pathologically-vascular tissues (e.g.
intracranial metastases, meningiomas). This process involves injecting 5-15ml of contrast
intravenously, with images taken shortly thereafter. Gadolinium appears bright in signal,
allowing for detection of detailed abnormalities (e.g. intracranial pathologies). Typical
intracranial abscesses have a “ring-enhancement” pattern, while metastases enhance
homogeneously. Meningiomas will have a homogenous enhancement after the contrast, but
will also have a “dural tail,” meaning the lesion appears continuous with the dura (Figure 2).4

Dr. Hiranmayee Bagwe (PT). MGMSOPNM Diagnostic Radiology

Figure 2. Meningioma is shown more clearly by gadolinium contrast with a dural tail

Inversion recovery (IR) sequences

These types of images are manipulations of T1 and T2. They nullify certain tissue types based
on their inversion timings, thereby stopping tissues such as fat and CSF from appearing as
bright signals. This is helpful to identify pathological signals. The two main types are discussed
below.

Short tau inversion recovery (STIR)

STIR is based on a T2 image, but the image is manipulated in a way that results in fat (and any
other materials with similar signals) being nullified. Unlike fat-suppressed images, however,
STIR can not be used with gadolinium contrast.4 As previously discussed, fat can make the
interpretation of oedematous areas and bone marrow difficult. Figure 3 shows how this
nullified fat signal can assist with the identification of oedema due to fractures.

Figure 3. STIR highlighting marrow oedema in L1 vertebra, indicative of a fracture

Fluid attenuated inversion recovery (FLAIR)

FLAIR is also similar to T2, however, the CSF signal is nullified. This is particularly useful
for evaluating structures in the central nervous system (CNS), including the periventricular
areas, sulci, and gyri. For example, FLAIR can be used to identify plaques in multiple sclerosis,
subtle oedema after a stroke, and pathology in other conditions whereby CSF may interfere
with interpretation (Figure 4).1

Dr. Hiranmayee Bagwe (PT). MGMSOPNM Diagnostic Radiology

 Figure 4. Multiple sclerotic plaques in periventricular regions and corpus collosum

Diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC)

DWI is an imaging modality that combines T2 images with the diffusion of water. With DWI
scans, ischaemia can be visualised within minutes of it occurring (Figure 5). This is because
DWI has a high sensitivity for water diffusion, thereby detecting the physiological changes that
happen immediately after a stroke.

Figure 5. Recent right-sided ischaemic stroke

ADC should be used alongside DWI in order to confirm whether there is true restricted
diffusion and not simply “shine through” from T2. The table below explains the key differences
between the two.

A systematic approach to MRI interpretation

Verify details
Begin by verifying the following details:

 Patient details (i.e. name, date of birth, hospital number)

 Image details (i.e. date, type)

Dr. Hiranmayee Bagwe (PT). MGMSOPNM Diagnostic Radiology

 Make sure it is the most recent image for the correct patient
 Look for previous cross-sectional imaging (if available)

Look at the T2 weighted images

Inspect the T2 weighted images:

 Look at each available plane (axial, coronal, sagittal)

 Check for abnormal MRI signals
 Work through the anatomy of the areas you are looking at to make sure nothing is
missed/abnormal
 Comparing both sides of an image (if possible) can reveal clear areas of abnormal signaling
 Shape, size, location, and intensity of the signal

Compare different MRI image sequences

Compare the available MRI image sequences to help differentiate pathology:

 Comparing fat sensitive images (e.g. T1) vs water-sensitive images (e.g. T2 or STIR) can
help differentiate pathologies such as ischaemia and inflammation.
 Post-contrast enhancement is useful for vascular pathology or pathologically-vascular tissue.
 Learn why each image type is used – this will enable you to know what you are looking for
(e.g. for MR brain it’s useful to look at T2, then FLAIR, then DWI/ADC, as this will help
distinguish between most differentials).

Compare against other imaging modalities

Compare the MRI images to other imaging modalities (e.g. ultrasound, CT, plain film):

 Can you view the pathology on other imaging modalities?

 Plain films can be particularly useful when assessing musculoskeletal pathology.

Compare against previous images

Compare the current MRI images to previous MRI scans if available:

 Are the abnormal signals new or old?

 Are there any changes in the size/shape/brightness of the abnormal signals?

Consider the clinical context

Finally, place your findings in context with the clinical presentation in order to ascertain a
radiological diagnosis:

 Are the symptoms acute or chronic?

 How unwell is the patient?
 Does the imaged pathology correlate with the presenting symptoms?

Dr. Hiranmayee Bagwe (PT). MGMSOPNM Diagnostic Radiology

 References

1. Westbrook, C., Roth, C. K. & Talbot, J. MRI in practice. Published in 2005. Available from:
2. Bitar, R. et al. MR pulse sequences: What every radiologist wants to know but is afraid to
ask. Published in 2006. Available from
3. Dr Hidayatullah Hamidi. Normal brain MR shows differences between T1 and T2 images.
Licence: [CC BY-SA].
4. Andrew Murphy, et al. MRI sequences (overview). Radiopaedia.org, the wiki-based
collaborative Radiology resource. [Internet] (Accessed: 21st March 2020). Available from:
5. Assoc Prof Frank Gaillard. Meningioma shown more clearly by gadolinium contrast with a
dural tail. Licence: [CC BY-SA]. Available from:
6. Dr Dalia Ibrahim. STIR shows marrow oedema in L1 vertebra, indicative of a fracture.
Licence: [CC BY-SA].
7. Dr Mahmoud Rashed. Multiple sclerotic plaques in periventricular regions and corpus
callosum. Licence: [CC BY-SA].
8. Dr Bahman Rasuli. Recent right-sided ischaemic stroke. Licence: [CC BY-SA].

Dr. Hiranmayee Bagwe (PT). MGMSOPNM Diagnostic Radiology

 Ultrasonography (USG)
What is ultrasound?
Ultrasound is a common imaging modality that allows visualisation in real-time. As such it is
becoming increasingly popular on the wards for diagnosis and management purposes. You
should be familiar with its operation and know in which situations it may help your clinical
decision making.

What is ultrasound used for?

Ultrasound can be used for:

 Assessment of jugular venous pressure (JVP)

 Venepuncture
 Focused assessment for screening in trauma (FAST)
 Lumbar puncture
 Thoracentesis
 Paracentesis
 Evaluation of abdominal organs
 Biopsy
 Pregnancy

How does ultrasound work?¹

1. High-frequency sound waves are transmitted from a transducer.
2. These sound waves are then reflected by different tissue types in different ways.
3. The reflected sound waves are then picked up by the ultrasound transducer.
4. The sound waves are then transformed into an image by special software.

How do tissue types differ in their reflection of sound waves?

Bones, fat and stones

Bones, fat and stones produce a hyperechoic signal.
A hyperechoic signal is bright as most ultrasound waves are reflected.

Cartilage and muscle

Cartilage and muscle produce a hypoechoic signal.
A hypoechoic signal appears dark as most waves pass through the tissue.

Fluid and fluid-filled structures

Fluid and fluid-filled structures produce an anechoic signal.
An anechoic signal appears black as there is no reflection of ultrasound waves.

Dr. Hiranmayee Bagwe (PT). MGMSOPNM Diagnostic Radiology

 Other
A shadow may be noted on an ultrasound when a hypoechoic area is
located behind a hyperechoic structure.

How do I know which probe I should use?

Typically there are 3 different types of ultrasound probe: linear, curvilinear and phased.

Linear probe:

 High frequency (7-15MHz):

 High resolution but superficial (1-6cm) depth
 Good for vascular access, nerve blocks, assessment of testes and superficial lung tissue

Curvilinear:

 Low frequency (2-5MHz)

 Low resolution, but greater depth (10-20cm)
 Useful for abdominal, pelvic, obstetric and deep lung tissue
Phased:

 The lowest frequency (1-3MHz)

 Useful for echocardiography

Common settings for achieving an optimal view

Gain:

 Adjusting the gain of an ultrasound changes the brightness of the image.

 Gain is typically controlled by a knob.
 The gain should be adjusted until fluid appears black and soft tissue appears mid-grey with
some parts of the image appearing white
Depth:

 Depth measures are shown in cm on the side of the ultrasound monitor.

 It is often best to begin deep to orientate yourself and then work more superficially to bring
the object of interest into the middle of the screen.

General tips for achieving an optimal view

Some general tips for achieving an optimal view include:

 Use lots of gel

 Make good contact between the probe and skin (whilst ensuring the patient is comfortable)
 Dim the lights to improve your view of the monitor
 Ensure the probe is perpendicular to the skin

Dr. Hiranmayee Bagwe (PT). MGMSOPNM Diagnostic Radiology

 References

1. Toronto Notes 2016: Medical Students Essential Med Notes.

2. Clay Kurtz (Author’s own work)
3. Emergency Ultrasonography. Resources and Tutorials on EM Ultrasound. Available from:
4. Canadian Internal Medicine Ultrasound (CIMUS). Available from: Joing S, Strote S, Caroon
L, et al. Ultrasound-guided peripheral IV placement. N Engl J Med. 2012;366(25):e38.
5. UpToDate. Principles of ultrasound-guided venous access. Jeremiah J Sabado, MD and
Mauro Pittiruti, MD. Available from:
6. Ltyore. Morison’s pouch. Public Domain. Available from:
7. The POCUS Atlas. Available from:

Dr. Hiranmayee Bagwe (PT). MGMSOPNM Diagnostic Radiology

 Chest X-ray interpretation
Confirm details
Begin chest X-ray interpretation by checking the following details:
 Patient details: name, date of birth and unique identification number.
 Date and time the film was taken
 Previous imaging: useful for comparison.

Assess image quality

Next, you should assess the quality of the image: a mnemonic you may find useful is ‘RIPE’.

Rotation
The medial aspect of each clavicle should be equidistant from the spinous processes.
The spinous processes should also be in vertically orientated against the vertebral bodies.
Inspiration
The 5-6 anterior ribs, lung apices, both costophrenic angles and the lateral rib edges should be
visible.
Projection
Note if the film is AP or PA: if there is no label, then assume it’s a PA film (if the scapulae are
not projected within the chest, it’s PA).
Exposure
The left hemidiaphragm should be visible to the spine and the vertebrae should be visible
behind the heart.

ABCDE approach

The ABCDE approach can be used to carry out a structured interpretation of a chest X-
ray:
 Airway: trachea, carina, bronchi and hilar structures.
 Breathing: lungs and pleura.
 Cardiac: heart size and borders.
 Diaphragm: including assessment of costophrenic angles.
 Everything else: mediastinal contours, bones, soft tissues, tubes, valves, pacemakers and
review areas.

AIRWAY
Trachea
Inspect the trachea for evidence of deviation:
 The trachea is normally located centrally or deviating very slightly to the right.
 If the trachea appears significantly deviated, inspect for anything that could be pushing or
pulling the trachea. Make sure to inspect for any paratracheal masses and/or
lymphadenopathy.

Causes of true and apparent tracheal deviation

True tracheal deviation:

Dr. Hiranmayee Bagwe (PT). MGMSOPNM Diagnostic Radiology

 Pushing of the trachea: large pleural effusion or tension pneumothorax.
 Pulling of the trachea: consolidation with associated lobar collapse.
Apparent tracheal deviation:
 Rotation of the patient can give the appearance of apparent tracheal deviation, so as
mentioned above, inspect the clavicles to rule out the presence of rotation.

Figure 6. Pleural effusion with tracheal deviation

Carina and bronchi

The carina is cartilage situated at the point at which the trachea divides into
the left and right main bronchus.
On appropriately exposed chest X-ray, this division should be clearly visible. The carina is an
important landmark when assessing nasogastric (NG) tube placement, as the NG tube should
bisect the carina if it is correctly placed in the gastrointestinal tract.
The right main bronchus is generally wider, shorter and more vertical than
the left main bronchus. As a result of this difference in size and orientation, it is more
common for inhaled foreign objects to become lodged in the right main bronchus.
Depending on the quality of the chest X-ray you may be able to see the main bronchi branching
into further subdivisions of bronchi.

Figure 7. Carina and bronchi (normal CXR)

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 Hilar structures
The hilar consist of the main pulmonary vasculature and the major bronchi.
Each hilar also has a collection of lymph nodes which aren’t usually visible in healthy
individuals.
The left hilum is often positioned slightly higher than the right, but there is a wide degree of
variability between individuals.
The hilar are usually the same size, so asymmetry should raise suspicion of pathology.
The hilar point is also a very important landmark; anatomically it is where
the descending pulmonary artery intersects the superior pulmonary vein. When this is
lost, consider the possibility of a lesion here (e.g. lung tumour or enlarged lymph nodes).

Causes of hilar enlargement or abnormal position

Hilar enlargement can be caused by a number of different pathologies:
 Bilateral symmetrical enlargement is typically associated with sarcoidosis.
 Unilateral/asymmetrical enlargement may be due to underlying malignancy.
Abnormal hilar position can also be due to a range of different pathologies. You should
inspect for evidence of the hilar being pushed (e.g. by an enlarging soft tissue mass)
or pulled (e.g. lobar collapse).

BREATHING

Lungs
Inspect the lungs for abnormalities:
 When interpreting a chest X-ray you should divide each of the lungs into three zones, each
occupying one-third of the height of the lung.
 These zones do not equate to lung lobes (e.g. the left lung has three zones but only two
lobes).
 Inspect the lung zones ensuring that lung markings are present throughout.
 Compare each zone between lungs, noting any asymmetry (some asymmetry is normal and
caused by the presence of various anatomical structures e.g. the heart).
 Some lung pathology causes symmetrical changes in the lung fields, which can make it more
difficult to recognise, so it’s important to keep this in mind (e.g. pulmonary oedema).
 Increased airspace shadowing in a given area of a lung field may indicate pathology (e.g.
consolidation/malignant lesion).
 The complete absence of lung markings should raise suspicion of a pneumothorax.

Dr. Hiranmayee Bagwe (PT). MGMSOPNM Diagnostic Radiology

 Figure 8. Right-sided pneumonia Figure 9. Lung tumour

Pleura
Inspect the pleura for abnormalities:
 The pleura are not usually visible in healthy individuals. If the pleura are visible it indicates
the presence of pleural thickening which is typically associated with mesothelioma.
 Inspect the borders of each lung to ensure lung markings extend all the way to the edges of
the lung fields (the absence of lung markings is suggestive of pneumothorax).
 Fluid (hydrothorax) or blood (haemothorax) can accumulate in the pleural space, resulting
in an area of increased opacity on a chest X-ray. In some cases, a combination of air and
fluid can accumulate in the pleural space (hydropneumothorax), resulting in a mixed pattern
of both increased and decreased opacity within the pleural cavity.

Tension pneumothorax
A tension pneumothorax is a life-threatening condition which involves an increasing amount
of air being trapped within the pleural cavity displacing (pushing away) mediastinal structures
(e.g. the trachea) and impairing cardiac function.
If a tension pneumothorax is suspected clinically (shortness of breath and tracheal deviation)
then immediate intervention should be performed without waiting for imaging as this condition
will result in death if left untreated.

Figure 10 Right-sided pneumothorax Figure 11. Pleural thickening in the context of mesothelioma

Dr. Hiranmayee Bagwe (PT). MGMSOPNM Diagnostic Radiology

 Cardiac
Assess heart size
In a healthy individual, the heart should occupy no more than 50% of the thoracic
width (e.g. a cardiothoracic ratio of less than 0.5).
This rule only applies to PA chest X-rays (as AP films exaggerate heart size), so you should
not draw any conclusions about heart size from an AP film.
Cardiomegaly is said to be present if the heart occupies more than 50% of the thoracic
width on a PA chest X-ray. Cardiomegaly can develop for a wide variety of reasons including
valvular heart disease, cardiomyopathy, pulmonary hypertension and pericardial effusion.

Assess the heart’s borders

Inspect the borders of the heart which should be well defined in healthy individuals:
 The right atrium makes up most of the right heart border.
 The left ventricle makes up most of the left heart border.
The heart borders may become difficult to distinguish from the lung fields as a result of
pathology which increases the opacity of overlying lung tissue:
 Reduced definition of the right heart border is typically associated with right middle lobe
consolidation.
 Reduced definition of the left heart border is typically associated with lingular consolidation.

Figure 12.Cardiomegaly

Diaphragm
The right hemi-diaphragm is, in most cases, higher than the left in healthy individuals (due
to the presence of the liver). The stomach underlies the left hemi-diaphragm and is best
identified by the gastric bubble located within it.
The diaphragm should be indistinguishable from the underlying liver in healthy
individuals on an erect chest X-ray, however, if free gas is present (often as a result of bowel
perforation), air accumulates under the diaphragm causing it to lift and become visibly
separate from the liver. If you see free gas under the diaphragm you should seek urgent

Dr. Hiranmayee Bagwe (PT). MGMSOPNM Diagnostic Radiology

senior review, as further imaging (e.g. CT abdomen) will likely be required to identify the
source of free gas.
There are some conditions which can result in the false impression of free gas under the
diaphragm, known as pseudo-pneumoperitoneum, including Chilaiditi syndrome.
Chilaiditi syndrome involves the abnormal position of the colon between the liver and
the diaphragm resulting in the appearance of free gas under the diaphragm (because the bowel
wall and diaphragm become indistinguishable due to their proximity). As a junior doctor, you
should always discuss a scan that appears to show free gas with a senior colleague
immediately

Figure 13 Pneumoperitoneum

Costophrenic angles
The costophrenic angles are formed from the dome of each hemidiaphragm and
the lateral chest wall.
In a healthy individual, the costophrenic angles should be clearly visible on a normal chest X-
ray as a well defined acute angle.
Loss of this acute angle, sometimes referred to as costophrenic blunting, can indicate the
presence of fluid or consolidation in the area. Costophrenic blunting can also develop
secondary to lung hyperinflation as a result of diaphragmatic flattening and subsequent loss
of the acute angle (e.g. chronic obstructive pulmonary disease).

Figure 14 Costophrenic blunting secondary to pneumonia

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Everything else
Mediastinal contours
The mediastinum contains the heart, great vessels, lymphoid tissue and a number
of potential spaces where pathology can develop. The exact boundaries of the mediastinum
aren’t particularly visible on a chest X-ray, however, there are some important structures that
you should assess.
Aortic knuckle
The aortic knuckle is located at the left lateral edge of the aorta as it arches back over the
left main bronchus. Reduced definition of the aortic knuckle contours can occur in the context
of an aneurysm.
Aorto-pulmonary window
The aorto-pulmonary window is a space located between the arch of the aorta and the
pulmonary arteries. This space can be lost as a result of mediastinal
lymphadenopathy (e.g. malignancy).

Bones
Inspect the visible skeletal structures looking for abnormalities (e.g. fractures, lytic lesions).

Soft tissues
Inspect the soft tissues for obvious abnormalities (e.g. large haematoma).

Tubes, valves and pacemakers

Tubes
Nasogastric tube placement is something you’ll often be asked to assess on a chest X-ray to
confirm safe placement for feeding.

Lines
Various tubes and cables will be visible as radio-opaque lines on the chest X-ray (e.g. central
line, ECG cables).

Dr. Hiranmayee Bagwe (PT). MGMSOPNM Diagnostic Radiology

 Artificial heart valves
Artificial heart valves typically appear as ring-shaped structures on a chest X-ray within the
region of the heart (e.g. aortic valve replacement).

Pacemaker
Pacemakers typically appear as a radio-opaque disc or oval in the infra-
clavicular region connected to pacemaker wires which are positioned within the heart.

Review areas

Finally, before completing your assessment of a chest X-ray, make sure you’ve looked at the
‘review areas’ where pathology is often missed. These areas include:
 the lung apices
 the retrocardiac region
 behind the diaphragm
 the peripheral region of the lungs
 the hilar regions
This ensures you’ve comprehensively assessed the X-ray and reduces the risk of missing subtle
pathology (e.g. a small nodule).

References
1. James Heilman, MD. Right-sided pneumonia. Licence: CC BY-SA 3.0.
2. James Heilman, MD. Cardiomegaly. Licence: CC BY-SA 3.0.
3. Hellhoff. Pneumoperitoneum. Licence: CC BY-SA 3.0.
4. Steven Fruitsmaak. Chilaiditi syndrome. Licence: CC BY-SA 3.0.

Dr. Hiranmayee Bagwe (PT). MGMSOPNM Diagnostic Radiology