Abnormal Cases

• Bone
• Cardiovascular
• Airspace Disease including Silhouette Sign
• Interstitial Disease and Pulmonary Edema
• Atelectasis
• Pulmonary Nodule
• Pleura and Diaphragm
• Mediastinal Mass

2
Bone and Soft Tissues

3
Fractures

4
Presenting CXR

5
6
Pancoast Tumour

MRI

Computed Tomography

7
Cardiovascular

8
 Increased Cardiac Size: Can be
Cardiac or Pericardial
Dilated Cardiomyopathy Pericardial Effusion

differentiate between the two9 ?

What imaging would you use154toslides
 Left Ventricular Enlargement

IVC
Left
Ventricle
154 slides 10
Enlargement of Left Ventricle
Pulmonary embolism
Pulmonary embolism
Airspace Disease and Silhouette
Sign

14
 Normal lung

Individual alveoli are

too small to resolve,
but together they
appear radiolucent.

15
 Air-space Disease

Filling of alveoli by: water, blood,

pus, proteinaceous fluid, or cells

-opacities
-consolidation

16
Air-space pattern of lung disease 17
 Airspace Disease
• Filling in of acini (air space)
• Air space (acinar) nodules
• Coalesce to consolidation
• Air bronchograms
• Silhouette Sign

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 Air Space Disease: Etiology

• Water-Pulmonary Edema
• Pus-Infections, Non-infectious
inflammatory process
• Blood-Pulmonary Hemmorhage
• Protein-Alveolar Proteinosis
• Tumour-BAC, Lymphoma

19
 Air Bronchogram
• Airways are not normally seen in a normal
chest radiograph because they are an air
structure within an aerated lung
• When the aerated lung opacify, the bronchii
become visualized because of the
surrounding contrast effect.

22
airbronch

154 slides 23
24
 25
CT Consolidation: Air Bronchograms
 Silhouette Sign
• Definition: The effacement of a normal structure
• Example: Airspace disease may silhouette:
– right heart margin with right middle lobe pneumonia
– diaphragm with lower lobe pneumonia

26
 Silhouette sign

• sign describes the observation that an

intrathoracic lesion will obliterate borders
of shadows of similar radiodense structures
that it contacts
• example: right middle lobe pneumonia will
obliterate apex of the right heart border

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 Silhouette sign

Normal

Pneumonia
(-) silhouette sign
(visible heart silhouette)

Pneumonia
(+) silhouette sign
(no heart silhouette)
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Pulmonary edema
+ silhouette sign

29
Pulmonary edema
+ silhouette sign

30
Where is the Pneumonia?

154 slides 31
32
Right Lower Lobe Pneumonia

Right:
Partially seen
Left 154 slides 33
Left Lower Lobe Pneumonia

154 slides 34
Where is the pneumonia?

154 slides 35
36
Horizontal (minor fissure)

Oblique(major)
fissure

154 slides 37
Right Middle Lobe Pneumonia

154 slides 38
Interstitial Disease with Emphasis
on Pulmonary Edema

39
• In a normal chest
radiograph, the visible
interstitium is the
branching pulmonary
vessels
• The branching
disappears peripherally
because they are beyond
resolution of the xray

40
Interstitial Disease

41
Interstitial Disease

• Hazy or ill defined interstitial lung disease

usually indicates acute disease
• Sharp, well defined and distorted interstitial
lung disease usually indicates chronic
disease
• Interstital dz appears as linear, nodular, or
reticular (net-like)

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Interstitial pattern of
lung disease

43
Interstitial Disease: Pulmonary Fibrosis
154 slides 44
 Interstitial Disease

• Reticular=net-like
• Nodular
• Reticulonodular: Combination of the
two patterns

45
Reticular Pattern
154 slides 46
 Honeycombing in patient with single
lung transplant for pulmonary fibrosis

Honeycomb Native Lung Normal Transplanted Lung

154 slides 47
 Miliary

Nodular Pattern: Miliary

154 slides 48
cuffing

154 slides 55
Normal 56
Kerley lines are a sign seen on CXR
with interstitial pulmonary edema.

They are thin linear pulmonary opacities

caused by fluid or cellular infiltration
into the interstitium of the lungs

57
58
Kerly B Lines 154 slides 59
 Edema kerly A

Minor fissure

Pulmonary Edema
154 slides 60
Edema kerly A

Septal Lines 154 slides 61

Alveolar Edema

Alveolar Pulmonary
154 slides Edema 62
Kerley A 63
Other Lung Diseases

64
 Emphysema (imaging findings)
• bilaterally flat, depressed hemidiaphragm
• lung overinflation
• increased pulmonary radiolucency
• increased retrosternal space (>4.5cm)
• accentuated kyphosis
• increased intercostal spaces
• prominent hilar vasculature, decreased
peripheral
• bullae
65
 normal
emphysema
66
Emphysema

67
68
Normal vs.
emphysematous
lung tissue

69
Bullous emphysema
71
Bullous emphysema
72
Bullous Emphysema

Enlarged
Retrosternal
Air Space

154 slides 73
Flattened Diaphragms
Atelectasis

74
154 slides 75
 Left lower lobe collapse
• Further investigations?

154 slides 76
154 slides 77
154 slides 78
 Diagnosis: LLL Collapse
• Collapse secondary to central obstructing
tumour

154 slides 79
Pulmonary Nodule

80
 Solitary Pulmonary Nodule: What Would You Do Next?
1) Compare with Any Available Previous
2) Computed Tomography
154 slides 81
 Solitary Pulmonary Nodule can be:

Malignant: Adenocarcinoma Benign: Densely calcified nodule

154 slides 82
Multiple Nodules: Diagnosis?
154 slides
Metastases 83
Pleura

84
 Pleura and Diaphragm
• Pleural Effusion
– Lateral decubitus>Lateral>PA in sensitivity
• Pneumothorax
– Upright
– Deep sulcus sign in supine

85
Small Pleural Effusion

154 slides 86
 Small Pleural Effusion

Normal:
Sharp Angles

87
Blunted posterior costophrenic154sulcus
slides
Large Pleural Effusion

154 slides 88
Lateral Decubitus

154 slides 89
 Pleural Effusion in Supine Patient

• Pleural effusion
layers posteriorly
in a supine
position
• Cause diffuse
increased density

154 slides 91
93
Inspiration Expiration
154 slides 95
 Tracheal Deviation

Collapsed Right Lung

What would you do with this patient?

Tension Pneumothorax:
154 slidesRequires chest tube 96
Supine chest radiograph of a neonate illustrates the deep sulcus sign with abnormal
deepening and lucency of the left lateral costophrenic angle ( ∗).
97
 Deep sulcus sign

It is seen on chest radiographs obtained with the

patient in the supine position.

It represents lucency of the lateral costophrenic

angle extending toward the hypochondrium.

The abnormally deepened lateral costophrenic

angle may have a sharp, angular appearance

98
Supine Patient

154 slides 99
Deep Sulcus
Non Dependent Portion of Lung at Base in Supine Patient

Deep Sulcus:
What can you do to confirm?

100
Left lateral decubitus 154 slides 101
 Mediastinum: Overview
• Classification of Mediastinum
• Examples of mediastinal masses

102
 Classification of Mediastinum
• Anatomic
– Superior: above sternal angle
– Anterior
– Middle: heart and pericardium
– Posterior
• There are radiographic classification e.g.
Felson’s

103
 Classification of Mediastinum
ANATOMIC CLASSIFICATION

The mediastinum is divided into 4 parts

Superior mediastinum
Apex of thorax to a plane
passing through the manubrio-
sternal junction and fourth
dorsal vertebral body

Posterior mediastinum
Contains descending thoracic
aorta, azygous/hemiazygous
veins,esophagus, thoracic duct,
Anterior mediastinum nerves & lymph nodes
Is anterior to heart & great
vessels

Middle mediastinum
Contains heart & great
vessels, lymph nodes
104
 Anterior Mediastinal Mass
• The 4 T’s
– Thyroid
– Thymus (Thymoma)
– Teratoma
– Terrible Lymphoma (Tumour)

105
Thyroid Goiter

• Most common
superior
mediastinal mass
extending to
thoracic inlet

Note Tracheal Deviation

154 slides 106
Benign thymoma

154 slides 107

Normal
Lateral CXR shows: mass is anterior

154 slides NORMAL 108

 Computed Tomography

Thymoma

Do you know any

associated
clinical syndrome?

154 slides 109

Hiatus hernia

154 slides 110

Lymphadenopathy

111
 Lung
Cancer

Lymphadenopathy
112
Small cell CA

113
Hilar and Mediastinal Lymphadenopathy154 slides
Diagnosis?
Normal 114
Hilar Lymphadenopathy on lateral

Normal
154 slides 115
Sarcoidosis

154 slides 116