Medicine 2:

Phase IIIA

Department of Biomedical Imaging, Faculty of Medicine

REVIEW : CHEST X-RAY (PA VIEW)

Normal centering medial ends of clavicle equidistant from the spinous processes Full inspiration anterior 6th rib meets at the mid diaphragm CTR 0.5. In elderly and infants can go up to 0.6 Outlines of heart and mediastinum Costophrenic angles Hidden areas

NORMAL PA CHEST X-RAY

NORMAL LATERAL CHEST X-RAY

HILAR PROMINENCE
Hilar

prominence can be due to unilateral hilar lymphadenopathy (TB , Lymphoma, Metastases, Lung Ca). Bilateral hilar lymphadenopathy is usually due to sarcoidosis or lymphoma.

BILATERAL HILAR LYMPHADENOPATHY

CAUSES OF ANTERIOR MEDIASTINAL MASSES

Thymoma

Teratoma
Terrible

The 4 Ts

Lymphoma Retrosternal thyroid

ANTERIOR MEDIASTINAL MASS

ANTERIOR MEDIASTINAL MASS

CT SCAN OF ANTERIOR MEDIASTINAL MASS WITH PLEURAL EFFUSION

CAUSES OF MIDDLE MEDIASTINAL MASSES

Vascular lesions Aneurysms Duplication cysts * Enteric cysts * Bronchogenic cysts Inflammatory and neoplastic adenopathy

No picture

Differential diagnoses:

Bronchogenic carcinoma Lymphoma Metastasis

CAUSES OF POSTERIOR MEDIASTINAL MASSES

Neurogenic tumours, Vertebral infections, Thoracic aneurysms, Hiatus / diaphragmatic hernias.

CARDIOVASCULAR

DISEASES

Heart size and shape

An enlarged heart is an abnormal heart. An enlarged transverse diameter to the cardiac silhouette Causes of gross cardiac silhouette does not necessarily mean ventricular failure. A pericardial effusion can cause it and sometimes in MV disease the right an left atria can become extremely enlarged, widening the cardiac silhouette, whilst the ventricles remain relatively undilated.

Gross cardiac enlargement on PA CXR:

Multiple valvular disease aortic and mitral valve Pericardial effusion ASD Cardiomyopathy Ebsteins anomaly posterior cusp of tricuspid valve arises from base of RV. Therefore, there is marked tricuspid incompetence, and most of the RV becomes the RA.

GLOBULAR HEART

PROSTHETIC VALVES

PERICARDIAL EFFUSION

CARDIOMEGALY WITH PLEURAL EFFUSION

LEFT ATRIAL ENLARGEMENT

MITRAL STENOSIS
Features on CXR: Upper lobe diversion of vessels Interstitial edema Haemosiderosis (secondary to pulmonary venous hypertension) Pulmonary arterial hypertension Double heart shadow (enlarged left atrium) Splaying of main bronchi

ENLARGED LEFT ATRIUM - MITRAL STENOSIS

MITRAL STENOSIS WITH HEMOSIDEROSIS

LEFT TO RIGHT SHUNTS

(Congenital heart disease: ASD,VSD, PDA) CXR features : plethoric lung fields enlarged heart large central and peripheral pulmonary arteries.

LEFT TO RIGHT SHUNT (VSD)

LEFT TO RIGHT SHUNT (PLETHORA)

CARDIAC FAILURE, PULMONARY OEDEMA AND PLEURAL EFFUSION

Right heart failure, as a result of pulmonary hypertension, has less effect on the cardiac silhouette, and the heart may not become enlarged.

ACUTE PULMONARY OEDEMA

Perihilar opacities (Bats wing appearance) Kerley B lines short lines perpendicular to the pleura and mostly found at the costophrenic angles. Prominence of upper lobe vessels Pleural effusion Cardiac enlargement

ACUTE PULMONARY OEDEMA (BATS WING)

PULMONARY OEDEMA

Pulmonary blood vessels

The PA CXR provides useful information .concerning the pulmonary circulation. Bronchial vessels are not seen in a normal CXR. In pulmonary arterial hypertension the peripheral branches become narrower and the central branches become larger/ prominent. In the upper lobes, the larger PA branches lie medial to the pulmonary veins which become more obvious when congested in heart failure.

ENLARGED PULMONARY ARTERIES

AORTIC ANEURYSM

AORTIC ANEURYSM

CENTRAL NERVOUS SYSTEM

STROKE
The term stroke implies the sudden onset of focal neurological signs with or without diminished consciousness. The acute onset implies a vascular accident consistent with one of the following: Cerebral haemorrhage spontaneous or into a tumour or AVM Embolism Cerebral thrombosis Transient ischaemic attack (TIA) or mini stroke

Investigation
CT brain is indicated soon after the event, particularly if anticoagulant therapy is planned. CT differentiates infarction for which anticoagulation may be indicated and haemorrhage, when it is generally not. CT may indicate underlying pathology and provide prognostic information.

CT BRAIN : ACUTE INFARCT IN THE RIGHT BASAL GANGLIA AND HEAD OF CAUDATE NUCLEUS.

CT BRAIN : WEDGE SHAPED HYPODENSE AREA AFFECTING BOTH GREY AND WHITE MATTER = ACUTE LEFT MCA INFARCTION

INTRAPARENCHYMAL HAEMATOMA

CT BRAIN : OLD INFARCT IN RIGHT TEMPOROPARIETAL REGION

CT BRAIN : SUBARACHNOID BLEED

ARTERIOVENOUS MALFORMATION (AVM)

ACUTE SUBDURAL BLEED

CHRONIC SUBDURAL EFFUSION

ANY QUESTIONS ???