Chest X-ray Anatomy

Heart size and contours

• Heart size is not assessed by an absolute measurement, but rather is
measured in relation to the total thoracic width - the Cardio-Thoracic
Ratio (CTR).
• CTR = Cardiac Width : Thoracic Width
• The CTR is frequently expressed as a percentage. A CTR of greater
than 1:2 (50%) is considered abnormal.
• Accurate assessment of heart size assumes the projection is Posterior-
Anterior (PA), and that cardiac size is not exaggerated by factors such
as patient rotation.
Cardiothoracic ratio (CTR)
Cardiothoracic ratio (CTR)
• Cardiac size is measured by drawing
vertical parallel lines down the most lateral
points on each side of the heart, and
measuring between them.
• Thoracic width is measured by drawing
vertical parallel lines down the inner
aspect of the widest points of the rib cage,
and measuring between them.
• The cardio-thoracic ratio can then be
calculated.
• Here the CTR is approximately 15 : 33 (cm)
and is therefore within the normal limit of
50%.
Normal cardiac contours
Normal cardiac contours
• The left heart contour (red line)
consists of the left lateral border of
the Left Ventricle (LV). The right heart
contour is the right lateral border of
the Right Atrium (RA).
Assessing the heart
• The heart size should be assessed on every chest X-ray.
• If the CTR is <50% on either a Posterior - Anterior (PA) or an
Anterior - Posterior (AP) view, then the heart size is within
normal limits.
• However, a PA view is required to confidently diagnose cardiac
enlargement. This is because an AP view will exaggerate the
heart size due to magnification.
Assessing the heart
• If the heart contours are not clearly seen, this may be because of
increase in density of the adjacent lung.
• The lingula - part of the upper lobe of the left lung - wraps over the
left ventricle, and so loss of definition of the left heart border may be
related to disease in this area of lung.
• On the right, the middle lobe is located adjacent to the right atrium,
and therefore loss of definition of the right heart border may be due
to increased density caused by disease in this lung lobe.
Mediastinal contours
• The mediastinum itself contains the heart and great vessels (middle
mediastinum) and potential spaces in front of the heart (anterior
mediastinum), behind the heart (posterior mediastinum) and above
the heart (superior mediastinum).
• These potential spaces are not defined on a normal chest X-ray, but an
awareness of their position can help in describing the location of
disease processes.
• There are several structures in the superior mediastinum that should
always be checked. These include the aortic knuckle, the aorto-
pulmonary window, and the right para-tracheal stripe.
Normal aortic knuckle
Normal aortic knuckle
• The aortic knuckle (red line) represents the
left lateral edge of the aorta as it arches
backwards over the left main bronchus,
and pulmonary vessels. The contour of the
descending thoracic aorta (yellow line) can
be seen in continuation from the aortic
knuckle.
• Displacement or loss of definition of these
lines can indicate disease, such as
aneurysm or adjacent lung consolidation.
Aorto-pulmonary window
Aorto-pulmonary window
• The aorto-pulmonary window lies between
the arch of the aorta and the pulmonary
arteries. This is a potential space in the
mediastinum where abnormal enlargement
of lymph nodes can be seen on a chest X-
ray.
• In this chest X-ray, which is entirely normal,
the curved arrow points towards the aorto-
pulmonary window between the Aortic
Knuckle (AK) and the Left Pulmonary Artery
(LPA).
• (AA) = Ascending Aorta
• (DA) = Descending Aorta
Right para-tracheal stripe
Right para-tracheal stripe
• From the level of the clavicles to the azygos
vein the right edge of the trachea is seen as a
thin white stripe. This appearance is created
by air of low density (blacker) lying either
side of the comparatively dense (whiter)
tracheal wall. If this stripe is thickened
(normally less than 3mm) this may represent
pathology such as a paratracheal mass or
enlarged lymph node.
• The left side of the trachea is not so well
defined because of the position of the aortic
arch and great vessels.
Assessing the mediastinal
contours
• Whenever you look at a chest X-ray it is well worth looking for
abnormalities in the region of the aortic knuckle, the aorto-
pulmonary window, and the right para-tracheal stripe.
• Appreciation of the range of normal appearances of these
structures will come with viewing as many chest X-rays as you
can.