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AN APPROACH TO CARDIAC XRAY
Dr. Muhammad Bin ZulfiqarPGR IV FCPS Services Institute of Medical Sciences / Hospital [email protected]
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AIMS Basic Approach to Radiograph Chest
Basic Anatomy
Cardiac Pathologies
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TOPICS DISCUSSED 1. BASICS OF CXR
2.STRUCTURES IN ANTERIOR VIEW
3.STRUCTURES IN LATERAL VIEW
4.CHAMBER ENLARGEMENT
5.PULMONARY CIRCULATION
6.CONGENITAL HEART DISEASE
7.PERICARDIAL DISEASE
8.PACEMAKER & ICD
9.CARDIAC CALCIFICATION
10.PROSTHETIC HEART VALVE
11.DISEASES OF AORTA
12. MISCELLENOUS
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BASICS OF X-RAY TECHNICAL QUALITY
R – ROTATION I -- INSPIRATION P -- PROJECTION E -- EXPOSURE
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ROTATION
The medial ends of both clavicles should be equidistant from the spinous process of the vertebral body projected between the clavicles
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The increase in blackness (radiolucency) of one hemithorax is always on the side to which the patient is rotated, irrespective of whether the CXR has been taken PA or AP
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DEGREE OF INSPIRATION It is ascertained by counting either the
number of visible anterior or posterior ribs
Adequate inspiratory effort – five to seven complete anterior or ten posterior ribs are visible
Poor inspiratory effort - fewer than five anterior ribs
Hyperinflated lung-more than seven anterior ribs
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IMPORTANCE OF AN INSPIRATORY FILMPOOR INSPIRATORY FILM NORMAL INSPIRATORY FILM
1
23
1. Mediastinal Widening 2.Cardiomegaly 3.Lower lobe patchy opacification
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PROJECTION OF X-RAY
Projection is defined as the direction of x-ray with relation to the patient
If the direction of x-ray projection is from front – AP projection
If the direction of x-ray projection is from behind –PA projection
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AP VIEW PA VIEW
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PA VIEW AP VIEW
In erect patients Vertebral spines more
prominent Scapulae clear of lungs Clavicles are horizontal
In supine patients Vertebral bodies clear Apparent cardiomegaly Scapulae overlap Clavicles are oblique
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ERECT SUPINE
Gas bubble in fundus with a clear air fluid level
Gas bubble in antrum Apparent cardiomegaly
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EXPOSURE OF X-RAY
Normal exposure - the vertebral bodies should just be visible at the lower part of cardiac shadow
Underexposed -If the vertebral bodies are not visible , insufficient number of x-ray photons have passed through the patient to reach the x-ray film
Similarly, if the film appears too ‘black’, then too many photons have resulted in overexposure of the x-ray film.
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UNDERPENETRATION NORMAL OVERPENETRATION
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SYSTEMATIC APPROACH
Technical factors Skeletal abnormalities and hardware Situs: gastric air bubble, cardiac apex, and aortic knob Heart: position, size, and shape Great vessels: position, size, and shape Lung fields and vascularity by zone Search for calcifications
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STRUCTURES SEEN IN ANTERIOR VIEW
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STRUCTURES IN LATERAL VIEW
RV
PTAA
LA
LV
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Gastric air bubble
Left upper lobe bronchus
IVC
Right hemidiaphragm
LV
LARV
Pulmonary outflow tract
AortaRight upper lobe bronchus
RPA LPA
Confluence of pulmonary veins
Brachiocephalic vessels Trachea
Left hemidiaphragm
ScapulaMan
ubriu
m
Body
of s
tern
umRe
troste
rnal
spac
e
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Aortic knob is the junction formed by the arch and descending aorta
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MAIN PULMONARY ARTERY
LPA
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HOW TO MEASURE MAIN PULMONARY ARTERY
If we draw atangent line from the apex of the leftventricle to theaortic knob(red line) and measure along a perpendicularto that tangentline (yellow line)
The distance between the tangent and the main pulmonary artery (between two small green arrows) falls in a range between 0 mm (touching the tangent line) to as much as 15 mm away fromthe tangent line
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PROMINENT MPA
Main pulmonary artery projects more than the tangent
Causes:
1. Increased pressure
2. Increased flow
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HYPOPLASTIC PA
MPA > 15 mm from the tangent Concave PA segment Causes:
1. TOF
2. TRUNCUS ARTERIOSUS
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LEFT ATRIAL APPENDAGE
L
LA ENLARGEMENT
HYPERTROPHIEDLA APPENDAGE
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LEFT VENTRICLE
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CARDIOMEGALY
The cardiothoracic ratio should be less than 0.55 on PA view. i.e. A+B/C<0.55
A cardiothoracic ratio > 0.55 suggests cardiomegaly in adults
A cardiothoracic ratio > 0.6 suggests cardiomegaly in newborn
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CTR is more than 50% but heart is normal
Spurious causes of cardiac enlargement Portable AP films Obesity Pregnant Ascites Straight back syndrome Pectus excavatum
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CTR is less than 50% but heart is abnormal
Obstruction to outflow of the ventricles
Ventricular hypertrophy Must look at cardiac contours
< 50%
ASCENDING AORTA DILATED LV CONTOUR
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CRITERIA'S FOR CARDIOMEGALY
Cardiothoracic ratio >0.55 in adults on PA view Cardiothoracic ratio >0.6 in newborn on PA view Any increase in transcardiac diameter > 2 cm compared
to old x-ray In old age and emphysema a transcardiac diameter
more than 15.5 cm in males &>12.5 cm in females
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CHAMBER ENLARGEMENT
RA enlargement LA enlargement RV enlargement LV enlargement
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CRITERIA FOR RA ENLARGEMENT
Rt. Cardiac border becomes more convex > 50% of right border
Rt. Atrial border extends >3 intercostal spaces
Measurement from mid vertical line to max. convexity in rt. Border>5 cm in adult & >4cm in children
Lateral view – fullness in space between sternum and front of upper part of cardiac silhouette
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CRITERIA FOR LA ENLARGEMENT
Widening of carina( normal 45-75 degree) Elevation of left bronchus Straightening of left border Double atrial shadow( shadow within shadow) Grade 1 –double cardiac contour Grade2 - LA touches RA border Grade 3 – LA overshoots the Rt. Cardiac border Displaces the descending aorta to the left and esophagus to
right seen in barium swallow
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LA ENLARGEMENT HYPERTROPHIEDLA APPENDAGE
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LEFT ATRIAL ENLARGEMENT
DOUBLE ATRIAL SHADOW
WIDENING OF CARINA
ELEVATION OF LEFT BRONCHUS
Left atrial appendageenlargement
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Widening of carina
Elevation of lt. bronchusAneurysmal LA
Aneurysmal LA – When La enlarges to left and right and approaches within an inch of lateral chest wall
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LATERAL VIEW-LA ENLARGEMENT
LA pushing theEsophagus posterior
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LEFT VENTRICULAR ENLARGEMENT
PA view
(a)Left cardiac border gets enlarged and becomes more convex resulting in cardiomegaly
(b)Lt. cardiac border dips into lt. dome of diaphragm (c) rounded apical segment (d) cardiophrenic angle is obtuse
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LEFT VENTRICULAR ENLARGEMENT
Lateral view
(a) Left ventricle enlarges inferiorly and posteriorly (b)Rigler’s measurement A is >17 mm (c)Rigler,s measurement B is< 7.5 mm (d) Eyeler’s ratio becomes > 0.42
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RIGLER’S MEASUREMENT
Rigler’s A & B used to differentiate left ventricular and right ventricular enlargement
Possible only when IVC shadow is present
Jn. Of IVC with Lt. Atrium – J point Rigler’s A- from J point along line of IVC
draw a line of 2 cm above and mark the point X.
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Draw a horizontal line from pt. A to posterior Cardiac border and mark that pt. y
Distance between points x & y is Rigler’s measurement A
NORMAL<17 mm Rigler’s B-from the pt. J drop a perpendicular
line to the dome and this distance is Rigler’s measurement B
NORMAL>7.5 mm
RIGLER’S MEASUREMENT
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When LV enlarges, Posterior cardiac border gets displaced
posteriorly & IVC shadow gets included in cardiac shadow, without getting displaced posteriorly
Rigler’s measurement A >17 mm in lt. ventricular enlargement
RIGLER’S MEASUREMENT
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EYELER’S RATIO
To differentiate lt. & rt. Ventricular enlargement
Valid when IVC shadow is absent or cannot be visualised
Mark the point of jn. where postero inferior cardiac border meets the dome as B
From this point B draw a horizontal line to the posterior border of sternum-AB
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From pt.B - draw another horizontal line posteriorly to the inner border of the rib-BC
Ratio of AB/BC is Eyeler’s ratio < 0.42
EYELER’S RATIO
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LA Oblique view There is a retrocardiac space( prevertebral)
(a)Mild lt. Ventricular enlargement-obliteration of retrocardiac space
(b) mod. Lt.ventricular enlargement-cardiac shadow overlaps vertebral column
(c)Marked Lt.ventricular enlargement-cardiac shadow overshoots vertebral column
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Chest X ray shows left ventricular enlargement. Left heart border is displaced leftward, inferior and posteriorly. Rounding of the cardiac apex.
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RV ENLARGEMENT
PA VIEW
Cardiophrenic angle is acuteClockwise rotation of heart causes RV to form the
middle portion of the left heart border.
RIGHT LATERAL VIEWObliteration of retrosternal spac
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RV ENLARGEMENT
LEFT LATERAL VIEWRigler’s measurement will be17mm or less
Rigler’s measurement will be 7.5mm or more
Eyeler’s ratio is 0.42 or less
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PERICARDIAL EFFUSION Narrow vascular pedicle Cardiomegaly directly proportional to severity of pericardial
effusion This shadow has a rounded, globular appearance with no
particular chamber enlargement Cardiophrenic angle become more and more acute Oligaemic pulmonary vascular markings Marked change in cardiac silhouette in decubitus posture ‘Epicardial fat pad sign’- anterior pericardial strip bordered
by epicardial fat post. and mediastinal fat ant.>2mm
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Narrow vascular pedicle
Acute cardiophrenic angle
‘Water bottle’appearence
Pulmonary oligaemia
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DILATED CARDIOMYOPATHY VS PERICARDIAL EFFUSION
Chambers can be identified Cardiophrenic angle is obtuse Increased pulmonary venous hypertension No change in cardiac silhouette in decubitus Vascular pedicle is dilated or normal Fluoro shows cardiac pulsation
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CONSTRICTIVE PERICARDITIS
1.Straightening of the right border2.Pericardial thickening > 4 mm3.Pericardial calcification (50% cases)4.Dilatation of SVC and azygous vein
Pericardial calcification
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CONGENITAL ABSENCE OF PERICARDIUM
Focal bulge in area of main pulmonary artery
Sharply marginated Absent right cardiac border Increased distance between sternum
and heart due to absence of sterno pericardial ligament
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PULMONARY VASCULARITY
1.RDPA<17MM
NORMAL PULMONARY CIRCULATION – 3 FEATURES
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PULMONARY VASCULARITY
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PULMONARY VENOUS HYPERTENSION
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PULMONARY VENOUS HYPERTENSION LARRY ELLIOT’S CLASSIFICATION OF PVH
RADIOGRAPHIC GRADE OF PVH
ACUTE DISEASE
PCWP
CHRONIC DISEASE
PCWP
1 13-17 MMHG 13-17 MMHG
2 18-25 MMHG 18-30 MMHG
3 >25 MMHG >30 MM HG
4 HEMOSIDEROSIS AND OSSIFICATION
LONG STANDING PVH
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GRADE 0 -PCWP< 12 MM HG Upper lobe pulmonary veins are less prominent than lower lobe veins
GRADE 1- PCWP 13-17MMHG
Redistribution of blood flow with cephalization-’ANTLER SIGN’ 1) increased resistance to flow due to interstitial odema 2) alveolar hypoxia in lower lobes causes reflex vasoconstriction 3) vasoconstriction of the arterioles due to LA or pulmonary vein reflex
PULMONARY VENOUS HYPERTENSION
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GRADE 2- PCWP 18-25mm hg
Interstitial edema Peribronchial cuffing Kerley A,B,C lines Interlobular effusion Pleural effusion Hilar haze
Peribronchial cuffing
PULMONARY VENOUS HYPERTENSION
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KERLEY A LINES
Distended lymphatic channels within edematous septa coursing from peripheral lymphatics to central hilar nodes
Towards the hilum Less specific for Pulmonary venous
hypertension
KERLEY A LINES
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KERLEY B LINES
Horizontal lines 1-3 mm thick Perpendicular to pleural surface Towards the costophrenic angle Accumulation of fluid in interlobular
septa and lymphatics Highly specific for PVH
KERLEY B
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Crisscross lines seen between A &B
GRADE 3 – pcwp > 25mm hg
Alveolar odema
Bilateral diffuse patchy
cotton wool opacities
KERLEY C LINES
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Pulmonary circulation
Pulmonary plethora – features Enlargement of central pulmonary artery , lobar and segmental
artery Prominent nodular vascular shadows in frontal CXR- shunt vessels
that course ventral to dorsal Upper & lower lobe vessels prominent RPDA > 17mm Right descending pulmonary artery> tracheal diameter Ratio of
RPDA to diameter of trachea > 1 Plethora seen if shunt size >2:1
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PLETHORA
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Decreased flow proximal to orgin of main pulmonary artery Small pulmonary artery Empty pulmonary bay Pulmonary vessels small Lung hypertranslucent Lateral view shows diminution of hilar vessels
Pulmonary oligaemia
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OLIGAEMIA
Empty pulmonary bay
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High pressure left to right shunts are associated with obliterative changes in the smaller pulmonary arteries & arterioles
Large main & large central pulmonary arteries taper down rapidly to very small vessels
Seen in Eisenmenger’s syndrome Precapillary PAH
Pruning
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PRUNING
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PULMONARY EMBOLISM
Hamptons humpWedge opacity
Westermark signHampton’s humpFleischner’s sign- prominent central pulmonary arteryPalla’s sign-dilated rt. Descending pulmonary arteryChang’s sign – dilatation and abrupt change in calibre of the rt. Descending PA
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VALVULAR HEART DISEASE MITRAL STENOSIS
Small aortic knob from decreased cardiac output
Features of left atrial enlargement Right atrial enlargement from tricuspid
insufficiency Pulmonary venous hypertension Enlarged MPA Calcified mitral valve
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Mitral regurgitation
LA enlargementLV enlargementPulmonary venous hypertension
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Ascending aorta dilated Left ventricular hypertrophy Aortic valve calcification
AORTIC STENOSIS
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Dilated ascending aorta LV enlargement
AORTIC REGURGITATION
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No obvious cardiomegaly Enlarged PA Dilated left pulmonary artery Normal to decreased pulmonary
vasculature
VALVULAR PS
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Concave PA segment RVH
Infundibular Pulmonary stenosis
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MPA DILATED
RPA DILATED
RV APEX
PULMONARY PLETHORAASD
CONGENITAL HEART DISEASE
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HOW TO DIFFERENTIATE ASD VSD PDA
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MPA DILATED
RPADILATED
LV APEX
PLETHORA
VSD
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Linear or railroad track calcification at site of ductus may be seen in adults with PDA PROMINENT
MPA
LV APEX
PLETHORA
AORTIC KNOB
PDA
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• “FIGURE OF 3” in CXR• “REVERSE 3” or “E sign” in Barium
meal
COARCTATION OF AORTA
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DD OF INFERIOR RIB NOTCHING
1)Aortic obstruction- Takayasu arteritis Coarctation of aorta2) Subclavian artery obstruction –Classic BT shunt Takayasu arteritis3)Chronic Svc obstruction4)Intercostal Av fistula5)Neurofibromatosis
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Cyanosis With Decreased Vascularity
Tetralogy of Fallot
Truncus-type IV
Tricuspid atresia
Transposition of great arteries
Ebstein’s anomaly
Cyanosis With Increased Vascularity
Truncus types I, II, III
TAPVC
Tricuspid atresia
Transposition
Single ventricle
Cyanotic Congenital Heart Disease
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CYANOTIC CHD—TOF
• Rv apex• Underfilled LV• Concave pulmonary artery• Pulmonary oligaemia
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‘Egg on string’ 1)Narrow pedicle 2)Rt. Border RA 3)Lt. border LV 4)Increased vascularity 5)Hypoplastic thymus
CYANOTIC CHD—TGA
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‘figure of 8’ “snowman” Rt border-SVC Upper border-left innominate Left border-left vertical vein Body of snowman-RA
CYANOTIC CHD—TAPVC (supracardiac)
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The scimitar sign is produced by an anomalous pulmonary vein that drains any or all of the lobes of the right lung.
Scimitar vein empties into the inferior vena cava
CYANOTIC CHD—PAPVC(Scimitar sign)
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‘Box shaped heart Enlarged RA Hypoplastic pulmonary trunk Decreased vascularity
CYANOTIC CHD—EBSTEIN
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LV apex Rt pulmonary artery has a superior
orgin (20%) ‘waterfall sign’ ‘Hilar comma sign’ Associated right aortic arch (33%) Concave PA segment
ELEVATED RIGHT HILUM
CYANOTIC CHD—TRUNCUS ARTERIOSUS
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CYANOTIC CHDEisenmenger’s syndrome
• Chest xray show dilation of central pulmonary arteries and pruning of peripheral pulmonary arteries, right ventricular and atrial enlargement. Left heart would return to normal size.
• Left to right shunts such as atrial septal defect, ventricular septal defect and patent ductus arteriosus, cause increased pulmonary blood flow. With time, high pulmonary vascular resistance will develop, ultimately causing right to left shunt.
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PACEMAKER
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BIVENTRICULAR PACING
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RA LEADRV LEAD
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PACEMAKER PROBLEMS
LEAD FRACTURE
DISPLACED RA LEADDISPLACED RV LEAD
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ICD
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A) Valvular – Mitral , aortic valve
B) Pericardial – constrictive pericarditis
C) Myocardial – left atrial wall, LV aneurysm
D) Endocardial – Endomyocardial fibrosis
E) Intraluminal – La thrombus , La myxoma , Lv thrombus
F) Vascular – aortic calcification , coronary artery
CARDIAC CALCIFICATIONS
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CARDIAC CALCIFICATION
MITRAL VALVE CALCIFICATION
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MYOCARDIAL CALCIFICATION
CALCIFIED LV APICAL ANEURYSM
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CONSTICTIVE PERICARDITIS
CALCIFIED PERICARDIUM
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PERICARDIAL VS MYOCARDIAL CALCIFICATION
PERICARDIAL SEEN IN BOTH SIDES OF HEART MOST
COMMONLY IN AV GROOVE DIFFUSE CALCIFICATION AROUND THE
HEART CALCIFICATION IS CHUNKY & UGLY
MYOCARDIAL SEEN IN ONLY LEFT SIDE MOST COMMON SITE IS ANT.
WALL LOCALIZED TO THE LEFT CALCIFICATION IS FINE &
CURVILINEAR
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GIANT LA CALCIFICATION
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ATRIAL MYXOMA
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TILTING DISK VALVE
PROSTHETIC HEART VALVE
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STARR EDWARD BALL VALVE
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STARR EDWARD PROSTHETIC VALVE
MITRAL PROSTHESIS
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ST. JUDE VALVE
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Aneurysm of ascending &Descending aorta
Diseases of aorta
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Egg shell sign
Aortic dissection
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MISCELLENOUS X-RAYS
LEFT SVC
Occurs in less than 0.5% of people Failure of regression of L common
and Ant. Cardinal veins Drains left jugular and left
subclavian vein Most patients also have right sided
SVC Drains into dilated coronary sinus
LEFT SVC
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RIGHT AORTIC ARCH
Leftward displacement of barium filled esophagus
Rt. Indentation of trachea Aortic knob is absent from left side Aorta descends on right Associated with TOF Truncus arteriosus
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AORTIC NIPPLE
Left superior intercostal vein Seen in 5% of cases To be differentiated from a mass Also called pseudo dissection It drains into hemiazygous vein
Hartman T .Pearls & Pitfalls in Thoracic imaging,Variants and other difficult diagnosis
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CERVICAL AORTIC ARCH
Left sided cervical aortic arch Aortic knob at apex of lung Descend on the left
CERVICAL AORTIC ARCH
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SITUS INVERSUS WITH DEXTROCARDIA SITUS INVERSUS WITH LEVOCARDIA
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DEXTROCARDIA
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HYDROPNEUMOPERICARDIUM
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PDA CLIP
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BIBLIOGRAPHY(1)Jefferson K, Rees S. Clinical cardiac radiology, 2nd edition Butterworths; 1980. (2) Lipton MJ. Plain film diagnosis of heart disease: cardiac enlargement. Contemporary Diagnostic
Radiology 1988;11:1-6. (3) Boxt LM, Reagon K, Katz J. Normal plain film examination of the heart and great arteries in the
adult. J Thorac Imaging 1994;9:208-18. (4)Murray G. Baron,Wendy M. Book .Congenital heart disease in the adult.North American Clinics of
Radiology 2004;3(5) Ramesh M. Gowda,Lawrence M. Boxt. Calcifications of the heart.North American Clinics of
Radiology 2004;4(6) Martin J. Lipton, Lawrence M. Boxt. How to approach cardiac diagnosis from the chest
radiograph.North American Clinics Of Radiology 2004;5(7) Murray G. Baron .PLAIN FILM DIAGNOSIS OF COMMON CARDIAC ANOMALIES IN THE ADULT.North
American Clinics Of Radiology 2004;6 (8) Radiology imaging – sutton 6th edition(9) Pediatric cardiology- Perloff’s clinical recognition of congenital heart disease(10)Radiology of congenital heart disease-Amplatz(11)Grainger & Allisons- diagnostic radiology vol1 , 4th edition(12)Cardiac Xrays- v.Chockalingam(13)Braunwald heart diseases 9th edition(14) Emma C. Ferguson,Rajesh Krishnamurthy,Sandra A. A.Oldham. Classic Imaging Signs of Congenital Cardiovascular Abnormalities; RadioGraphics 2007; 27:1323–1334(15)www.learningradiology.com
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QUIZ
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QUIZ
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EBSTEIN’S ANOMALY
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8 YR OLD ACYANOTIC CHILD
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ATRIAL SEPTAL DEFECT
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25 YR OLD LADY WITH DYSPNOEA
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MITRAL STENOSIS
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65 YR OLD MAN WITH DYSPNOEA
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PERICARDIAL EFFUSION
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35 YR OLD ACYANOTIC FEMALE
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ASD WITH PAH
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RT AORTIC ARCH WITH RT DESCENDING AORTA
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4 MO CYANOTIC CHILD
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TAPVC SUPRACARDIAC
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3 MO CYANOTIC CHILD
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D-TGA
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8 YR OLD ACYANOTIC CHILD
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VSD