lines & mediastinal stripes 02

Dr Mazen QusaibatyMD, DIS

Head Pulmonary and Internist Department Ibnalnafisse Hospital

Ministry of Syrian healthEmail: [email protected]

Lines & mediastinal Stripes - 02

2

Topic Outline

1. Anterior junction line complex2. Aortic-Pulmonary Stripe3. Right Paraspinal Line4. Posterior Tracheal Stripe

(Tracheoesophageal Stripe)5. Azygoesophageal Recess

Anterior junction line complex

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Chest radiograph with superimposed mediastinal stripes

Purple• Anterior

junction line

complex

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Anterior junction line on PA chest radiograph (arrows)

Note that the line does not extend above the level of the clavicles

5

Anterior junction line complex

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Quiz

• What are the signs that you see in chest x-ray?

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What are the signs that you see in chest x-ray?

• Loss in the volume of the right lung

• As demonstrated by elevation of the right hemidiaphragm.

8

What are the signs that you see in chest x-ray?

• Frontal chest radiograph shows the anterior junction line (arrows) displaced to the right.

9

CT scan helps confirm rightward displacement of the anterior junction line (arrow) with volume loss in the right lung.

10

Guess the Diagnosis ?

• Abnormal-appearing anterior junction line in a patient who had undergone a right middle lobectomy11

Anterior and posterior junction lines mediastinum

12

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Aortic-Pulmonary Stripe

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Aortic-Pulmonary Stripe (A mediastinal interface )

Formed

The pleura of the

anterior left lung

The mediastinal fat of anterolateral to

The left pulmonary artery

Aortic arch

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• The stripe is straight or mildly convex, crossing laterally over the aortic arch and the main pulmonary artery


• CT scan shows a normal aortic-pulmonary stripe (arrows)

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Aortic-Pulmonary Stripe / Chest x ray

• Abnormal contour of the aortic-pulmonary stripe (arrows)

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• CT scan shows anterior mediastinal lymphadenopathy (arrows) within the prevascular space


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Abnormal-appearing aortic-pulmonary stripe in a 42-year-old patient with lymphoma

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Elevation of the aortic-pulmonary stripe

Pneumomediastinum Anterior mediastinal disease

Thyroid masses

Thymic masses

Prevascular lymphadeno

pathy

KeatsTE. The aortic-pulmonary mediastinal stripe. Am J Roentgenol Radium Ther Nucl Med1972; 116: 107–109

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Right Paraspinal Line


Light blue

Right paraspinal stripe

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Right and left paraspinal stripes (A mediastinal interface )

• It represents an interface between the right lung and the posterior mediastinal fat and soft tissues.

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Right paraspinal stripes

• The right paraspinal line appears straight and typically extends from T8 – T12

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Right paraspinal stripes

• Its presence on 23%

of posteroanterior

radiographs

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The right paraspinal line may be displaced laterally

Osteophytes

A mediastinal fat

A mediastinal hematoma

Abnormal-appearing right paraspinal line in a Frontal chest radiograph

• An abnormal bulge

in the right

paraspinal line

inferiorly (arrows)

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Abnormal-appearing right paraspinal line in CT scan

• An abnormal bulge

in the right

paraspinal line

inferiorly (arrows)

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Abnormal-appearing right paraspinal line in a 27-year-old patient who had sustained traumatic injury

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30

Left Paraspinal Line


Light blue

Left paraspinal stripe

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Contact of

The left lung Pleura

Posterior mediastina

l fat

Left paraspinal

musclesAdjacent soft

tissues

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• The left paraspinal line extends vertically from the aortic arch to the diaphragm

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• The normal left paraspinal line typically lies medial to the lateral wall of the descending thoracic aorta.

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• Reported on 41% of

PA radiographs

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• The left paraspinal line is seen more frequently than the right paraspinal line due to the presence of the descending thoracic aorta on the left

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An abnormal contour of the left paraspinal line

Tortuosity Of The

Descending Thoracic

AortaOsteophyt

es

A Mediastina

l Fat

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A Mediastinal Hematoma

Extramedullary Hematopoiesis

Esophageal Varices

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• CT scan shows extensive esophageal varices (arrow), which are responsible for the abnormal contour of the left paraspinal line.

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Posterior Tracheal Stripe (Tracheoesophageal Stripe)

The posterior tracheal stripe

41FranquetT, Erasmus JJ, Gimenez A, Rossi S, Pratts R. The retrotracheal space: normal anatomic and pathologic appearances.RadioGraphics2002; 22(spec no): S231–S246.

• Is a vertical stripe seen on lateral chest radiographs


• That is formed by air within the trachea and right lung outlining the posterior tracheal wall and intervening soft tissues

42FranquetT, Erasmus JJ, Gimenez A, Rossi S, Pratts R. The retrotracheal space: normal anatomic and pathologic appearances.RadioGraphics2002; 22(spec no): S231–S246.


• It typically measures up to 2.5 mm in thickness

43ProtoAV, Speckman JM. The left lateral radiograph of the chest. I.Med Radiogr Photogr1979; 55: 29–74.

Refresh your Knowledge

1. ………………

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1. Trachea

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2. ………….

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2. Right mainstem

bronchus

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3. ………………

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3. Left mainstem bronchus

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4………………

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4. Aortic “knob” or arch

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5. ………………..

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5. azygosvein emptying into superior

vena cava

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6. …………………..

56


6. Right interlobar pulmonary

artery

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7. …………………

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7. Left pulmonary

artery

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8. ……………….

60


8. Right upper lobe pulmonary artery (truncus

anterior)

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9. ……………..

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9. Right inferior pulmonary vein

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10…………….

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10. right atrium

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11. ……………

66


11. left ventricle

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01. …………………

68


01.Retrosternal space

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02. ……………..

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02. Ascending aorta

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03. …………..

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03. Aortic arch

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04. ………………..

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04. brachiocephalicvessels

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05. ………….

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05. Trachea

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06. ……………….

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06. Right upper lobe bronchus

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07…………………

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07. Left upper lobe bronchus

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08. ………………

82


08. right pulmonary artery

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09. …………………….

84


09. Left pulmonary artery

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10. …………………

86


10. confluence of pulmonary veins

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• Retro-tracheal triangle

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89

post

erio

r

trac

heal

strip

e

thoracic inlet

spin

e

aortic arch

Why should we distinguish the posterior tracheal stripe & Retro-tracheal triangle ?

• Franquet et al observed that the most common abnormalities within the retrotracheal space are congenital developmental anomalies of the aortic arch

90 FranquetT, Erasmus JJ, Gimenez A, Rossi S, Pratts R. The retrotracheal space: normal anatomic and pathologic appearances.RadioGraphics2002; 22(spec no): S231–S246.

Abnormal thickening of the posterior tracheal stripe

Acquired vascular lesions

Esophageal lesions

Lymphatic malformations

Mediastinitis

Post-traumatic hematomas

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Lateral chest radiograph

Shows widening of the posterior tracheal stripe

(arrows)

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CT scan

Demonstrates a dilated

esophagus (arrow) filled with food and

contrast material

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Abnormal posterior

tracheal stripe in a 49-year-old patient with

……………………

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Abnormal posterior

tracheal stripe in a 49-year-old patient with

Achalasia

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96

AZYGOESOPHAGEAL RECESS


Red

Azygoesophageal stripe

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Azygoesophageal recess

Not considered a mediastinal line or

stripe

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Azygoesophageal recess

An important mediastinal

interface caused by differences in

density between the mediastinum

and the posteromedial

portion of the right lower lobe

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CT scan

The azygoesophageal recess represents a space lying lateral or posterior to the

esophagus and anterior to the spine

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Mild leftward convexity superiorly and a straight edge inferiorly

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Abnormal contour of Azygoesophageal recess

Lymphadenopathy

Hiatal hernias

Bronchopulmonary-foregut malformations

Esophageal neoplasms

Pleural abnormalities

Cardiomegaly with left atrial enlargement

102

Abnormal contour of Azygoesophageal recess

• The distal third of the azygoesophageal recess demonstrates an abnormal contour and right lateral convexity (arrows)

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Guess the diagnosis

• A large hiatal hernia

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A large hiatal hernia

• CT scan shows a large hiatal hernia (arrow) that causes a rightward bulge of the distal azygoesophageal recess.

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Dark green

Para-aortic line

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Brown

pleuroesophageal stripe

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