Welcome

Principles

Underlying complexity there is simplicity –

The Common Vein

• Principles of Structure
  • Parts
  • Size
  • Shape
  • Position
  • Character
  • Time

Why We See Things?

Silhouetting

How to approach the Field of Radiology
My Story – Curiosity

• 

  Sherlock Holmes Quotes

In the Pursuit of Excellence

In the pursuit of excellence of piano playing … principles are

Notes Scales and Music

• • 

• 

  

  

  TIGER WOODS AND TOM BRADY
  NOTES SCALES AND MUSIC IN THE PURSUIT OF PERFECTION
  Both images are in the public domain

Story of Dr Jerry Balikian

Application to Radiology

• 

  • Where to look, how to look and

  • what to look for

  Ashley Davidoff thecommonvein.net

Notes

• • • Anatomy of the Lungs

       

       

      Frontal Examination of the Lungs

      

      Parts of the Lungs-  Basics

      Left Lung ? Left Upper Lobe ? Frontal Projection

      

      Frontal Projection Left Lower Lobe

      

      Lateral Examination of the Lungs

      
      Major Fissure on the Left 

      

      

      Lateral Projection ? Left Upper Lobe

      

      Lateral Projection left Lower Lobe

      

       

       

      Major and Minor Fissures on the Right

      

      

      Right Upper Lobe ? Lateral  Projection

      

      Right Middle Lobe ? Lateral Projection

       

      

      Right Lower  Lobe ? Lateral Projection

      

      Summary

      

      CXR of LEFT LUNG
      Ashley Davidoff MD

      

      Trachea, Main Stem Bronchi, and Carina

       

      

      NORMAL FRONTAL CXR NORMAL ASYMMETRIC BRANCHING OF MAINSTEM BRONCHI
      The normal CXR shows the characteristic asymmetric branching of the main stem bronchi. The right is short and stout and slightly more vertical while the left is long and thin and slightly more obtuse.
      The normal carinal angle is between 40-80 degrees.
      Ashley Davidoff MD

      

      

      

      

      

      ET TUBE IN RIGHT MAIN STEM BRONCHUS
      Courtesy Radiopaedia

Chambers that are Border Forming on the PA Examination

 There are Two Basic Common Shapes of Cardiomegaly

CARDIOMEGALY ? TWO BASIC TYPES -OVOID and TRIANGULAR
The ovoid form which suggests left ventricular dominance and triangular form which suggests right ventricular dominance.
Ashley Davidoff MD

The Ovoid Form of Cardiomegaly ? Consider LVE

SHAPE OF THE LEFT VENTRICLE
The enlarged LV (a,b) is shaped like an oval and it is likened to a rugby ball or an American football placed on the field at kick off time. LVE on CXR is mostly assessed by an increased cardiothoracic ratio as well as the accentuation of the ovoid shape. (lower images c, d,e, f)
Ashley Davidoff MD

Vector of the Enlarging LV  ? Rotate  Down and to the Left

VECTOR FOR LV ENLARGEMENT
DOWN AND OUT
The left ventricle (LV) enlarges in a posterior, downward and lateral direction resulting in the characteristic changes of LVE on CXR
Ashley Davidoff MD

Clinical  Exam ? Focal LV Thrust

The Triangular Form of Cardiomegaly 

Consider RVE or any disease from the left side that may cause RVE eg mitral stenosis

TRIANGULAR SHAPED HEART ? SUGGESTING RIGHT VENTRICULAR DOMINANCE.     MITRAL STENOSIS PULMONARY HYPERTENSION
71 year old Asian female with rheumatic heart disease dominated by calcific mitral stenosis mild MR, moderate tricuspid regurgitation and secondary pulmonary hypertension.
Ashley Davidoff MD

Note the Basic Shape of the RV is Triangular in almost all Views

Vector of the Enlarging RV ? Rotate  Laterally to the Right

Clinical  Exam of the RV  ? Diffuse Anterior Parasternal Heave

What about the Right Atrium (RA) and Right Heart Border?

The RA does not make much a statement on the frontal CXR unless very large

The Enlarged Right Atrium

The right atrium is the most difficult chamber to assess unless it is very large in which case it will manifest on the frontal CXR with a very large right paravertebral border.

• • enlarged, globular heart
  • narrow pedicle
  • gross enlargement of the right atrial shadow, i.e. increased convexity in the lower half of the right cardiac border
    • right atrial convexity is more than 50% of the cardiovascular height
    • right atrial margin is more than 5.5 cm from the midline

The Left Atrium

3 signs

• • Carinal Angle
  • Double Density
  • Filling in of the Left Atrial Appendage Bay

The Carina and the Carinal Angle

NORMAL FRONTAL CXR NORMAL ASYMMETRIC BRANCHING OF MAINSTEM BRONCHI
The normal CXR shows the characteristic asymmetric branching of the main stem bronchi. The right is short and stout and slightly more vertical while the left is long and thin and slightly more obtuse.
The normal carinal angle is between 40-80 degrees.
Ashley Davidoff MD

ASYMMETRIC BRANCHING PATTERN ? RIGHT SHORT AND STOUT AND THE LEFT LONG AND THIN
CARINAL ANGLE ? 40-80 degrees
Ashley Davidoff MD

 The Abnormal Carinal Angle

MITRAL STENOSIS WITH ENLARGED LEFT ATRIUM ? WIDENED CARINAL ANGLE DOUBLE DENSITY ENLARGED LEFT ATRIAL APPENDAGE
The frontal CXR demonstrates findings consistent with mitral stenosis including a widened carinal angle (teal blue and black arc), a double density (red arc) and an enlarged left atrial appendage (maroon arc).
The overall shape of the heart is triangular suggesting right ventricular enlargement. A mitral valve prosthesis is in position
Courtesy of Radiopaedia

PARTS OF THE ENLARGED HEART ON  FRONTAL CXR  in MITRAL STENOSIS PULMONARY HYPERTENSION AND COR BOVINUM
71 year old Asian female with rheumatic heart disease dominated by calcific mitral stenosis mild MR, moderate tricuspid regurgitation and secondary pulmonary hypertension.
The frontal view shows an enlarged RA (light blue) characterized by a prominent right heart border. The right ventricle is enlarged as noted by the triangular shape of the cardiac silhouette, an the upturned (?proud breast?) appearance of the left heart border, both reminiscent of RVE. The left atrium is also significantly enlarged characterised by the widened carina and the straight heart border caused by a combination of atrial appendage enlargement and pulmonary hypertension.  The LV (maroon) is normal in size
Ashley Davidoff MD

• • • Where to Look The Physics of Air and Fluid

      • Gravity, Air and Fluid

    • notes-scale-music-0013-low-res-1.jpg

      Gravity Air and Fluid
      Remember the roles they play in Supine and upright projections
      Ashley Davidoff thecommonvein.net

    • 

  • Pneumothorax

  • 

  • 

    

    Pleural Effusion

    

     

  • Small Effusion May Only Seen on the Lateral Exam

    

  • 

     

  • Veiling Opacity

    

  • Scales

  • Learning how to look so that you can see

  • 

  • Notes Scales and Music

  •  Scales
    • Have a fluid and logical method  of looking (search pattern) and
      • practice practice practice

SCALES

• 4 Review Spaces relating to 4 areas of major disease
  • Pleura – PTX and Effusions
  • Lungs – Pneumonia and Masses
  • Hila  – Masses and CHF
  • Heart – Megalies and Failure

First Scale – Pleural Run

Pattern – start at the white lines  to the right and left of the thoracic vertebra running along the diaphragms into the pleural recesses, up the lateral walls to the apices

2nd Scale – Lung Loops

• Pattern –
  • • Come down the trachea and and
    • loop the upper lung fields, then the
    • mid lung fields, and finally the
    • lower lung fields
    • looking for
      • symmetry,
      • masses,
      • infiltrates,
      • interstitial changes

3rd Scale – Skiing on the Moguls

• Pattern of the Ski Run –
• Start at the left apex at the left subclavian artery,
• jump the aortic mogul and
• land in the AP window, and then
• jump the PA mogul,
• land in the LA appendiceal  bay, and then
• ski all the way down the LV.
• Walk back to the ski lift via the inferior border of the RV and then the RA.
• At the bottom of the RA get on to the ski lift as the IVC enters the RA
• and then take the lift up the mountain via the RA ,
• portion of the ascending aorta and the
• the SVC

4th  Scale – Hilar Hoops

• Pattern of the Hilar Hoops –
  • • Trip down the trachea – Specifically to look at the carinal angle
    • Upper hoop specifically to look at pa- bronchus ratio
    • Middle Hoop – Specifically to look at hilar size and shape
    • Lower Hoop – Specifically to look for redistribution and clarity of RPA

Normal Pulmonary Artery

Pulmonary Hypertension

Music

• Music
  • Know how best you learn
  • accumulate integrate and continually improve your
    • knowledge
    • experience and
    • memory so you can make
    • sound judgment when it is
  • game time

Structured Reporting The Template

• EXAMINATION:
  • Chest, 2 views
• HISTORY:
  •  cough
• Single PA view or 2 views o the chest
• COMPARISON:
  • No prior studies are available.
• FINDINGS:
  • Lines and Tubes
  • Heart and mediastinum: Normal.
  • Lungs and pleura:
    • Lungs are clear.
    • No pneumothorax.
    • No pleural effusions.
  • Bones: No acute osseous abnormality.
• IMPRESSION:
  • 1. No active chest disease.

• • Comparison Studies
  • Lines and Tubes
  • Cardiac exam on the CXR
    • Approach to CHF
  • Lungs

?Infiltrates

?Effusions

?Pneumothorax

The Secondary Lobule
 A Love Story

Summary

• Principles of Structure
  • Parts
  • Size
  • Shape
  • Position
  • Character
  • Time

• 

  

  

  • Music
    • Know how best you learn
    • accumulate integrate and continually improve your
      • knowledge
      • experience and
      • memory so you can make
      • sound judgment when it is
    • game time

Links and References

• TCV
  • Sherlock Holmes Approach to the CXR
  • Notes Scales and Music in the Heart Module
  • Sherlock Holmes Quotes

DOMElement Object
(
    [schemaTypeInfo] => 
    [tagName] => table
    [firstElementChild] => (object value omitted)
    [lastElementChild] => (object value omitted)
    [childElementCount] => 1
    [previousElementSibling] => (object value omitted)
    [nextElementSibling] => (object value omitted)
    [nodeName] => table
    [nodeValue] => 




The Shapes of the Heart in Health and Disease




From top left ti right and across the rows they are:  The normal heart , the ?football? of LV enlargement the ?triangle? or ?proud breast? of RV enlargement, ?snowman? of total anomalous pulmonary venous return,  big PA mogul of pulmonary hypertension,  ?egg on its side? of D transposition of the great vessels,   ?boot shaped? heart seen in both pulmonary atresia and Tetralogy of Fallot, the long smooth combined Ao and PA mogul that has a differential diagnosis of L transposition, absence of the pericardium, and juxtaposition of the atrial appendages, the box shaped large heart of Ebstein?s anomaly, dextrocardia , and the water bottle? heart of a large pericardial effusion.
07197 Images are  a combination of images from a personal collection and borrowed from the internet for educational purposes only. Some of the  sources are unknown and are used for educational  purposes alone 86774b02




    [nodeType] => 1
    [parentNode] => (object value omitted)
    [childNodes] => (object value omitted)
    [firstChild] => (object value omitted)
    [lastChild] => (object value omitted)
    [previousSibling] => (object value omitted)
    [nextSibling] => (object value omitted)
    [attributes] => (object value omitted)
    [ownerDocument] => (object value omitted)
    [namespaceURI] => 
    [prefix] => 
    [localName] => table
    [baseURI] => 
    [textContent] => 




The Shapes of the Heart in Health and Disease




From top left ti right and across the rows they are:  The normal heart , the ?football? of LV enlargement the ?triangle? or ?proud breast? of RV enlargement, ?snowman? of total anomalous pulmonary venous return,  big PA mogul of pulmonary hypertension,  ?egg on its side? of D transposition of the great vessels,   ?boot shaped? heart seen in both pulmonary atresia and Tetralogy of Fallot, the long smooth combined Ao and PA mogul that has a differential diagnosis of L transposition, absence of the pericardium, and juxtaposition of the atrial appendages, the box shaped large heart of Ebstein?s anomaly, dextrocardia , and the water bottle? heart of a large pericardial effusion.
07197 Images are  a combination of images from a personal collection and borrowed from the internet for educational purposes only. Some of the  sources are unknown and are used for educational  purposes alone 86774b02




)

DOMElement Object
(
    [schemaTypeInfo] => 
    [tagName] => td
    [firstElementChild] => (object value omitted)
    [lastElementChild] => (object value omitted)
    [childElementCount] => 2
    [previousElementSibling] => 
    [nextElementSibling] => 
    [nodeName] => td
    [nodeValue] => 
From top left ti right and across the rows they are:  The normal heart , the ?football? of LV enlargement the ?triangle? or ?proud breast? of RV enlargement, ?snowman? of total anomalous pulmonary venous return,  big PA mogul of pulmonary hypertension,  ?egg on its side? of D transposition of the great vessels,   ?boot shaped? heart seen in both pulmonary atresia and Tetralogy of Fallot, the long smooth combined Ao and PA mogul that has a differential diagnosis of L transposition, absence of the pericardium, and juxtaposition of the atrial appendages, the box shaped large heart of Ebstein?s anomaly, dextrocardia , and the water bottle? heart of a large pericardial effusion.
07197 Images are  a combination of images from a personal collection and borrowed from the internet for educational purposes only. Some of the  sources are unknown and are used for educational  purposes alone 86774b02

    [nodeType] => 1
    [parentNode] => (object value omitted)
    [childNodes] => (object value omitted)
    [firstChild] => (object value omitted)
    [lastChild] => (object value omitted)
    [previousSibling] => (object value omitted)
    [nextSibling] => (object value omitted)
    [attributes] => (object value omitted)
    [ownerDocument] => (object value omitted)
    [namespaceURI] => 
    [prefix] => 
    [localName] => td
    [baseURI] => 
    [textContent] => 
From top left ti right and across the rows they are:  The normal heart , the ?football? of LV enlargement the ?triangle? or ?proud breast? of RV enlargement, ?snowman? of total anomalous pulmonary venous return,  big PA mogul of pulmonary hypertension,  ?egg on its side? of D transposition of the great vessels,   ?boot shaped? heart seen in both pulmonary atresia and Tetralogy of Fallot, the long smooth combined Ao and PA mogul that has a differential diagnosis of L transposition, absence of the pericardium, and juxtaposition of the atrial appendages, the box shaped large heart of Ebstein?s anomaly, dextrocardia , and the water bottle? heart of a large pericardial effusion.
07197 Images are  a combination of images from a personal collection and borrowed from the internet for educational purposes only. Some of the  sources are unknown and are used for educational  purposes alone 86774b02

)

DOMElement Object
(
    [schemaTypeInfo] => 
    [tagName] => td
    [firstElementChild] => (object value omitted)
    [lastElementChild] => (object value omitted)
    [childElementCount] => 2
    [previousElementSibling] => 
    [nextElementSibling] => 
    [nodeName] => td
    [nodeValue] => 

The Shapes of the Heart in Health and Disease

    [nodeType] => 1
    [parentNode] => (object value omitted)
    [childNodes] => (object value omitted)
    [firstChild] => (object value omitted)
    [lastChild] => (object value omitted)
    [previousSibling] => (object value omitted)
    [nextSibling] => (object value omitted)
    [attributes] => (object value omitted)
    [ownerDocument] => (object value omitted)
    [namespaceURI] => 
    [prefix] => 
    [localName] => td
    [baseURI] => 
    [textContent] => 

The Shapes of the Heart in Health and Disease

)