Uncategorized

The Common Vein:  

Principles of Structure

 

Ashley Davidoff MD

Parts
Size
Shape
Position
Character
Time

Common Terms

Word First Definition
air bronchogram  
atelectasis  
bleb  
bronchiectasis  
bulla  
congestive heart failure (CHF)  
consolidation  
effusion pleural (small, large, subpulmonic, decubitus films, supine and upright)  
ground glass opacity (GGO)  
mass solid lung mass  
nodule solitary pulmonary (spn)   
pneumothorax  
pneumothorax tension  
silhouette sign  
white out opacification distinguishing causes of hemithorax (effusion, vs vs pneumonia vs pneumonectomy)

Why We See Things?

Contrasts Differences and Visibility
Ashley Davidoff thecommonvein.net
How many squares
Ashley Davidoff thecommonvein.net
How many squares
Ashley Davidoff thecommonvein.net

Silhouetting

NORMAL AND SILHOUETTING OF THE LEFT DIAPHGRAGM
Silhouette sign, right middle lobe pneumonia. Initial frontal (A) and lateral (B) radiographs in a patient with clinical suspicion of pneumonia demonstrate obliteration of the right heart border. Follow-up radiographs the next day (C, D) illustrate dense opacification on the lateral view and persisting loss of the right heart border, confirming the presence of a right middle lobe pneumococcal pneumonia.
Source
Signs in Thoracic Imaging
Journal of Thoracic Imaging 21(1):76-90, March 2006.

 

Air Bronchograms
Ashley Davidoff thecommonvein.net

How to Approach the Field of Radiology
My Story – Curiosity

 

  • Sherlock Holmes
    Not invisible but unnoticed Watson….
    Ashley Davidoff thecommonvein.net

    Sherlock Holmes Quotes

In the Pursuit of Excellence

In the pursuit of excellence of piano playing … principles are

Notes Scales and Music

    • THE ART OF PERFECTING MUSIC
      Ashley Davidoff
      Scales from MusicNotes.com
      thecommonvein.net

  • THE ART OF PERFECTING DANCE
    Ashley Davidoff
    thecommonvein.net
    THE ART OF PERFECTING TENNIS
    Ashley Davidoff
    thecommonvein.net

    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

THE HEART, LUNGS, PLEURA, DIAPHRAGM, ARTERIES, VEINS, PROXIMAL TRACHEOBRONCHIAL TREE and SKELETON
Ashley Davidoff MD
Parts of the Lungs-  Basics

Left Lung ? Left Upper Lobe ? Frontal Projection

LEFT UPPER LOBE IN THE FRONTAL PROJECTION
Ashley Davidoff MD

Frontal Projection Left Lower Lobe

LEFT LOWER LOBE IN THE FRONTAL PROJECTION
Ashley Davidoff MD
Right Lung ? Right Upper Lobe ? Frontal Projection
RIGHT UPPER LOBE IN THE FRONTAL PROJECTION
Ashley Davidoff MD
Right Middle Lobe ? Frontal Projection

 

RIGHT MIDDLE LOBE IN THE FRONTAL PROJECTION
Ashley Davidoff MD
Right Lower Lobe ? Frontal Projection

 

RIGHT MIDDLE LOBE IN THE FRONTAL PROJECTION
Ashley Davidoff MD

Lateral Examination of the Lungs


Major Fissure on the Left 

LATERAL PROJECTION ? FISSURE DIVIDES THE LEFT UPPER LOBE (INCLUDING LINGULA) AND LEFT LOWER LOBE
Ashley Davidoff MD
MAJOR FISSURE ON THE LEFT
Ashley Davidoff MD

Lateral Projection ? Left Upper Lobe

LATERAL PROJECTION, LEFT UPPER LOBE
Ashley Davidoff MD

Lateral Projection left Lower Lobe

LATERAL CXR SHOWING LEFT LOWER LOBE
Ashley Davidoff MD

 

Major and Minor Fissures on the Right

ANATOMIC SPECIMEN SHOWING MAJOR and MINOR FISSURES DIVIDING THE RIGHT LUNG INTO 3 LOBES
The right lung has a small right upper lobe (RUL) separated from the middle lobe (RML) by the minor fissure (pink,lower image) . Both the RUL and RML are anterior and are separated from the lower lobe  by the major fissure (orange line)
Ashley Davidoff MD
LATERAL X-RAY SHOWING MAJOR and MINOR FISSURES DIVIDING THE RIGHT LUNG INTO 3 LOBES
The right lung has a relatively small right upper lobe (RUL) separated from the middle lobe (RML) by the minor fissure (pink,lower image). Both the RUL and RML are anterior and are separated from the lower lobe  by the major fissure (orange line)
Ashley Davidoff MD
Right Upper Lobe ? Lateral  Projection
LATERAL CXR SHOWING RIGHT UPPER LOBE
Ashley Davidoff MD
Right Middle Lobe ? Lateral Projection

 

LATERAL CXR SHOWING RIGHT MIDDLE LOBE
Ashley Davidoff MD
Right Lower  Lobe ? Lateral Projection
LATERAL CXR SHOWING RIGHT LOWER LOBE
Ashley Davidoff MD
Summary

CXR of LEFT LUNG
Ashley Davidoff MD

CXR of RIGHT 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

ASYMMETRIC BRANCHING PATTERN ? RIGHT SHORT AND STOUT AND THE LEFT LONG AND THIN
CARINAL ANGLE ? 40-80 degrees
Ashley Davidoff MD
THE RIGHT ? SHORT STOUT AND CUTE
THE LEFT ? TALL THIN AND GRACILE
The carinal angle
OLIVER HARDY AND STAN LAUREL IN THE 1939 FILM ? THE FLYING DEUCES
SCREW IN THE RIGHT MAIN STEM
http://www.wikiradiography.net/
N-G TUBE IN RIGHT MAIN STEM BRONCHUS
Courtesy Radiopaedia

ET TUBE IN RIGHT MAIN STEM BRONCHUS

Anatomy of the Heart
Chambers that are Border Forming on the PA Examination
FRONTAL CXR AND PARTS OF THE HEART
If we were to ?crack open? the chest of the chest X-ray, the structures that would dominate this bloody, black and white scene, would be the right sided chambers. The right ventricle (RV) would be the dominant anterior chamber, and would form the dominant interface with the diaphragm. The right atrium (RA) would form the border with the right lung. The RA would of course be slightly posterior to the RV. The left border would be formed by the left ventricle. Most the left ventricle is hidden posteriorly in this view. The left anterior descending artery would be visible from this anterior view. It marks the position of the interventricular septum.
Ashley Davidoff MD
CARDIOMEGALY – THE CARDIOTHORACIC RATIO
The maximum transverse length of the heart is expressed as a percentage of the maximum length of the internal diameter of the chest. When this ratio – the cardiothoracic ratio (c t r) is greater than 50% cardiomegaly is present. The top image is normal and the bottom reflects cardiomegaly
Ashley Davidoff MD
 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

CLINICAL EVALUATION OF LVE ? DOWN AND OUT
The left ventricle (LV) enlarges in a downward and lateral direction resulting in the apical impulse displacement and increase forcefulness of the apical tap.
Ashley Davidoff MD
ISCHEMIC CARDIOMYOPATHY S/P RCA OCCLUSION
62 year old female with acute chest pain atrial fibrillation, hypotension admitted to ICU. Clinical evaluation was considered to be non-ischemic cardiomyopathy with EF by echo of about 20%. She was hypotensive and, in the ICU, and CXR showed acute CHF with cardiomegaly. The TEE was more in keeping with segmental dyssynergy, Cardiac cath showed occluded RCA bot good collateralization from the LAD. MRI showed subendocardial LGE in the inferior and inferolateral portions of the LV consistent with a prior infarction and EF of 20%
Ashley Davidoff MD

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
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 shap. (lower images c, d,e, f)
Ashley Davidoff MD

Vector of the Enlarging RV ? Rotate  Laterally to the Right

VECTOR FOR RV ENLARGEMENT
ANTERIOR LEFTWARD
The right ventricle (RV) enlarges with a clockwise rotation resulting in an upward turning of the apex and enlargement in a anterior and leftward lateral direction.
Ashley Davidoff MD

Clinical  Exam of the RV  ? Diffuse Anterior Parasternal Heave

CLINICAL EVALUATION OF RVE ? PARASTERNAL HEAVE
The right ventricle (RV) enlarges in a anterior, upward and lateral direction resulting in the broad based parasternal pulsation which on clinical examination is identified as a parasternal heave identified with the base of the extended hand
Ashley Davidoff MD

The Straight Left Heart Border

MITRAL STENOSIS
Triangular shaped heart with RVE LAE
Ashley Davidoff MD
The Main Pulmonary Artery
Normal

 

Normal Main Pulmonary Artery
When a line is drawn from the aortic knob to the left edge of the heart, (red line) the pulmonary artery should lie medial to that line  (ie along the line drawn to 1.5cms medial to the line) 
Ashley Davidoff MD TheCommonVein.net

                                          Pulmonary Hypertension

Pulmonary Arteries in Pulmonary Hypertension
When a line is drawn from the aortic knob to the left edge of the heart, (red line) the pulmonary artery lies lateral to that line indicating an enlarged pulmonary artery most commonly caused by hypertension . In this instance the size of the descending right pulmonary artery is greater than 15 mms confirming the presence of pulmonary hypertension
Ashley Davidoff MD TheCommonVein.net
PULMONARY HYPERTENSION
Frontal x-ray with triangular shaped heart due to pulmonary hypertension with enlarged MPA and enlarged descending RPA .
Ashley Davidoff MD
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

FRONTAL CXR AND PARTS OF THE HEART
If we were to ?crack open? the chest of the chest X-ray, the structures that would dominate this bloody, black and white scene, would be the right sided chambers. The right ventricle (RV) would be the dominant anterior chamber, and would form the dominant interface with the diaphragm. The right atrium (RA) would form the border with the right lung. The RA would of course be slightly posterior to the RV. The left border would be formed by the left ventricle. Most the left ventricle is hidden posteriorly in this view. The left anterior descending artery would be visible from this anterior view. It marks the position of the interventricular septum.
Ashley Davidoff MD

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
RIGHT ATRIAL ENLARGEMENT ON FRONTAL X-RAY
The right atrium is the most difficult chamber to assess unless it is very large in which case it will present on the frontal CXR with a very large right paravertebral border. This is a 71 year old female person with rheumatic heart disease with pulmonary hypertension and tricuspid regurgitation hence resulting in a large right atrium (RAE)
Ashley Davidoff MD
RIGHT ATRIAL ENLARGEMENT ON FRONTAL X-RAY
The right atrium is the most difficult chamber to assess unless it is very large in which case it will present on the frontal CXR with a very large right paravertebral border. The frontal CXR and coronal CT through the RA is from a 71 year old female with rheumatic heart disease with pulmonary hypertension and tricuspid regurgitation resulting in a giant right atrium (RAE). The RA accounts for the large bulge of the right border of the cardiac silhouette. The black arrowhead in the loer image points to the calcified mitral valve.
Ashley Davidoff MD
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
NORMAL AND WIDENED CARINAL ANGLE
A dancer demonstrates a normal carinal angle (upper image) and as she continues to extend her left leg, (lower images) the angle becomes greater than 80 degrees and in terms of the carinal angle becomes abnormal.
Ashley Davidoff MD

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

 

      • 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

      • Air in the Upright and Supine Projection
        Ashley Davidoff thecommonvein.net

    • Pneumothorax
    • SMALL APICAL PNEUMOTHORAX IN AN UPRIGHT CXR TAKEN IN EXPIRATION.
      In an upright position a pneumothorax rises to the apex of the lung and assumes the shape of the apex because it exerts pressure on the lung apex which yield to the greater pressure. The expiration film accentuates the pneumothorax because it further reduces the pressure in the lungs and increases the pressure difference between the PTX and the intraparenchymal pressure.
      The PTX is barely seen in (a) and is better seen in the magnified views (b and c) and with increasing contrast (c) the faint line of the the pleura becomes better visualized (white arrowheads).
      Ashley Davidoff MD
    • DEEP SULCUS SIGN
      Portable supine examination in the ICU shows a pneumothorax in the right subpulmonic region
      Ashley Davidoff MD
      Spontaneous Tension Pneumothorax
      49 year old male with a cough presents for a Chest Xray which showed a tension pneumothorax. Chest tube was placed emergently in the radiology department.
      Ashley Davidoff MD TheCommonVein.net
      117300c

      Pleural Effusion

      Fluid in the Upright and Supine Projection
      Ashley Davidoff thecommonvein.net

       

    • Small Effusion May Only Seen on the Lateral Exam

      SMALL EFFUSION ONLY IDENTIFIED ON THE LATERAL EXAMINATION
      A small effusion is not identified on the PA chest since it is hidden by the diaphragm and the effusion first fills the posterior recess because it is most inferior. The lateral examination is required to identify the effusion
      Courtesy How to Interpret CXR Strong Medicine
      https://www.youtube.com/watch?v=wOpDvUO5sD8

    • Typical shape of a moderately large right pleural effusion
      Case courtesy of RMH Core Conditions, Radiopaedia.org, rID: 34401

       

    • Veiling Opacity

      Veiling Opacity left pleural effusion in the supine projection
      Case courtesy of RMH Core Conditions, Radiopaedia.org, rID: 34401

    • Scales

    • Learning how to look so that you can see

    • How to look and
      what to look for
      Ashley Davidoff thecommonvein.net

    • 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

 

PANORAMA WALK FOR PLEURAL ASSESSMENT
Ashley Davidoff MD

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
LUNG LOOPS – UPPER MID AND LOWER
Ashley Davidoff MD
  • 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
SKI TRIP DOWN THE MOGULS OF THE HEART
A methodical approach to evaluation of the cardiac silhouette is likened to skiing down a mogul laden ski slope and then taking a trip on the ski lift back to the top of the mountain. The ski slope starts at the left subclavian artery (light brown)
, followed by the mogul of the aortic knob (bright green) at the bottom of which is the A-P window (white) only to be presented with a second mogul of the main pulmonary artery(yellow), and then the bay of the left atrial appendage (pink)and finally free at last of moguls and an exciting and accelerating ski down the LV (red)
We then have to take a walk back to the ski lift. At the junction of the LV (red) and the RV (blue) , if we take a right ward look up the mountain we can spot the LAD on top of the interventricular septum.
The walk along the border of the RV is terminated at the junction of the RV (dark blue) and the right atrium (light blue). At this point we wait in line to get on to the ski lift. We ride up the right hand border of the right atrium (light blue) a little rough bump over the ascending aorta )maroon) and then straight to the top along the SVC (pink).
Ashley Davidoff MD
  • 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

 

        • Pericardial Effusion
          WATER BOTTLE HEART
          X-ray shows the typical appearance of a “water bottle heart? characteristic of a pericardial of a large pericardial effusion.
          Ashley Davidoff MD

          sn chest integrated 09ep finding br3 imaging

          Word First Definition
          air bronchogram  
          atelectasis  
          bleb <1-2cms
          bronchiectasis  
          bulla >1-2cms
          congestive heart failure (CHF)  
          consolidation  
          effusion pleural (small, large, subpulmonic, decubitus films, supine and upright)  
          ground glass opacity (GGO)  
          mass solid lung mass >3cms
          nodule solitary pulmonary (spn)  <3cms
          pneumothorax (small, large, supine and upright, decubitus and expiratory films, tension)  
          pneumothorax tension  
          silhouette sign  
          white out opacification distinguishing causes of hemithorax (effusion, vs vs pneumonia vs pneumonectomy)