CHEST X RAY
CONTENTS1. Identifying lung zones2. Stepwise approach to describe/read a
CXR.3. Coming to a diagnosis4. Hardware/ Equipment
CONCEPT OF ZONES
Anterior ribs Zones
2 - 4 UPPER zone
4 - 6 MIDDLE zone
BELOW 6 LOWER zone
Loss of normal silhouettes of structures aid in identifying lobes involved. E.g. Right heart border= right middle lobe
STEPWISE APPROACH
NAME, AGE, SEX & IP NO. DATE AND TIME OF STUDY
Do this before putting it on screen..
Ramu or GopalSequential improvement or worsening
TECHNICAL QUALITY
P • Position
I • Inspiration
E •Exposure
R • Rotation
POSITION AP v/s PAERECT V/S SUPINE
PA AP
INSPIRATION5-6 ant ribs in
MCL/ 8-10 posterior ribs
above diaphragm
Lung bases appear denser Apparent cardiomegaly
EXPOSURE
Just visible Intervertebral
spaces, spinous process / T4 visible
through cardiac shadow
ROTATION Medial ends of
clavicle equidistant from spinous process
Distort Mediastinal image Lung lesions hidden behind mediastinum Lung on rotated side appear denser
CENTRE PERIPHERY
Trachea & Bronchi Heart & Mediastinum Hila Lungs Pleura & angles Chest wall - Diaphragm - Soft tissue - Bony
AT EACH STEP LOOK AT..• Grey scale• Too white/Too black?G
• Position• Normal/ shifted?P
• Size/Shape• Normal/ alteredS
GREY SCALEBones- Denser – opaque
Tissue – Air – Grey
Air – Lucent - Darker
GREY SCALE (LUNGS)TOO WHITE
• Consolidation• Collapse• Lung mass/Nodule• Pleural mass/fluid/
thickening• ARDS/ Pulmonary
edema (Ground glass appearance)
TOO BLACK• Emphysema • Pneumothorax
TOO WHITE/ TOO BLACK
Focal/ Diffuse
Multiple/ Solitary
Homogenous/ Non homogenous
Signs of any surgery
NORMAL
Cardio-phrenic
Costo-phrenic
CENTRAL LINES
TRACHEAL TUBE POSITION 2-3 cm above the carina
T4 vertebra
1
32
4
NASOGASTRIC TUBE • Remains close to
midline and not follow the path of any of the main bronchi.
• Crosses the diaphragm in midline
• Tip is well below the diaphragm
PACING WIRES
RIGHT UPPER LOBE COLLAPSE Opacity Focal – R UL Homogenous Horizontal fissure pulled up
INDIRECT SIGNS Trachea pulled
ipsilaterally Compensatory
hyperinflation of RML Elevation of
hemidiaphragm
CONSOLIDATION RML
OpacityNon homogenous(Air bronchograms)
Focal- RML
PNEUMOTHORAX
• Lung field - Too black
• Visceral pleura – white line
• No vascular marking beyond pleural line.
• Trachea pushed to opposite side
• Widening of the ribs
CARDIOMEGALY
A
B
C
A= 6 cmB= 10 cm 0.61C= 26 cm
CT Ratio: A+B/C
Normal < 0.5
BATWING APPEARANCE
CONGESTIVE HEART FAILIURE
PNEUMONECTOMYHemithorax opacified
Ipsilateral mediastinal shiftContralateral lung
hyper-inflated
Absent left main bronchus
ISA MEETJUNE 2016
DR CHARULATHA R MD Assistant professor MGMCRI
Cervical spine injury in x ray Level of foreign body in chest x ray Ct brain in trauma
PART 1 CERVICAL SPINE INJURY IN XRAY
Cervical spine injury Spinal cord injuries -permanent paralysis Missed c spine fracture can lead to death
or life long neurological deficit 3 standard views – lateral view, AP view,
odontoid peg view or open mouth view Lateral view is the most informative
image Normal c spine xrays do not exclude
significant injuries
Cervical spine xray assessmentStep 1Assess adequacy and
alignmentA. Identify the presence of
all seven cervical vertebrae
B .Identify the 1. Anterior vertebral line 2. posterior spinal line 3. Spinolaminar line 4. Posterior spinous line
Step 21. Assess the bone2. Examine all
vertebrae for preservation of height and integrity of bony cortex
3. Examine facets4. Examine spinous
processes
Step3 1. Assess the
cartilage including examining cartilaginous disc spaces for narrowing or widening
Identify the fracture
Step 4 Assess the dens Examine the
outline of the dens Examine the
predental space Examine the
clivus;it should point to the dens
Assess the extraaxial soft tissue
Step 5 Examine the
extraaxial space and soft tissues
7 mm at C3 3 cm at C7 Widening of extra
axial space – possible fracture
PART 2 FOREIGN BODY ESOPHAGUS
Foreign body esophagus Nasopharynx is from base
of skull till soft palate. Oropharynx extends from
the plane of hard palate above till the plane of hyoid.
Hypopharynx is the lowest part of the pharynx and lies behind and partly on the sides of larynx.
Cervical esophagus starts at C6 level. Below this level F.B is in esophagus.
F.B in esophagus usually identified as it lies behind air column, and there will be prevertebral widening.
In this picture F.B is a the level of hypopharynx.
Esophagus or trachea? Foreign bodies in
esophagus appear face on in frontal projection
Foreign bodies in trachea appear end on
Foreign body esophagus
Coin or battery? Coin – single
shadow Button battery-
double density shadow
Foreign bodies in tracheobroncial tree usually lie in sagittal plane as they enter glottis in that plane.
PART 3 CT brain in trauma
What is a CT scan Is a diagnostic
imaging procedure Series of Xray
images taken from different angles
Processed to create cross sectional images of various tissues within our body
The internal structure of an object can be reconstructed from multiple images of the object
Reading the CT scan How to hold the film in
proper orientation ? Look at words on the
film Uppercase R and L on
the filmsIt is like looking at a
person from frontAnterior part of the body
on the top and posterior part on the bottom
NORMAL CT BRAIN ANATOMY
A. FALX CEREBRIB. FRONTAL LOBEC. BODY OF LAT.
VENTD. CORPUS
CALLOSUME. PARIETAL LOBEF. OCCIPITAL LOBEG. SUP.SAGITTAL
SINUS
Shades of Gray,White and black
Hounsefield units-represents the tissue density
Represented by assigned portion of gray scale Air ,Fat,
CSFBlack
White matter,gray matter
gray
Acute hemorrhage , bone
white
CT BRAIN –systematic approach
Check patient and image information Check date and time Check image quality Scalp and skull bones Brain volume Ischemia and Hemorrhage Mass effect
Look at old images and reports Check for movement artifacts and
medical artifacts Do not view only a single slice in isolation If you suspect brain stem
pathology ,consider MRI
Medical artifact -shunt
Movement artifact
Fracture or suture Sutures
found in typical anatomical locations
Jagged in appearance and corticated
Fracture passes across both inner and
outer table of the skull in a straight line
Edges of fractured skull bones are not corticated
Extra –axial hemorrhage Extradural hematoma Subdural hematoma Subarachnoid hemorrhage
Extradural hematoma Post traumatic event Injury to an intracranial
artery –middle meningeal artery
Leakage of injured artery –collection of blood which strips the dura mater away from inner table of skull
Lens shaped collection – dura is strongly adherent to the skull in the region of sutures
Extradural hematoma
Subdural hematoma Cerebral veins are
fragile Risk is increased in
elderly and anticoagulated patients
Not limited by attachment points of dura to bone
Crescent shaped collection
Arachnoid is intact-so blood does not pass into sulci
SDH- effaced sulci
Subarachnoid hemorrhage
Trauma or intracranial aneursym
Blood can pass into any part of CSF spaces-suci,fissures,basal cisterns and ventricles
Intracerebral hemorrhage Intra axial
hemorrhage -spontaneous or traumatic
Area of high density material (blood) surrounded by low density(oedema)
Intracerebral hemorrhage
Cerebral oedema Assess brain volume
by assessing volume of CSF spaces
Cerebral oedema- can cause the brain
to swell – generalised reduction of CSF volume and loss of differentiation between grey and white matter
Mass effect Can be caused by
intracranial masses,hemorrhage and oedema
Effacement of sulci, partial or complete effacement of adjacent ventricles
Displacement of midline structures
Effacement of contralateral ventricles and sulci
THANK YOU