INTERPRETATION OF

CXR, CT AND MRI

B45 GROUP B
CHEST X-RAY
PNEUMONIA & ASPIRATION PNEUMONIA
Pneumonia
Key radiographic features

● In consolidation, alveolar spaces become filled with fluid,

making them appear white in xray
● Airways retain air, making them appear black
○ Air bronchogram

● Fluid sinks, so shadowing will be denser and more clearly

demarcated at lower border
● Lobar pneumonia will appear localized while
bronchopneumonia will appear widespread
Lobar pneumonia
Bronchopneumonia
Aspiration pneumonia

● Caused by a direct chemical insult due to the entry of a foreign substance,

solid or liquid, into the respiratory tract
● The clinical and radiological manifestations varies from asymptomatic
focal inflammatory reaction with few or no radiological abnormalities to
severe life-threatening disease
● Posterior segment of the upper lobes and the superior segment of the
lower lobes commonly involved lung sites in a recumbent patient
● In an erect patient, aspiration is more likely to involve bilateral basal
segments, middle lobe, and lingula
► Patchy alveolar
infiltrates in all zones
of the left lung, more
prominent in the
lower zone.
► Bilateral
inhomogeneous
patchy airspace
opacities mainly in
the lower zones.
► Effacement of the
costophrenic
recesses consistent
with aspiration.
PLEURAL EFFUSION
Pleural effusion

★ Clear right hemi-diaphragm with sharp

costophrenic angle seen.

★ Homogenous opacification of the left lower

zone with meniscus sign noted.

★ Obliteration of the left cardiophrenic and

costophrenic angle of the lung.

★ Loss of left diaphragmatic and cardiac

silhouette.
Loculated pleural effusion

★ Loculated homogenous opacity along

lateral chest wall of right lung.

★ Produce opacity with “D”shape or “tear

drop” shape.

★ Loss of right costophrenic angle and lateral

portion of right diaphragmatic silhouette.

PNEUMOTHORAX
Pneumothorax
● The left lung is collapsed
(arrowheads).
● Hyperlucent lung field on left side
● The trachea is pushed to the right
(arrow)
● The heart is shifted to the
contralateral side - note right heart
border is pushed to the right (red
line)
● The left hemidiaphragm is depressed
(orange line)
BRONCHIECTASIS
 1.
Tram track sign
Dilated airways with thickened
walls, crowded together in parallel
 2.
Honeycomb
appearance
Seen in traction bronchiectasis, an
important feature of fibrosis
 3.
Glove finger
shadows
Dilated bronchi filled with mucus
PULMONARY FIBROSIS
&
LUNG COLLAPSE
 Reticular shadowing - Fibrosis
Reticular shadowing - Fibrosis

Reticular
shadowing -
Fibrosis
Pulmonary fibrosis causes reticular
(net-like) shadowing of the lung
peripheries which is typically more
prominent towards the lung bases

It may cause the contours of the

heart to be less distinct or ‘shaggy’

Chest X-rays can be helpful in

monitoring the progression of
pulmonary fibrosis
 Fibrosis

Fibrosis
(Same patient as image above – 20
months later)

As the disease progresses the fibrosis

(lung scarring) becomes more
widespread and leads to lung volume
loss

In the mid-clavicular lines on each side,

the diaphragm is positioned above the
level of the 4th and 5th ribs on the right
and left respectively

Compare with the image above which

showed normal lung volume
Effusion and
collapse
This is a more difficult case. At first
glance there is clearly "white out" of the
left hemithorax, with a meniscus sign.
This indicates the presence of a pleural
effusion. Why then is the trachea (arrow)
moved towards the side of the effusion?

The clue lies in the appearance of the left

main bronchus, which is abruptly cut off
(arrowhead), in this case due to a cancer.

There is both an effusion and lung

collapse. The volume loss due to the
collapse is greater than the volume of the
effusion. The collapse is therefore
dominant and the trachea is PULLED
towards this side.
Right lower lobe
collapse
This chest X-ray shows tracheal deviation
to the right. There is no pleural effusion
on the left, and there is overall volume
loss of the right hemithorax, compared
with the left. The mediastinum is
therefore PULLED to the right.

Bronchoscopy showed a cancer

occluding the right lower lobe bronchus.
The X-ray shows right lower lobe collapse
(ringed). Although the mass itself is not
seen clearly, collapse of a lung lobe in an
adult should raise the suspicion of a
malignant process.
Left lower lobe
collapse
The tracheal deviation seen in this chest
X-ray (arrow) is due to left lower lobe
collapse. This has a classical appearance
of a 'double left heart border,' or a 'sail
sign' (orange). The second heart border
(curved arrow) is due to the dense edge
of the collapsed left lower lobe, which
has been squashed into a triangle or sail
shape.

Note that the left hemidiaphragm cannot

be followed all the way to the spine. This
is because the left lower lobe sits directly
on top of the diaphragm, and as it no
longer contains air, it is of the same soft
tissue density as the diaphragm and
therefore blends into it.
Right upper lobe
collapse
There is volume loss of the right upper
lobe. The right upper zone has become
dense due to lobar collapse. The volume
loss has displaced the trachea which is
PULLED to the right, and the horizontal
fissure (arrow) has been PULLED
upwards.

Right upper lobe collapse is hardly ever

caused by plugging of mucous or foreign
bodies. The presence of right upper lobe
collapse in an adult should therefore
immediately raise the suspicion of an
underlying malignant process occluding
the right main bronchus.
Left upper lobe
collapse
Trachea deviated to the left (arrow)

Right heart border not visible - indicating

mediastinal shift to the left

Volume loss of the left hemithorax '

Veil-like' opacification of the left hemithorax

obscuring the left heart border -
characteristic of left upper lobe collapse

Ovoid density at the left hilum - CT (next

image) confirmed a large left hilar mass,
which occluded the left upper lobe bronchus

Note the left hemidiaphragm is still visible -

indicating sparing of the left lower lobe

The left lower lobe has increased in volume

to compensate for the volume loss and can
be seen wrapping round the medial side of
the collapsed upper lobe (red line) - the
'Luftsichel' (air crescent) sign
PULMONARY EMBOLISM
- Fleischner sign - enlarged
pulmonary artery (20%)
- Hampton hump - peripheral
wedge of airspace opacity which
implies lung infarction (20%)
- Westermark sign - regional
oligaemia (10%)
- Pleural effusion (35%)
- Palla sign - enlarged right
descending pulmonary artery
- Chang sign - dilated right
descending pulmonary artery with
sudden cut off
Westermark sign Palla sign
Chang sign Knuckle sign
PULMONARY TUBERCULOSIS
Miliary TB
LUNG CARCINOMA
&
PANCOAST TUMOR
LUNG CARCINOMA
● Moderately dense opacity with ill-
defined margins
LUNG CARCINOMA
● Large rounded mass on the upper
lobe of the lungs.
● Pleural effusion on the lower lobe
Lung Carcinoma with Pancoast tumor
● Opacity at the apex of the lungs
● Enlargement of mediastinum
 ACUTE PULMONARY OEDEMA
&
CONGESTIVE CARDIAC FAILURE
Main Features
Erect PA chest Xray is preferred

1. Cardiomegaly
2. Redistribution-
3. Interstitial edema-
4. Pleural effusion-
5. Alveolar edema-
Cardiomegaly
Cardiothoracic ratio>0.5 in
PA view)
Redistribution of
Pulmonary blood
flow
● Cephalisation (upper
lobe diversions)
● Increased artery to
bronchus ratio
Interstitial edema
● Kerley B lines-fluid in
interlobular septum at
borders of chest
● Peribronchial cuffing
● Thickened lung fissures
Pleural effusion,
Alveolar edema
● Pleural effusion- loss of
costophrenic /
cardiophrenic angles,
meniscus sign
● Alveolar edema- batwing
appearance
CHRONIC OBSTRUCTIVE PULMONARY
DISEASE
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE

● Hyperinflated lungs
● Liver is pushed down
● Tubular heart
● Diaphragm flattened
● Increased radiolucency of
the lungs
 MEDIASTINAL WIDENING
&
MEDIASTINAL LYMPHADENOPATHY
Mediastinum
● Mediastinum - area between pleural sacs.
● Divided into superior, anterior and middle mediastinum.
● Mediastinal tumours are rare and often incidentally diagnosed by X-ray or MRI.
● They can be classified according to location.
Mediastinal lesions
● Benign mediastinal tumours often incidentally diagnosed, can cause pressure
symptoms.
● Dermoid cyst may rupture into bronchus.
● Malignant mediastinal tumours invade and compress surrounding structures -
even small tumour can produce symptoms.
● Most common - mediastinal lymph node metastases from bronchogenic
carcinoma.
● Can also be lymphomas, leukemia, malignant thymic tumours and germ cell
tumours.
● Similar destructive features in aortic and innominate aneurysms.
 Anterior mediastinum
● Retrosternal / Intrathoracic thyroid ● Thymic tumours (thymomas)
● Most common mediastinal mass. ● Thymus large in childhood - superior
● Thyroid enlargement (goitre, malignancy, anterior mediastinum, involutes with age.
thyrotoxicosis) can displace trachea and ● Enlarged by cysts (~ asymptomatic) or
oesophagus to opposite side. tumours.
● Insidious onset of compression symptoms. ● Half of patients - myasthenia gravis.
● Cardinal feature - dyspnoea. ● Good’s syndrome (combined cellular &
● May cause dysphagia, hoarseness, vocal humoral immunity defect) in 10%.
cord paralysis. ● Tx - surgical removal.
● Flow volume loops - physiological impact.
● Tx - surgical removal.
Middle mediastinum Posterior mediastinum
● Bronchogenic cyst - benign ● Embryological remnants - neurogenic
embryological remnant. and neuro-enteric cysts.
● Mediastinal lymphadenopathy - ● Oesophageal abnormalities -
metastatic lesions, primary lung cancer,
oesophageal tumours, hiatus hernia,
infection (TB), lymphoma, etc.
● Pericardial cysts - <10 cm diameter, full etc.
of clear fluid, 70% in right anterior
cardiophrenic angle. Infection rare and
malignant change doesn’t occur. Dx MRI,
~ needle aspiration. Follow up, if change
occurs then surgical excision.
● Vascular abnormalities - aortic
aneurysm, aortic dissection.
● Tracheal tumours
Mediastinal lymphadenopathy
Investigations
● CXR - benign mediastinal tumour appears as sharply circumscribed mediastinal
opacity encroaching on one or both lung fields.
● CT / MRI - investigation of choice - malignancy has undefined margin, general
broadening of mediastinum.
● Bronchoscopy - primary bronchial ca. causing mediastinal lymphadenopathy.
● Endobronchial ultrasound - mass sampling, imaging and biopsy of posterior
mediastinum.
● Mediastinoscopy - under GA, can visualise and biopsy masses in superior and
anterior mediastinum.
 CXR - normal
mediastinum

CXR taken standing PA with good inspiration and no

rotation - if any widening, likely genuine
CXR - mediastinal mass
Mediastinal widening
- mediastinum
measurement of
≥8 cm or >1/3rd
the transthoracic
distance at the
level of the aortic
knob.
Mediastinal
lymphadenopathy
Mediastinal mass
● Wide upper mediastinum
(arrowheads)
● Poorly defined aortic knuckle
● Wide right paratracheal stripe
(circle)
● Normal lungs

Mass in anterior
mediastinum
Mediastinal
lymphadenopathy
Management
● Benign mediastinal tumours - remove surgically as produce pressure effects.
● Cysts may become infected.
● Neural tumours can become malignant.
● Low operative mortality in absence of COPD, cardiovascular disease or extreme
age.
AORTIC ANEURYSM
Aortic Aneurysm
- Widening of mediastinum silhouette

- Enlargement of aortic knob

- Displacement of trachea from midline

MITRAL STENOSIS WITH PULMONARY HYPERTENSION
&
LEFT ATRIAL ENLARGEMENT
 MITRAL
STENOSIS
Typical chest radiographic features

■ Left atrial enlargement

– convexity or straightening of the left auricle just below the main
pulmonary artery (along left heart border)
– double density sign: the right side of the enlarged left atrium pushes
into the adjacent lung and creates an addition contour superimposed
over the right heart
■ Elevation of the left main bronchus and splaying of the carina (>90 degrees)
■ Pulmonary edema
■ Mitral valve calcification
■ Double right heart border,
due to enlargement of the
left atrium.
■ Prominent left atrial
appendage.
■ Severe splaying of the
subcarinal angle (150
degrees).
RIGHT VENTRICULAR HYPERTROPHY
&
LEFT VENTRICULAR HYPERTROPHY
RIGHT VENTRICULAR HYPERTROPHY

● Conditions:
○ Pulmonary Valve Stenosis

○ Pulmonary Hypertension

○ Tetralogy of Fallot
Radiographic Features

● Frontal View:
○ Increased cardiothoracic ratio

○ Rounded left heart border

○ Uplifted cardiac apex

● Lateral view
○ Filling of retrosternal space

○ Rotation of Heart posteriorly

LEFT VENTRICULAR HYPERTROPHY

● Conditions:
○ Hypertension

○ Valvular Heart Disease( Aortic stenosis, Aortic Regurgitation, Mitral Regurgitation )

○ Genetic: Hypertrophic Cardiomyopathy

RADIOGRAPHIC FEATURES

● Left heart border is displaced inferiorly, posteriorly and more towards to left
● Rounding of the cardiac apex
● Shmoo Sign: Dilated ascending aorta with rounded left ventricle
 PERICARDIAL EFFUSION

Pericardial effusions occur when excess fluid collects in the pericardial space (a
normal pericardial sac contains approximately 30-50 mL of fluid).
Posterior-anterior CXR displaying
massive cardiac silhouette. The
gobular shape is consistent, also
know as the “water bottle sign”,
which is the typical appearance of the
cardiac silhouette that is present
when there is a large pericardial
effusion.
● This image shows some of the features
of heart failure
● 1 - Upper zone vascular prominence
● 2 - Airspace shadowing (alveolar
oedema)
● 3 - Septal lines (interstitial oedema)
● 4 - Pleural effusion
● The heart is also enlarged and has a
globular (rounded) appearance due to
a pericardial effusion (fluid
accumulation within the pericardial
sac
TETRALOGY OF FALLOT
PLEURAL PLAQUE & LUNG ABSCESS
● Translucent white areas behind
the rib cage shows the pleural
plaques
● They are areas of thickened tissue
that form in the lining of lungs
● Its also called as Hyaline Pleural
Plaque (contain hyaline tissue
found in cartilage)
● Single cavitation mass lesion in
the upper right lobe
● Air fluid level is seen
● Thick walled cavity
● Has black (radiolucent) inner
surface
CT BRAIN
Approach to CT Brain
1. Ensure details of patient & Scan
2. Confirm orientation of scan & use of contrast
3. Systemic approach to interpreting a CT Scan:
 Blood Cistern
- Circum-mesencephalic (surrounding the
- Presence of blood (origin, duration & midbrain)
cause of insult determined by location - Suprasellar (around the Circle of Willis)
& spread) - Quadrigeminal (located at the top of
- Extracerebral Hemorrhage (within the midbrain)
skull but outside of brain) - Sylvian (between temporal & frontal
lobes)
- Intracerebral Hemorrhage (within the
- Examine each cistern for evidence of
brain itself) effacement, asymmetry and presence of
blood
 Ventricles
Brain
- Examine the lateral ventricles, 3rd &
- Compare the sulcal pattern (gyri) 4th ventricles
- Look for midline shift (mass effect)
(asymmetry, dilatation (hydrocephalus),
- Look for any inconsistencies in the
effacement & hemorrhage)
grey-white differentiation
- Identify hyperdense & hypodense
regions
Bones
- Look for evidence of fracture/ tumors
- Best viewed on separate bone windows
- Cortical bone has highest density on CT
- Maxillary/ Ethmoid/ Sphenoid sinuses all
should be visible & aerated)
 ISCHEMIC STROKE
&
HEMORRHAGIC STROKE
Ischemic Stroke

Non-Contrast CT Scan of the Brain

● Irregular Hypodense Area in the right
cerebral hemisphere
● Swelling & Compression of right ventricle
with midline shift to the left
● Loss of Grey-White Matter Differentiation
● Massive right sided cerebral infarction
(Ischemic Stroke)
Hemorrhagic Stroke

Non-Contrast CT Scan of the Brain

● Irregular Hyperdense Area in the right cerebral
hemisphere
● Swelling & Compression of right ventricle with
midline shift to the left
● Presence of cerebral edema around the
hyperdense area
● Hemorrhagic Stroke on right cerebral hemisphere
SUBARACHNOID HEMORRHAGE
SAH
● Acute blood is hyperdense (bright) on CT

● Blood in the basal cisterns and sulci

(normally black subarachnoid cisterns and sulci
may appear white in acute hemorrhage)

● In the absence of trauma, think of an

aneurysm
SAH
Dense material in the Blood in the ventricles
Occasionally blood is may be the only sign of
basal cisterns and
seen layered over the subarachnoid
fissures is due to
tentorium which haemorrhage
acute bleeding into
appears denser than is
the subarachnoid
normally seen Calcification of the
space
choroid plexus
EXTRADURAL HEMATOMA
&
SUBDURAL HEMATOMA
MRI BRAIN
MULTIPLE SCLEROSIS
Multiple sclerosis
● A condition that affect the brain and spinal cord, causing a wide range of potential
symptoms, including problems with vision, arm or leg movement sensation or
balance
● It’s a lifelong condition that can cause serious disability, although it can
occasionally be mild
● Commonly diagnosed in people in their 20s until 40s, although it can develop at
any time
● More common in females
Clinical features
● Optic neuritis
● Relapsing/Remitting sensory symptoms
● Subacute painless spinal cord lesions
● Acute brainstem syndrome
● Subacute loss of function of upper limb
● 6th cranial nerve palsy
MRI Interpretation
● Examples of images and sequences
○ T1-weighted
○ T2- weighted
○ DWI and ADC
○ FLAIR
● Verify details
● Look at T2-weighted images
● Compare with different MRI image sequences
● Compare against other imaging modalities
● Compare against previous images
● Consider the clinical context