X-Rays

X-Rays

Kunal D Patel

Research Fellow

IMM

The 12-Steps

• 1: Name• 2: Date• 3: Old films• 4: What type of view(s)• 5: Penetration• 6: Inspiration• 7: Rotation• 8: Angulation• 9: Soft tissues / bony structures• 10: Mediastinum• 11: Diaphragms• 12: Lung Fields

Quality Control

Findings

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Reviewing these areasHeart• Size• Shape• Silhouette-margins should be sharp• Evidence of stents, clips, wires and

valves• Diameter (>1/2 thoracic diameter is

enlarged heart)

Mediastinum

•Width?

•Contour?

Lung fields

•Apices

•Lobes and fissures

•USE SILHOUETTES

•CP angles

•Diaphragm

•Gastric bubble

•NOTE normal pleura are NOT visible

FINDINGS!• A = Airway: are the trachea and mainstem bronchi

patent; is the trachea midline?

• B = Bones: are the clavicles, ribs, and sternum present and are there fractures, lytic lesions?

• C = Cardiac silhouette: is the diameter of the heart > ½ thoracic diameter (enlarged)?

• D = Diaphragm: are the costophrenic and costocardiac margins sharp? is one hemidiaphragm enlarged over another? is free air present beneath the diaphragm?

• E = Effusion/empty space: is either present?• F = Fields (lungs): are there infiltrates, increased

interstitial markings, masses, air bronchograms, increased vascularity, or silhouette signs?

• G = Gastric bubble: is it present and on the correct (left) side?

• H = Hilar region: is there increased hilar lymphadenopathy?

Summarise as well!

"The trachea is central, the mediastinum is not displaced. The mediastinal contours and hila seem normal. The lungs seem clear, with no pneumothorax. There is no free air under the diaphragm. The bones and soft tissues seem normal."

CASES

Remember!:

• Most disease states replace air with a pathological process

• Each tissue reacts to injury in a predictable fashion

• Lung injury or pathological states can be either a generalized or localized process

Evaluating an Abnormality

1. Identification of abnormal shadows

2. Localization of lesion

3. Identification of pathological process

4. Identification of etiology

5. Confirmation of clinical suspensionComplex problems

• Introduction of contrast medium• CT chest• MRI scan

A single, 3cm relatively thin-walled cavity is noted in the left midlung. This finding is most typical of squamous cell carcinoma (SCC). One-third of SCC masses show cavitation

LUL Atelectasis: Loss of heart borders/silhouetting. Notice over inflation on unaffected lung

Atelectasis

• Loss of air• Obstructive atelectasis:

• No ventilation to the lobe beyond obstruction

• Radiologically:• Density corresponding to a segment

or lobe• Significant loss of volume• Compensatory hyperinflation of

normal lungs

Right Middle and Left Upper Lobe Pneumonia

Consolidation

• Lobar consolidation:• Alveolar space filled with inflammatory

exudate• Interstitium and architecture remain

intact• The airway is patent• Radiologically:

• A density corresponding to a segment or lobe

• Airbronchogram, and• No significant loss of lung volume

Cavitation:cystic changes in the area of consolidation due to the bacterial destruction of lung tissue. Notice air fluid level.

TENSION PNEUMOTHORAX

Widened Mediastinum: Aortic Dissection

Right Middle Lobe Pneumothorax: complete lobar collapse

Perihilar mass: Hodgkin’s disease

28 y/o female with sudden onset SOB while jogging this morning

Well demarcated paucity of pulmonary vascular markings in right apex

Left spontaneous pneumothorax